Structural Vulnerability and TB Treatment Adherence Among a Homeless HIV-Positive Patient in South Africa: A Qualitative Case Study.
1
Health Programs, Eastern Cape Department of Health, Bhisho, South Africa
2
Health Science, Foundation for Professional Development, Pretoria, South Africa
3
NPO, Best Health Solutions, Johannesburg, South Africa
Popul. Med. 2026;8(Supplement Supplement 1):A594
ABSTRACT
BACKGROUND:
Tuberculosis (TB) treatment adherence remains a significant challenge in South Africa, particularly among individuals experiencing extreme social vulnerability, including homelessness, substance use, and HIV co-infection. These intersecting vulnerabilities increase the risk of treatment interruption and loss to follow-up, undermining TB control efforts and treatment outcomes.1,2,3. This study explores the lived experience of a homeless, HIV-positive male TB patient in East London, South Africa, with the aim of understanding the social and structural factors that influence TB treatment adherence and interruption among highly vulnerable populations.
METHODS:
An in-depth qualitative interview was conducted in isiXhosa with a 33-year-old homeless man living with TB and HIV. The interview was transcribed verbatim and translated into English. Thematic analysis was applied to explore treatment adherence behaviours and the broader social determinants shaping the participant’s treatment journey. Areas explored included homelessness, substance use, psychosocial distress, trauma, incarceration, informal support systems, and access to healthcare services.
RESULTS:
Six interrelated themes emerged: cumulative vulnerability and homelessness; psychosocial distress and stigma; the role of informal support systems; the burden of TB–HIV co-treatment; health system discontinuities; and competing survival priorities. Periods of incarceration temporarily enabled treatment adherence through structured routines, stable medication access, and supportive supervision. In contrast, post-release instability, lack of housing, and fragmented continuity of care contributed to treatment interruption and loss to follow-up.
CONCLUSIONS:
This case demonstrates that TB treatment adherence among highly vulnerable individuals is not solely a clinical issue but is deeply embedded within complex social and structural realities. The findings highlight that temporary stability can facilitate adherence, while fragmented health services, inadequate psychosocial support, and unmet basic needs undermine sustained engagement in care. Improving TB outcomes among vulnerable populations requires integrated, person-centred TB/HIV care that addresses social determinants, strengthened community outreach, psychosocial support, and improved continuity of care following periods of institutionalisation.
Tuberculosis (TB) treatment adherence remains a significant challenge in South Africa, particularly among individuals experiencing extreme social vulnerability, including homelessness, substance use, and HIV co-infection. These intersecting vulnerabilities increase the risk of treatment interruption and loss to follow-up, undermining TB control efforts and treatment outcomes.1,2,3. This study explores the lived experience of a homeless, HIV-positive male TB patient in East London, South Africa, with the aim of understanding the social and structural factors that influence TB treatment adherence and interruption among highly vulnerable populations.
METHODS:
An in-depth qualitative interview was conducted in isiXhosa with a 33-year-old homeless man living with TB and HIV. The interview was transcribed verbatim and translated into English. Thematic analysis was applied to explore treatment adherence behaviours and the broader social determinants shaping the participant’s treatment journey. Areas explored included homelessness, substance use, psychosocial distress, trauma, incarceration, informal support systems, and access to healthcare services.
RESULTS:
Six interrelated themes emerged: cumulative vulnerability and homelessness; psychosocial distress and stigma; the role of informal support systems; the burden of TB–HIV co-treatment; health system discontinuities; and competing survival priorities. Periods of incarceration temporarily enabled treatment adherence through structured routines, stable medication access, and supportive supervision. In contrast, post-release instability, lack of housing, and fragmented continuity of care contributed to treatment interruption and loss to follow-up.
CONCLUSIONS:
This case demonstrates that TB treatment adherence among highly vulnerable individuals is not solely a clinical issue but is deeply embedded within complex social and structural realities. The findings highlight that temporary stability can facilitate adherence, while fragmented health services, inadequate psychosocial support, and unmet basic needs undermine sustained engagement in care. Improving TB outcomes among vulnerable populations requires integrated, person-centred TB/HIV care that addresses social determinants, strengthened community outreach, psychosocial support, and improved continuity of care following periods of institutionalisation.
| eISSN: | 2654-1459 |
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