Doctors are under-reporting HIV as the cause of death on official forms and inadvertently undermining the government’s ability to monitor the effect of its programmes to counter the epidemic, a new study by the SA Medical Research Council (MRC) shows.
HIV was responsible for almost a quarter (23.3%) of all deaths in an eight-month period to April 2018, making it the leading cause of death, the MRC found. This is in sharp contrast to official statistics from Stats SA, which showed only 4.9% of registered deaths were due to HIV in this period, and that it was the fifth leading cause of death.
“If mortality data is reflecting the ranking of diseases incorrectly, [the government] will make decisions to prioritise diseases and allocate resources incorrectly,” said study co-author Pamela Groenewald, a senior scientist at the MRC’s burden of disease unit.
Stats SA’s mortality reports are based on the information recorded by doctors on death notification forms submitted to the department of home affairs, which then sends the records to the statistics agency.
Confidentiality
It is not clear why doctors are under-reporting HIV as the cause of death, and more research is needed to understand why they are not providing accurate information, said Groenewald. Doctors are legally required to record the cause of death as accurately as they can but feedback suggests they are concerned about breaching confidentiality if they disclose that a person had HIV, she said.
The study recommended the government improve case-finding, follow-up, prevention and treatment of HIV and TB to reduce mortality rates.
"[It] underlines the importance of the government’s rapid response to counter the recent abrupt withdrawal of Pepfar funding,” said study co author Debbie Bradshaw, chief specialist scientist at the MRC’s burden of disease unit.
US President Donald Trump last week terminated all US Agency for International Development (USAID) grants to organisations working with the US President’s Plan for Emergency Aids Relief (Pepfar). The cut forced organisations funded by USAID to close their doors, increasing pressure on the government’s HIV/Aids services.
The MRC study compared the information on individuals’ death notification forms to data gathered from medical records, forensic reports and verbal autopsy interviews for a sample of deaths that occurred between September 2017 and April 2018. It assessed more than 15,000 deaths from 27 subdistricts.
Face-to-face verbal autopsy interviews were conducted with next of kin, who disclosed that one in 10 (10.2%) of the people who died from HIV and 4% of those who died from tuberculosis had stopped taking their medication.
The study found extensive inaccuracies in the official recorded cases of death extending beyond HIV, with misclassification of injury-related deaths, particularly suicides. The researchers’ analysis of the underlying cause of death agreed with official records in only 36.9% of the cases.
The MRC study found stroke was the second leading cause of death, responsible for 7.7% of deaths, followed by TB (6.3%), hypertensive heart disease (6.3%) and diabetes (4.6%). Next on the list were cancer (4.5%), homicide (3.8%), road traffic injuries (3.6%), lower respiratory tract infections (3.6%) and ischaemic heart disease (3.5%).
Linked records from Stats SA showed the top five leading cause of death as TB (6.3%), followed by diabetes (5.8%), stroke (5.1%), lower respiratory infections (5.0%) and HIV (4.8%).
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