Diagnosed with TB? Here's What to Do About Your Medical Aid

A TB diagnosis — particularly in a working adult with medical aid — requires navigating two parallel systems: the state DOTS programme and your private scheme's PMB pathway. This guide helps you use your scheme correctly and complete treatment successfully.

The Honest Starting Point

TB is a PMB condition. Your scheme must fund your full 6-month treatment course, regardless of plan tier. There is no benefit limit on PMB medication for a PMB condition. This is legally mandated. (TB is not on the Chronic Disease List (CDL) — but its PMB Diagnosis-and-Treatment-Pair status carries the same protection.)

However, PMB protection only activates once your TB is registered with your scheme. If you are not registered as a PMB/chronic condition for TB, your medication defaults to your day-to-day benefit — which exhausts. Register immediately.

Step 1: Register Your TB as a PMB Condition — Do It Before You Fill Your First Prescription

Call your scheme before or at the same time you collect your first TB prescription:

"I have been diagnosed with TB (ICD-10 A15.0). I need to register TB as a Prescribed Minimum Benefit (chronic) condition so my medication is funded from risk. What documentation do you require?"

Typically required: - A letter from your treating doctor or TB clinic confirming the diagnosis with ICD-10 code (A15.0 for pulmonary TB; A15.1–A15.9 for other; A17–A19 for extrapulmonary/miliary TB) - Your positive sputum or GeneXpert result - Your proposed treatment regimen

Submit this immediately. PMB/chronic registration can often be backdated to diagnosis date, ensuring your initial medication is covered from day one.

Step 2: Decide: Private or State Treatment — Or Hybrid

Option A: Full private management (scheme-funded) - Treat through your private GP, pulmonologist, or TB specialist - The PMB covers all first-line medication - Monitoring bloods (LFTs, sputum cultures) covered under the PMB - More expensive for the scheme; same clinical outcomes as state

Option B: State DOTS programme (free) - Use your local clinic or TB clinic for treatment - Medication, DOT support, and sputum follow-up: free - Your scheme cover is preserved for other medical needs - Standard of care is consistent; first-line drugs are identical

Option C: State diagnosis + private ongoing management - Many patients are diagnosed at state facilities and transition to private GPs for follow-up - Use your PMB benefit to cover continuation-phase medication privately if you prefer

Good to know: For uncomplicated drug-sensitive TB, the state DOTS programme provides treatment at no cost, with equivalent outcomes. Your scheme's PMB benefit also covers TB, including more complex cases such as HIV co-infection, drug resistance and extrapulmonary TB. Which route you use is your choice — discuss it with your doctor.

Step 3: Monitor Your Liver Function — Critical During Intensive Phase

The intensive-phase drugs (RHZE — rifampicin, isoniazid, pyrazinamide, ethambutol) carry hepatotoxicity risk, particularly pyrazinamide. Your doctor should arrange:

• Baseline LFTs (ALT, AST, bilirubin) before starting treatment
• Repeat LFTs at 2 weeks and monthly during the intensive phase (2RHZE)
• If nausea, jaundice, dark urine, or right upper quadrant pain develops: stop TB medication and seek same-day medical assessment

Monitoring bloods are covered under your PMB benefit. Confirm with your scheme.

Step 4: Understand Drug Interactions — Especially if on Other Medications

Rifampicin is a potent inducer of liver enzymes (CYP450). It reduces blood levels of many medications, including: - Oral contraceptives (use additional contraception method) - Warfarin (INR monitoring required; dose adjustment needed) - Some HIV ARVs (efavirenz levels affected; nevirapine levels significantly reduced) - Corticosteroids, some antiepileptics, azole antifungals

Tell your GP about all medications you are taking when starting TB treatment. If you are on ARVs, your HIV doctor must review your ART regimen before TB treatment begins.

Step 5: If You Are HIV Positive

If you are HIV positive and newly diagnosed with TB:

1. Ensure both conditions are registered with your scheme (HIV on the CDL; TB as a PMB condition)
2. Your HIV doctor and TB treating doctor must communicate about ART timing — ART is usually started within 2–8 weeks of TB treatment initiation (earlier if CD4 is very low)
3. Rifampicin significantly reduces levels of some ARVs — an ARV regimen switch may be required (tenofovir-based regimens with dolutegravir or efavirenz are preferred with rifampicin)
4. All of this — both the TB and HIV management — is PMB covered

Step 6: Complete the Full Course — Do Not Stop Early

TB treatment failure and drug resistance arise from incomplete treatment. The most common reason for MDR-TB in SA is incomplete first-line treatment — someone stops when they feel better (2–3 months in) but before the continuation phase eradicates residual bacteria.

You must complete the full 6 months (or longer for drug-resistant TB).

If you are struggling with adherence: - State DOTS programme provides a community health worker to observe you swallowing medication each day — this is available in the public sector at no cost - Fixed-dose combination tablets (RHZE in one tablet) reduce pill burden - Your GP or TB specialist can provide adherence support in the private sector

Step 7: If Drug Resistance Is Confirmed (MDR-TB)

If your sputum culture shows resistance to rifampicin or isoniazid: - GeneXpert detects rifampicin resistance rapidly; drug sensitivity testing (DST) gives the full picture - MDR-TB treatment in the private sector is PMB-covered — Bedaquiline and the BPaL/BPaLM regimen are expensive but must be funded - Request written pre-authorisation for MDR-TB drugs from your scheme - Your scheme may have a designated MDR-TB specialist or pulmonologist contracted; ask for a referral

MDR-TB is also managed at provincial state MDR-TB units at no cost. For most people, state MDR-TB specialist units provide equivalent or superior management.

Key Calls to Make

Talk to Eldon

TB PMB registration is straightforward but time-sensitive — every day without registration is a day your treatment could be hitting your day-to-day benefit. AURA activates PMB registration on day one of diagnosis.

Review your plan for TB and infectious disease coverage →