Was HIV only SA’s 9th leading cause of death in 2006? Why Mbeki’s claim is misleading

Problems with the way HIV-related deaths are captured on official death certificates vastly underestimate the true death toll of the virus.

The Twitter-sphere and much of social media in South Africa exploded in a ball of AIDS-related fury last Monday as the words “#AIDS”, “#MbekiLetters” and “#ARVs” trended throughout the day and beyond.

Readers responded – at turns furiously and supportively – to former President Thabo Mbeki’s latest weekly letter, this one titled “A brief commentary on the question of HIV and AIDS”.

In it, he makes a number of claims relating to his personal legacy of controversial views on the causes of AIDS, the treatment for HIV and the campaign for state-provided treatment to people carrying the virus.

Using Statistics South Africa data from 2006, Mbeki argued that HIV-related deaths were relatively lower than other causes of disease by saying: “HIV… came 9th in terms of leading causes of death in South Africa in 2006, as indeed it did also in the preceding years…

“Why did it come about that so much noise was made internationally about the 9th leading cause of death in our country, with not even so much as a whimper about the 1st leading cause of death, tuberculosis?”

But is this true? Was HIV only the 9th leading cause of death in SA in 2006 and before?

HIV deaths grossly underestimated

Former president Thabo Mbeki weekly letter of 7 March 2016.
Former president Thabo Mbeki weekly letter of 7 March 2016.

In its annual report on causes of death for 2006, Statistics South Africa (Stats SA) does indicate that human immunodeficiency virus (HIV) disease was the 9th leading cause of natural death, accounting for 2.4% of all deaths.

Stats SA calculates the number of deaths per year using registered death certificates, signed by medical practitioners, as required by the Births and Deaths Registration Act, principal statistician for births and deaths, Vusi Nzimakwe, told Africa Check last year.

However, executive manager of demography at Stats SA, Diego Iturralde, told Africa Check these figures are a gross underestimate of the actual number of deaths due to HIV every year.

“Reported HIV deaths are heavily under-reported because it is not a notifiable disease. Doctors are not duty bound to report an HIV death as such,” he said.

“One usually dies of an infectious disease exacerbated by HIV and in most cases the infectious disease alone is reported either of the doctor’s own free will or due to the family requesting it to be so.”

Therefore, the number of deaths registered as HIV deaths are very low, Iturralde explained.

A senior researcher studying HIV at the University of Cape Town (UCT), Dr Wendy Burgers, told Africa Check that HIV-related deaths are misclassified not only due to under-reporting but also because the data quality of death certificates is poor.

One study found that over 90% of HIV/AIDS deaths were misattributed to other causes in the period 1996 to 2006, although it made up only 2% to 2.5% of all registered deaths in South Africa in those years.

Burgers cited stigma associated with HIV infection, low HIV testing uptake, fears over loss of health insurance benefits and confidentiality concerns as other potential causes for poor data quality.

Clear link between TB & HIV

Another common cause given for misreported HIV deaths is because of “co-infections”, or simultaneous infections by another parasite in addition to HIV.

This results in HIV deaths being attributed to a bacterial infection, most commonly tuberculosis, which spreads rapidly among immune-suppressed individuals as it is airborne.

Burgers said it would thus be “inaccurate to suggest that HIV was a less important problem than TB in 2006”.

Burgers explained that mortality rates from TB are three times higher when a patient is co-infected with HIV. The World Health Organisation estimated that 61% of TB patients in South Africa were infected with HIV in 2014.

“The two diseases are inextricably linked. HIV makes TB more difficult to diagnose, treat and manage,” she said.

The effectiveness of antiretroviral therapy has been cited as further evidence for the link between HIV and TB by Professor Linda-Gail Bekker, another medical researcher at UCT. She pointed to the declining rates of TB as the South African government’s rollout of antiretroviral therapy intensified.

“As CD4 counts (white blood cells responsible for fighting viral infection) increase, TB infection is decreasing… As CD4 counts drop, TB infections appear to increase. The link is clear,” she told Africa Check.

Estimates show 46.3% of deaths in 2006 due to HIV

In order to get a true sense of the number of HIV-related deaths, statisticians use models that take data from antenatal clinics, where mothers are on preventative treatment, as well as the number of people on antiretroviral therapy.

Based on these estimates, HIV deaths are far higher than those shown in the data presented by Mbeki, with AIDS accounting for 46.3% of all deaths in 2006.

When deciding how many deaths are HIV-related in order to formulate health policy, it is preferable to use the model-derived estimates rather than reported deaths, Iturralde of Stats SA said.


Conclusion: Mbeki’s claim is misleading

The measure of deaths attributed to HIV based on death certificates that Stats SA releases are not – by its own admission – an accurate indication of HIV-related deaths in South Africa.

In 2006, the year Mbeki referred to, Stats SA estimated that 46.3% of all deaths were HIV-related. But due to vast underreporting and the poor data quality of death certificates they were not registered as such.

Co-infection with TB and other infectious diseases linked to an HIV+ person’s suppressed immune system also resulted in a large number of TB-related HIV deaths.

HIV was therefore not “the 9th leading cause of death” in 2006, as Mbeki has claimed.

Edited by Kate Wilkinson & Anim van Wyk


Additional reading

Has Jacob Zuma hurt the fight against AIDS more than Thabo Mbeki?

Yes, South Africa has the world’s largest antiretroviral therapy programme

COMMENT: Why scientific AIDS explanations struggle in townships

CORRECTED: In the original report, we have used data from Statistics South Africa's 2014 midyear population estimates, instead of the latest available estimates for 2015. This put HIV-related deaths in 2006 at 46.3% of all deaths, not 49.%. We have updated the report and apologise for the error.

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