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.

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.

Mobile health (mHealth) interventions offer scalable support for adherence and self-management, yet their effects on health-related quality of life (HRQoL) among people living with HIV (PLWH) and comorbid hypertension remain unclear. We evaluated HRQoL outcomes using data from the MOPHADHIV trial, a 12-month short message service (SMS)-based randomized controlled trial conducted at four community health centres in Cape Town, South Africa. HRQoL was measured using the EuroQol 5-Dimension 5-Level (EQ-5D-5L) utility index (Ugandan value set) and the EuroQol Visual Analogue Scale (VAS) at baseline and 12 months. Between-group differences were assessed using two-sample t-tests and analysis of covariance (ANCOVA) models adjusting for baseline HRQoL and covariates. A total of 582 participants (279 control; 303 intervention) with complete HRQoL data at baseline and 12 months were included in the analysis. Baseline HRQoL was high and comparable across arms. At 12 months, EQ-5D-5L utility was slightly higher in the control arm (0.97 vs 0.95; mean difference 0.03; t = 2.66, p = 0.01), corresponding to a small effect size (Cohen’s d = 0.22). In adjusted models, intervention allocation was associated with a small reduction in EQ-5D-5L utility (β = − 0.02, p = 0.01; fully adjusted β = − 0.03, p < 0.01). VAS scores improved in both groups, with no significant between-arm differences. In this cohort of PLWH with hypertension, a 12-month SMS-based intervention did not improve HRQoL and was associated with a small reduction in EQ-5D-5L utility. High baseline HRQoL and limited sensitivity of EQ-5D-5L to HIV-related psychosocial domains may partly explain these findings.