title: Time and Money: The True Costs of Health Care Utilization for Patients Receiving "Free" HIV/Tuberculosis Care and Treatment in Rural KwaZulu-Natal.
abstract: BACKGROUND
  HIV and tuberculosis (TB) services are provided free of charge in many sub-Saharan African countries, but patients still incur costs.
  
  
  METHODS
  Patient-exit interviews were conducted in primary health care clinics in rural South Africa with representative samples of 200 HIV-infected patients enrolled in a pre-antiretroviral treatment (pre-ART) program, 300 patients receiving antiretroviral treatment (ART), and 300 patients receiving TB treatment. For each group, we calculated health expenditures across different spending categories, time spent traveling to and using services, and how patients financed their spending. Associations between patient group and costs were assessed in multivariate regression models.
  
  
  RESULTS
  Total monthly health expenditures [1 USD = 7.3 South African Rand (ZAR)] were ZAR 171 [95% confidence interval (CI): 134 to 207] for pre-ART, ZAR 164 (95% CI: 141 to 187) for ART, and ZAR 122 (95% CI: 105 to 140) for TB patients (P = 0.01). Total monthly time costs (in hours) were 3.4 (95% CI: 3.3 to 3.5) for pre-ART, 5.0 (95% CI: 4.7 to 5.3) for ART, and 3.2 (95% CI: 2.9 to 3.4) for TB patients (P < 0.01). Although overall patient costs were similar across groups, pre-ART patients spent on average ZAR 29.2 more on traditional healers and ZAR 25.9 more on chemists and private doctors than ART patients, whereas ART patients spent ZAR 34.0 more than pre-ART patients on transport to clinics (P < 0.05 for all results). Thirty-one percent of pre-ART, 39% of ART, and 41% of TB patients borrowed money or sold assets to finance health care.
  
  
  CONCLUSIONS
  Patients receiving nominally free care for HIV/TB face large private costs, commonly leading to financial distress. Subsidized transport, fewer clinic visits, and drug pick-up points closer to home could reduce costs for ART patients, potentially improving retention and adherence. Large expenditure on alternative care among pre-ART patients suggests that transitioning patients to ART earlier, as under HIV treatment-as-prevention policies, may not substantially increase patients' financial burden.
authors.affiliation: *Wellcome Trust Africa Centre for Health and Population Studies, University of KwaZulu-Natal, South Africa; †School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; ‡Department of Global Health, School of Public Health, Boston University, Boston, MA; §Faculty of Medicine and Faculty of Human and Social Sciences, University of Southampton, Southampton, United Kingdom; ‖Nijmegen International Center for Health System Analysis and Education (NICHE), Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands; ¶Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; #Department of Epidemiology and International Health Institute, Brown University School of Public Health, Providence, RI; **Department of Virology, University College London, London, United Kingdom; and ††Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA.
authors.forename: Natsayi
authors.initials: N
authors.lastname: Chimbindi
authors.forename: Jacob
authors.initials: J
authors.lastname: Bor
authors.forename: Marie-Louise
authors.initials: ML
authors.lastname: Newell
authors.forename: Frank
authors.initials: F
authors.lastname: Tanser
authors.forename: Rob
authors.initials: R
authors.lastname: Baltussen
authors.forename: Jan
authors.initials: J
authors.lastname: Hontelez
authors.forename: Sake J
authors.initials: SJ
authors.lastname: de Vlas
authors.forename: Mark
authors.initials: M
authors.lastname: Lurie
authors.forename: Deenan
authors.initials: D
authors.lastname: Pillay
authors.forename: Till
authors.initials: T
authors.lastname: Bärnighausen
mesh_terms: D000328:Adult; D017954:Africa South of the Sahara / Q000453:epidemiology; D000067012:Banking, Personal; D005260:Female; D006078:Government Programs; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy / Q000191:economics / Q000453:epidemiology; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D013997:Time Factors; D014376:Tuberculosis / Q000150:complications* / Q000188:drug therapy / Q000191:economics / Q000453:epidemiology; D055815:Young Adult