Capturing hidden HIV comorbidities at death in Uganda, Kenya, Tanzania and Nigeria (AFRICOS 2013-2023)
1
1Department of Population Studies, College of Business and Management Sciences, P.O. Box 7062, Makerere University, Uganda, Makerere University, Makerere, Uganda
2
Makerere University Walter Reed Program (MUWRP), Makerere University, Uganda
Popul. Med. 2026;8(Supplement Supplement 1):
ABSTRACT
INTRODUCTION:
Comorbidities are among the most inadequately documented in cause-of-death statistics in sub-Saharan Africa, especially among people living with HIV (PLHIV), whose deaths increasingly involve chronic non-communicable diseases.
OBJECTIVE:
To assess concordance between clinical morbidity documentation and physician-certified cause-of-death records.
METHODS:
Using longitudinal data from the African Cohort Study (AFRICOS) across Kenya, Uganda, Tanzania, and Nigeria, we analysed confirmed deaths among HIV-positive adults with complete clinical histories and harmonised ICD-coded mortality data. Multimorbidity was measured as the number of chronic non-HIV conditions before death, and the quality of cause-of-death reporting was evaluated by comparing clinical and certified records, focusing on hypertension.
RESULTS:
Among 164 adult PLHIV who died, the number of clinically documented comorbid conditions present at or before death increased markedly with age. Mean Comorbidity Index for Mortality (CIM) rose from 0.18 among adults aged 20–34 years to approximately 0.72 among those aged 55 years and older, while the proportion with at least one documented comorbidity increased from 17.9% to over 70%. Clinically documented hypertension was present in 30.5% of decedents but appeared on only 2.4% of death certificates, corresponding to a sensitivity of 0.08 and an underreporting rate of 92%, despite perfect specificity. Higher CIM values were observed among individuals with longer HIV duration and higher CD4 counts. Single-cause certification was associated with markedly lower capture of hypertension compared with multi-cause certification.
CONCLUSIONS:
These findings demonstrate that CIM provides a simple, transferable documentation-based metric for detecting missed comorbidity and informing efforts to strengthen HIV-related mortality coding in CRVS systems. CIM involves linking clinically documented morbidity histories with death certification. The approach identifies misclassification pathways, quantifies under-reporting, and highlights demographic and clinical profiles most affected by incomplete certification. CIM can support mortality surveillance in sub-Saharan Africa as HIV cohorts age.
Comorbidities are among the most inadequately documented in cause-of-death statistics in sub-Saharan Africa, especially among people living with HIV (PLHIV), whose deaths increasingly involve chronic non-communicable diseases.
OBJECTIVE:
To assess concordance between clinical morbidity documentation and physician-certified cause-of-death records.
METHODS:
Using longitudinal data from the African Cohort Study (AFRICOS) across Kenya, Uganda, Tanzania, and Nigeria, we analysed confirmed deaths among HIV-positive adults with complete clinical histories and harmonised ICD-coded mortality data. Multimorbidity was measured as the number of chronic non-HIV conditions before death, and the quality of cause-of-death reporting was evaluated by comparing clinical and certified records, focusing on hypertension.
RESULTS:
Among 164 adult PLHIV who died, the number of clinically documented comorbid conditions present at or before death increased markedly with age. Mean Comorbidity Index for Mortality (CIM) rose from 0.18 among adults aged 20–34 years to approximately 0.72 among those aged 55 years and older, while the proportion with at least one documented comorbidity increased from 17.9% to over 70%. Clinically documented hypertension was present in 30.5% of decedents but appeared on only 2.4% of death certificates, corresponding to a sensitivity of 0.08 and an underreporting rate of 92%, despite perfect specificity. Higher CIM values were observed among individuals with longer HIV duration and higher CD4 counts. Single-cause certification was associated with markedly lower capture of hypertension compared with multi-cause certification.
CONCLUSIONS:
These findings demonstrate that CIM provides a simple, transferable documentation-based metric for detecting missed comorbidity and informing efforts to strengthen HIV-related mortality coding in CRVS systems. CIM involves linking clinically documented morbidity histories with death certification. The approach identifies misclassification pathways, quantifies under-reporting, and highlights demographic and clinical profiles most affected by incomplete certification. CIM can support mortality surveillance in sub-Saharan Africa as HIV cohorts age.
| eISSN: | 2654-1459 |
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