**Background:** Tuberculosis (TB) symptoms, despite limited sensitivity, remain a key entry point into the TB care cascade. In high-burden settings, many people with TB remain undetected. Understanding barriers to healthcare seeking is critical to improving case detection. This study analyzed data from the first South African national TB prevalence survey (2017–2019) to investigate self-reported healthcare seeking among participants with TB symptoms.
**Methods:** The survey enrolled 35,191 participants aged ≥15 years from 110 clusters across all nine provinces. Participants were screened using four TB symptoms (cough of any duration, unexplained weight loss, unexplained fever ≥2 weeks, drenching night sweats ≥2 weeks) and digital chest X-ray. A structured questionnaire collected data on sociodemographics, behaviors, and reasons for not seeking care (categorized as: intending to seek care, symptoms regarded as benign, access barriers [distance/cost], health system barriers, use of other medications, fear of TB diagnosis). Those screening positive submitted sputum for Xpert MTB/RIF Ultra and liquid culture; HIV status was determined by dried blood spot or self-report. Logistic regression identified factors associated with care seeking.
**Key Results:** Of 35,191 participants, 5,168 (14.7%) reported ≥1 TB symptom (median age 47 years, 59.3% women). Overall, 3,442/5,168 (66.6%) had not sought care. Among these, 2,064 (60.0%) intended to seek care, 912 (26.5%) regarded symptoms as benign, 399 (11.6%) reported access barriers, 36 (1.0%) used other medications, 20 (0.6%) reported health system barriers, and 4 (0.1%) feared a TB diagnosis. Among 98 symptomatic participants with bacteriologically confirmed TB, 57 (58.2%) had not sought care; of these, 38 (66.7%) intended to seek care, 8 (14.0%) regarded symptoms as benign, and 6 (10.5%) reported access barriers. In multivariate analysis of all symptomatic participants, factors associated with higher care seeking included age ≥50 years (aOR 3.14, 95% CI 2.50–3.96), rural residence (aOR 1.17, 95% CI 1.03–1.33), history of past TB (aOR 1.61, 95% CI 1.37–1.90), and diabetes (aOR 1.48, 95% CI 1.18–1.84). Factors associated with lower care seeking included HIV-negative status (aOR 0.57, 95% CI 0.49–0.67), unknown HIV status (aOR 0.45, 95% CI 0.37–0.56), smoking (aOR 0.64, 95% CI 0.54–0.74), and alcohol consumption (aOR 0.81, 95% CI 0.70–0.94). Among the 98 with bacteriologically confirmed TB, unknown HIV status (OR 0.16, 95% CI 0.03–0.82, p=0.03) and smoking (OR 0.39, 95% CI 0.17–0.89, p=0.03) were significantly associated with not seeking care.
**Clinical Implications:** The majority of symptomatic participants delayed care seeking, with many intending to seek care but not acting, and a substantial proportion (26.5%) not perceiving symptoms as serious. Among those with confirmed TB, 14% regarded symptoms as benign. These findings underscore the need for community-based interventions to increase awareness of TB symptom significance and reduce access barriers. Self-screening tools (e.g., TB Healthcheck App) and community health worker programs could facilitate earlier entry into the care cascade. The strong association of unknown HIV status with lower care seeking highlights the importance of integrating TB and HIV services and addressing stigma. The study was conducted pre-COVID-19; post-pandemic patterns may differ. Limitations include potential desirability bias and lack of exact symptom duration data.