New study shows AIDS deaths under-recorded in South Africa

Former South African President Thabo Mbeki disputed that there was a large AIDS epidemic in South Africa. (1) This was a cornerstone of his promotion of denialist policies. It was echoed by journalist Rian Malan in articles he wrote in Rolling Stone, the Spectator and Noseweek. (2) Mbeki expressed his scepticism when a state institution, the Medical Research Council, released a report titled Adult Mortality in South Africa. It presented unequivocal evidence that HIV was a growing and major cause of death in the country. (3) Mbeki's health minister, Manto Tshabalala-Msimang, tried to suppress the publication of this report. (4)

Over the last decade, the evidence of the country's large AIDS epidemic has accumulated. It is perhaps most succinctly explained with this graph, which demonstrates the unusual and disturbing changing age-pattern of death among adult women in South Africa from 1997 to 2004 , that can only be explained by the AIDS epidemic:

Source: http://www.tac.org.za/community/node/2182

The graph shows how in 2004 the vast majority of female adult deaths occur in young adults as opposed to older ones (compared with Brazil in 2004 and South Africa in 1997). The same pattern occurs in males, albeit that it is not quite as stark.

One of the arguments raised by Malan is that HIV was ranked quite low as a cause of recorded deaths in Statistics South Africa's mortality data and therefore was not a major cause of death. Malan is wrong: many doctors do not write HIV or AIDS as the cause of death on death notification forms (the source of Stats SA's mortality data). There are probably two reasons for this: (1) the disease is highly stigmatised and doctors do not want to put surviving family members at risk of discrimination, despite the fact that death certificate data is supposed to be confidential, and (2) patients with AIDS often die without finding out their status.

A new study has been published in AIDS that confirms this, i.e. that doctors often do not write HIV, AIDS or even a euphemism for these terms (such as retroviral disease or immunocompromised) on death notification forms of people who have died of AIDS.

Patricia Yudkin and her colleagues examined the medical records of all people 28 days or older who died in two suburbs in Cape Town from 1 June 2003 to 31 May 2004. 683 death notification forms were included in their final analysis. (5) Two doctors independently analysed the medical records to determine if AIDS was the cause of death. In the case of a conflicting diagnosis, a third doctor decided. They identified 129 deaths caused by HIV according to medical records. Yet only 35 (27.1%) were ascribed to AIDS on the death notification form. When the various euphemisms for AIDS were accounted for (known as interpretive coding) only 83 (64.3%) indicated AIDS.

With one exception (a 12% sample of all the mortality data published seven years ago), Stats SA reports since 2001 have classified a death as HIV/AIDS only if explicitly coded as such on the death notification form. They do not use interpretive coding because it would be extremely time-consuming to classify all the country's deaths this way.

Only one death was noted as AIDS on a death notification form but not classified as such by the study doctors, though even in this case the death was suggestive of HIV. The method of classification used by Yudkin et al. would still not have identified deaths of people who died of AIDS before presenting to a health facility or private doctor for diagnosis.

This study provides further evidence against the dogma that there is not a large HIV epidemic in South Africa.

References

1. Cherry M. Mbeki disputes AIDS statistics [Internet]. Nature Medicine. 2001 Nov ;7(11):1170.[cited 2009 Jul 4 ] Available from: http://www.popline.org/docs/1558/175308.html

2. Geffen N. Rian Malan Spreads Confusion about AIDS Statistics [Internet]. 2004 Jan 20;[cited 2009 Jul 5 ] Available from: http://www.tac.org.za/newsletter/2004/ns20_01_2004.htm

3. Dorrington R, Bourne D, Bradshaw D, Laubscher R, Timæus IM. The Impact of HIV/AIDS on Adult Mortality in South Africa [Internet]. 2001 Sep ;[cited 2009 Jul 5 ] Available from: http://www.mrc.ac.za/bod/complete.pdf

4. Cape Argus. Minister demanded 'corrective action' at MRC [Internet]. 2002 Apr 17;[cited 2008 Dec 29 ] Available from: http://www.capeargus.co.za/index.php?fSectionId=3571&fArticleId=ct200204...

5. Yudkin P, Burger E, Bradshaw D, Groenewald P, Ward A, Volmink J. Deaths caused by HIV disease under-reported in South Africa [Internet]. AIDS. 2009 Jun 10;[cited 2009 Jul 5 ] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19521232