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J Int AIDS Soc. 2015 Dec 16;18:20628. doi: 10.7448/IAS.18.1.20628. eCollection 2015.

A comparison of death recording by health centres and civil registration in South Africans receiving antiretroviral treatment.

Author information

Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa;
Centre for Actuarial Research, University of Cape Town, Cape Town, South Africa.
Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa.
Aurum Institute, Johannesburg, South Africa.
Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA.
Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa.
Center for Global Health and Development, Boston University, Boston, MA, USA.
Health Economics and Epidemiology Research Office, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa.
Division of Infectious Diseases, Department of Medicine, Tygerberg Academic Hospital, University of Stellenbosch, Cape Town, South Africa.
Wellcome Trust Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa.
School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.



There is uncertainty regarding the completeness of death recording by civil registration and by health centres in South Africa. This paper aims to compare death recording by the two systems, in cohorts of South African patients receiving antiretroviral treatment (ART).


Completeness of death recording was estimated using a capture-recapture approach. Six ART programmes linked their patient record systems to the vital registration system using civil identity document (ID) numbers and provided data comparing the outcomes recorded in patient files and in the vital registration. Patients were excluded if they had missing/invalid IDs or had transferred to other ART programmes.


After exclusions, 91,548 patient records were included. Of deaths recorded in patients files after 2003, 94.0% (95% CI: 93.3-94.6%) were recorded by civil registration, with completeness being significantly higher in urban areas, older adults and females. Of deaths recorded by civil registration after 2003, only 35.0% (95% CI: 34.2-35.8%) were recorded in patient files, with this proportion dropping from 60% in 2004-2005 to 30% in 2010 and subsequent years. Recording of deaths in patient files was significantly higher in children and in locations within 50 km of the health centre. When the information from the two systems was combined, an estimated 96.2% of all deaths were recorded (93.5% in children and 96.2% in adults).


South Africa's civil registration system has achieved a high level of completeness in the recording of mortality. However, the fraction of deaths recorded by health centres is low and information from patient records is insufficient by itself to evaluate levels and predictors of ART patient mortality. Previously documented improvements in ART mortality over time may be biased if based only on data from patient records.


HIV; South Africa; antiretroviral therapy; vital statistics registration

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