Lestari, Bony WiemSaptiningrum, EkaHuria, LavanyaFikri, Auliya RamandaDaniels, BenjaminVasquez, Nathaly AguileraSassi, AngelinaDas, JishnuOga-Omenka, CharityMcAllister, Susan M.Pai, MadhukarAlisjahbana, Bachti2025-06-032025-06-032025-04-01https://doi.org/10.1371/journal.pone.0320401https://hdl.handle.net/10012/21811© 2025 Lestari et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.The tuberculosis (TB) program was massively disrupted due to the COVID-19 pandemic, which may have impacted on an increase in costs for people with TB (PWTB) and their households. We aimed to quantify the pre-treatment out-of-pocket costs and the factors associated with these costs from patients' perspective during the COVID-19 pandemic in Bandung, Indonesia. Adults with pulmonary TB were interviewed using a structured questionnaire for this cross-sectional study recruiting from 7 hospitals, 59 private practitioners, and 10 community health centers (CHCs) between July 2021 to February 2022. Costs in rupiah were converted into US dollars and presented as a median and interquartile range (IQR). Factors associated with costs were identified using quantile regression. A total of 252 participants were recruited. The median total pre-treatment cost was $35.45 (IQR 17.69-67.62). The highest median cost was experienced by participants from private hospitals ($54.51, IQR 29.48-98.47). The rapid antigen and PCR for SARS-CoV-2 emerged as additional medical costs among 26% of participants recruited in private hospitals. Visiting >-6 providers before diagnosis ($38.40 versus $26.20, p < 0.001), presenting first at a private hospital ($50.68, p< 0.05) and private practitioners ($34.97, p < 0.05), and being diagnosed in the private health sector ($39.98 versus $20.30, p < 0.05) were significantly associated with higher pre-treatment costs. PWTB experienced substantial out-of-pocket costs in the process of diagnosis during the COVID-19 pandemic despite free TB diagnosis and treatment. Early detection and identification play an important role in reducing pre-diagnostic TB costs.enAttribution 4.0 Internationalhttp://creativecommons.org/licenses/by/4.0/COVID 19tuberculosispandemicstuberculosis diagnosis and managementhealth care providersfinanceIndonesiavirus testingArticle