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

Background: The rising co-occurrence of HIV and hypertension in sub-Saharan Africa (SSA) presents complex challenges for patients and health systems. In South Africa, despite free healthcare services for HIV and hypertension in the public sector, patients with multiple chronic conditions frequently incur substantial out-of-pocket (OOP) costs. However, limited empirical evidence quantifies this burden from the patient perspective. Purpose: To quantify the economic burden of managing comorbid HIV and hypertension among South African patients, identify socio-demographic predictors of monthly OOP expenditure, and assess financial coping mechanisms. Methods: We conducted a cross-sectional analysis using patient-level data from the MOPHADHIV trial [Trial number: PACTR201811878799717], a randomized controlled trial evaluating SMS 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 (GLMs) 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) when valuing indirect costs by actual income and ZAR 182.3 (USD 9.9) using minimum wage assumptions. Indirect costs were the largest cost component. Regression models revealed a significant income gradient: participants in the richest quintile incurred ZAR 131.9 (95% CI: 63.6–200.1) more costs per month than the poorest participants (p < 0.00). However, when indirect costs were standardized by minimum wage, cost gradients attenuated or reversed, indicating greater relative burden among middle-income groups. Other socio-demographic factors (gender, employment, education) were not significantly associated with total costs, which may reflect the relative success of South Africa’s district health system and its emphasis on equitable access to primary care that is free at the point of service. Nearly half the participants reported coping costs. Conclusion: Managing comorbid HIV and hypertension imposes substantial economic burdens on patients, primarily driven by indirect costs. Income-related disparities dominate cost variation, with important implications for financial protection and equity. Strengthening the integration of HIV and NCD services and targeting financial support for lower-income patients are critical to advancing South Africa’s Universal Health Coverage reforms.