Ending HIV deaths in South Africa: progress made but still a long way to go

Mortality trends and differentials in South Africa from 1997 to 2012: second National Burden of Disease Study.

Pillay-van Wyk V, Msemburi W, Laubscher R, Dorrington RE, Groenewald P, Glass T, Nojilana B, Joubert JD, Matzopoulos R, Prinsloo M, Nannan N, Gwebushe N, Vos T, Somdyala N, Sithole N, Neethling I, Nicol E, Rossouw A, Bradshaw D. Lancet Glob Health. 2016 Sep;4(9):e642-53. doi: 10.1016/S2214-109X(16)30113-9.

Background: The poor health of South Africans is known to be associated with a quadruple disease burden. In the second National Burden of Disease (NBD) study, we aimed to analyse cause of death data for 1997-2012 and develop national, population group, and provincial estimates of the levels and causes of mortality.

Method: We used underlying cause of death data from death notifications for 1997-2012 obtained from Statistics South Africa. These data were adjusted for completeness using indirect demographic techniques for adults and comparison with survey and census estimates for child mortality. A regression approach was used to estimate misclassified HIV/AIDS deaths and so-called garbage codes were proportionally redistributed by age, sex, and population group population group (black African, Indian or Asian descent, white [European descent], and coloured [of mixed ancestry according to the preceding categories]). Injury deaths were estimated from additional data sources. Age-standardised death rates were calculated with mid-year population estimates and the WHO age standard. Institute of Health Metrics and Evaluation Global Burden of Disease (IHME GBD) estimates for South Africa were obtained from the IHME GHDx website for comparison.

Findings: All-cause age-standardised death rates increased rapidly since 1997, peaked in 2006 and then declined, driven by changes in HIV/AIDS. Mortality from tuberculosis, non-communicable diseases, and injuries decreased slightly. In 2012, HIV/AIDS caused the most deaths (29.1%) followed by cerebrovascular disease (7.5%) and lower respiratory infections (4.9%). All-cause age-standardised death rates were 1.7 times higher in the province with the highest death rate compared to the province with the lowest death rate, 2.2 times higher in black Africans compared to whites, and 1.4 times higher in males compared with females. Comparison with the IHME GBD estimates for South Africa revealed substantial differences for estimated deaths from all causes, particularly HIV/AIDS and interpersonal violence.

Interpretation: This study related the reversal of HIV/AIDS, non-communicable disease, and injury mortality trends in South Africa during the study period. Mortality differentials show the importance of social determinants, raise concerns about the quality of health services, and provide relevant information to policy makers for addressing inequalities. Differences between GBD estimates for South Africa and this study emphasise the need for more careful calibration of global models with local data.

Abstract [1]   Full-text [free] access [2] 

Editor’s notes: In South Africa in 2012, almost 500 people died every day from HIV or TB. One in every three deaths was associated with HIV or TB. Although these figures represent a substantial decline from the peak of the epidemic impact in 2006, they highlight the enormous challenge still facing this country.

South Africa is one of the few countries in Africa to have a robust civil registration system for deaths. However, there continue to be problems with misclassification of HIV-associated deaths. This analysis relied on somewhat complicated analytical methods to adjust mortality estimates. Only around half of those deaths ultimately defined as HIV associated had been originally coded as such in the registration system. The methods for adjustment differed from those used in the Global Burden of Disease (GBD) study. This explains the quite marked discrepancy in number of deaths attributed to HIV - this study estimated 40% fewer HIV-associated deaths than the GBD study.

This highlights that there is still quite a lot of uncertainty around cause-specific mortality estimates. So, although these data are useful to guide national and provincial priority setting, more fine-grain analysis is required to properly inform public health policies. There is a particular need to unpick the contribution of TB. In this respect, the recent announcement by the South African Department of Science of Technology to establish a network of health and demographic surveillance sites as a key component of the national research infrastructure is very welcome. With established verbal autopsy methods and innovations such as routine linkage to health service records, this will provide a framework to allow a deeper understanding of mortality.

Africa [7]
South Africa [8]
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