Suicide and HIV/AIDS in
Transkei, South Africa
Head, Department of Forensic Medicine
Faculty of Health Sciences, University of Transkei P/bag X1
Umtata 5100, South Africa,
HIV/AIDS has devastating effects in terms of personal and family
suffering. The disease is highly stigmatised and there are many
instances of discrimination against sufferers and their
families. This could lead to suicide, both in infected as well
as affected individuals. The literature lacks clarity and the
subject is traditionally problematic to research as it is
attached with ethical issues. This study has tried to correlate
between the growing number of suicidal deaths and HIV infection
in the region.
To establish the relationship between HIV/AIDS and suicide in
The mortality statistics for 1996-2000 (inclusive) were obtained
from the office of the Medical Superintendent, Umtata General
Hospital. Suicide statistics were collected from the
medico-legal laboratory at UGH.
Over the past five years, there has been an almost two-fold
increase in mortality at Umtata General Hospital. There has been
a one and half times increase in suicidal deaths (e.g. by
hanging), and in deaths from gunshot injuries (which may or may
not be suicidal). Fatal poisoning, possibly suicidal, has
increased five-fold. The natural deaths were doubled at Umtata
General Hospital and at the same time, two-fold increase in
All these circumstantial evidences suggest that suicide rates
have risen in parallel to the rise in mortality due to HIV/AIDS.
HIV/AIDS; Suicide; Hanging; Poisoning; Gunshot
In the last 45 years suicide rates have increased by 60%
worldwide. Suicide is now among the three leading causes of
death among those aged 15-44 years. Suicide attempts are up to
20 times more frequent than completed suicide. Mental disorders
are associated with more than 90% of all cases of suicide.1
Depression affects approximately 25% of those with chronic
illness including HIV/AIDS.2 A survey carried out by National
Injury Mortality Surveillance System (NIMSS) in 1999 indicated
that suicide accounted for almost 8% of all non-natural deaths.
Firearm and hanging each were accounted for one third of all
suicides. Most suicide victims were between 20 and 30 years of
age.3 A study carried out in New York City (1997) found that 9%
of suicide victims were HIV positive.4 The HIV seroconversion
among the victims of suicide was found to be twice that of the
general population.5 The suicide rate in young people increased
dramatically over the last few decades. In 1997, suicide was the
3rd leading cause of death among 15 to 24 years olds.6 In South
Africa, suicidal tendency in teens and young adults is emerging
as an important mental health issue that needs to be addressed.7
Psychiatric disorders represent 10% of all diseases worldwide.
It is thus estimated that about 5 million people in South Africa
suffer from psychiatric disorders. In South Africa about 10,000
people commit suicide yearly.8 There is an increase in suicide
rates, and suicidal behavior among black South Africans as
reported in 1992.9 Depressed patients with a personality
disorder attempted significantly more suicidal attempts.10 In
all depressed patients, a careful history and physical
examination are needed to identify any drugs or concurrent
illnesses (HIV), which might cause or exacerbate the
depression.11 Depressive symptoms are common among patients with
HIV infection.12,13 The lifetime prevalence of depression in
patients infected with HIV has been estimated at 22-45%.
Depression may alter the course of HIV infection by impairing
immune function or influencing behaviour.14Many people with HIV
suffer from depression and suicidal ideation, which responds to
antidepressants, counselling, education, and cognitive
strategies.15 There was a significant rise in all measures of
depression, which reached a plateau within 6 months before AIDS
developed. There is a dramatic, sustained rise in depressive
symptoms as AIDS develops, beginning as early as 18 months
before clinical AIDS is diagnosed.17
Table 1: Click to enlarge The purpose of this circumstantial
report is to suggest for further study so that if this
hypothesis found true, could target for an early intervention in
HIV/AIDS individuals to prevent suicide.
The mortality statistics for 1996-2000 (inclusive) were obtained
from the office of the Medical Superintendent, Umtata General
Hospital. Suicide statistics were collected from the
medico-legal laboratory at UGH. Deaths due to hanging,
poisoning, and gunshot injuries were manually extracted from
medico-legal register. Student enrolment records were obtained
from the Academic Support section of the University of Transkei.
