Research Article: HIV-attributable causes of death in the medical ward at the Chris Hani Baragwanath Hospital, South Africa

Date Published: May 6, 2019

Publisher: Public Library of Science

Author(s): Andrew Black, Freddy Sitas, Trust Chibrawara, Zoe Gill, Mmamapudi Kubanje, Brian Williams, Richard John Lessells.


Data on the association between HIV infection and deaths from underlying medical conditions are needed to understand and assess the impact of HIV on mortality. We present data on mortality in the Chris Hani Baragwanath Hospital (CHBH) South Africa and analyse the relationship between each cause of death and HIV.

From 2006 to 2009 data were collected on 15,725 deaths including age, sex, day of admittance and of death, HIV status, ART initiation and CD4+ cell counts. Causes of death associated with HIV were cases, causes of death not associated with HIV were controls. We calculate the odds-ratios (ORs) for being HIV-positive and for each AIDS related condition the disease-attributable fraction (DAF) and the population-attributable fraction (PAF) due to HIV for cases relative to controls.

Among those that died, the prevalence of HIV was 61% and of acquired immune deficiency syndrome (AIDS) related conditions was 69%. The HIV-attributable fraction was 36% in the whole sample and 60% in those that were HIV-positive. Cryptococcosis, Kaposi’s sarcoma and Pneumocystis jirovecii, TB, gastroenteritis and anaemia were highly predictive of HIV with odds ratios for being HIV-positive ranging from 8 to 124, while genito-urinary conditions, meningitis, other respiratory conditions and sepsis, lymphoma and conditions of skin and bone were significantly associated with HIV with odds ratios for being HIV-positive ranging from 3 to 8. Most of the deaths attributable to HIV were among those dying of TB or of other respiratory conditions.

The high prevalence of HIV among those that died, peaking at 70% in those aged 30 years but still 7% in those aged 80 years, demonstrates the impact of the HIV epidemic on adult mortality and on hospital services and the extent to which early anti-retroviral treatment would have reduced the burden of both. These data make it possible to better assess mortality and morbidity due to HIV in this still high prevalence setting and, in particular, to identify those causes of death that are most strongly associated with HIV.

Partial Text

A study using data collected between 2002 and 2006, immediately before these data were collected, suggested that 1.8% of deaths in a public hospital in the Eastern Cape, South Africa were due to HIV [1] but the HIV status of those that died was not recorded. A more recent study [2] suggested that in 2006 283 thousand deaths or 42% of all deaths in South Africa were attributable to HIV and the authors compared this to other estimates for 2006 of 225 thousand using the Actuarial Society of South Africa Model [3], 250 thousand using the Thembisa model [2], 270 thousand in the Global Burden of Disease study [4,5], 350 thousand using the UNAIDS Spectrum model and 354 thousand based on changes in the age-distribution of deaths over time [6]. The considerable variation in these estimates was attributed to misclassification of AIDS deaths associated with different underlying conditions [2].

Of the 15,981 adults that died 15,722 were included in the analysis, 7630 men and 8092 women, while 527 cases were excluded as the cause of death occurred in less than 20 patients, and an additional 529 cases were excluded as the cause of death was not recorded.

We estimate the excess mortality from conditions known, or suspected from the literature, to be HIV/AIDS related. Our imputation of HIV status goes some way to avoiding classifying deaths by their exposure status bearing in mind that in some cases HIV/AIDS is given as the cause of death. The data in Table 1 and Fig 3 show that almost all deaths from Kaposi sarcoma, cryptococcosis or Pneumocystis jirovecii infections could be attributed to HIV. Kaposi sarcoma was rare before the HIV epidemic struck [14] and odds ratios for being HIV-positive compared to controls was 56 (23–176) with a DAF of 94% (92%–95%) which concurs with previous work in Soweto, Johannesburg in which the corresponding OR for being HIV-positive was 47 (32–70) [15] and 89% of patients with Kaposi sarcoma were HIV positive. Likewise cryptococcosis or Pneumocystis jirovecii infections were extremely rare pre-HIV, almost always occurring in persons who were immune compromised [16]. ORs for being HIV-positive for lymphomas in this analysis of 2.9 (1.7–5.0) resemble those found in a previous case control study where the OR for being HIV-positive was 5.9 (4.3–8.1) for non-Hodgkin and 1.6 (1.0–2.7) for Hodgkin lymphoma [15].