Economic Burden of Human Immunodeficiency Virus and Hypertension Care Among MOPHADHIV Trial Participants: Patient Costs and Determinants of Out-of-Pocket Expenditure in South Africa

Background: Human immunodeficiency virus and hypertension increasingly co-occur in South Africa. Despite publicly funded care, patients with multimorbidity face high out-of-pocket costs, yet limited evidence exists from the patient perspective. Purpose: To quantify the economic burden of comorbid HIV and hypertension, assess predictors of monthly out-of-pocket costs, and explore coping mechanisms. Methods: We conducted a cross-sectional analysis using patient-level data from the Mobile Phone Text Messages to Improve Hypertension Medication Adherence in Adults with HIV (MOPHADHIV trial) [Trial number: PACTR201811878799717], a randomized controlled trial evaluating short messages services adherence support for hypertension care in people with HIV. We calculated the monthly direct non-medical, indirect, and coping costs from a patient perspective, valuing indirect costs using both actual income and minimum wage assumptions. Generalized linear models with a gamma distribution and log link were used to identify cost determinants. Catastrophic expenditure thresholds (10–40% of monthly income) were assessed. Results: Among 683 participants, mean monthly total costs were ZAR 105.81 (USD 5.72) using actual income and ZAR 182.3 (USD 9.9) when valuing indirect costs by minimum wage. These time-related productivity losses constituted the largest share of overall expenses. Regression models revealed a strong income gradient: participants in the richest quintile incurred ZAR 131.9 (95% CI: 63.6–200.1) more per month than the poorest. However, this gradient diminished or reversed under standardized wage assumptions, suggesting a heavier proportional burden on middle-income groups. Other socio-demographic factors (gender, employment, education) not significantly associated with total costs, likely reflecting the broad reach of South Africa’s primary health system. Nearly half of the participants also reported resorting to coping mechanisms such as borrowing or asset sales. Conclusions: Comorbid HIV and hypertension impose substantial patient costs, predominantly indirect. Income disparities drive variation, raising equity concerns. Strengthening integrated human immunodeficiency virus—non-communicable diseases care and targeting financial support are key to advancing South Africa’s Universal Health Coverage reforms.