The data was analysed qualitatively and quantitatively, and is
presented in tabular and graphic forms.
The setting of the present study was Umtata General Hospital
(UGH), a tertiary hospital attached to the University of
Transkei medical school. UGH is the only centre in the region
for tertiary medical training, and serves a population of nearly
five million. Permission to extract, analyse and report the data
was duly obtained from the Superintendent, Umtata General
Figure 1: Click to enlarge Table 1 (above) shows that the
percentage of UGH mortality from natural causes has increased
from 15% in 1996 to 25% in 2000 (Fig 1). Similarly, deaths from
hanging have increased from 16 to 24% (Fig. 2 - below left).
Most of these (suicide) deaths were males in the 20-30 years age
group. Deaths due to poisoning have increased from 4% to 28%
over the past 8 years (Table I & Fig. 3), with males
predominating over females (66% cf. 34%). Gunshot related deaths
have also increased from 14% in 1996 to 25% in 2000 (Fig.4). All
these increases correspond to the increase in the estimated
prevalence of HIV infection in South Africa from 14% in 1996 to
25% in 2000 (Table 1 - See above). Over the same period student
enrolment at the University of Transkei has decreased from 7 038
in 1996 to 3 783 in 2000, a drop of nearly 50% as shown in Fig.
South Africa is experiencing an HIV/AIDS epidemic of shattering
dimensions.17To-date, up to 200 000 have died of AIDS-related
illness in South Africa, and more than four million are infected
with HIV or have AIDS. The inevitable disruption of HIV/AIDS on
all aspects of society will be so profound that it is virtually
impossible to contemplate its dimensions.18 In 1991, the
national survey of women attending antenatal clinics found that
only 0.8 % was infected in South Africa. In 1994, when the ANC
government took power, the figure was still comparatively low at
7.6 %. In 2001 it was 25%.19
South Africa has one of the worst epidemic of HIV require a
multi-dimensional approach to curb the tide. There is a
prediction that approximately 500 000 AIDS-related deaths in the
year 2010.20 South Africa's largest city was looking at burying
it's dead in disused mines as death rate here increased due to
factors including AIDS. There is currently burying 20 000 people
a year, with the figure expected to rise to 70 000 in 2010.21
The equal number of HIV/AIDS infected, who remains uncounted
could be died as a result of non-natural deaths like homicide,
suicide and accidents. It is difficult to know that how many
deaths could be associated with non-natural. The risk of suicide
among people with psychiatric disorders is well
documented.22HIV/AIDS often generates related psychiatric and
neuropsychiatric sequelae, including depression and anxiety; the
cumulative effects of extreme and chronic stress; and CNS
manifestations from changes in affect, behaviour and
cognition.23 HIV/AIDS changes human behaviour and could lead to
unnatural deaths like suicide.24 Marzuk et al (1988) reported
that such CNS problems increased suicide rates.25 Feelings of
helplessness and hopelessness are two signs of depression that
occur in people with HIV/AIDS.26
Figure 2: Click to enlarge Human immunodeficiency virus (HIV)
infection of the nervous system is unique when compared with
other viral encephalitides. Neuronal cell loss occurs in the
absence of neuronal infection result in neuronal dysfunction and
cell loss.27 Compared to a serostatus conversion, AIDS is more
closely linked to psychiatric illnesses that are themselves risk
factors for suicide, such as depression and psychosis.28 The
brain, including its serotonergic pathways that have been linked
to a propensity for impulsive suicidal behaviours, is likely to
be much more involved in AIDS through HIV encephalitis and
There is still much to be learned about suicide in the context
of HIV illness. True, low-grade depressive mental symptoms are
frequent among HIV positive individuals.30 Mental disorders are
associated with more than 90% of all cases of suicide.1
Depression affects approximately 25% of those with chronic
illness.2 Depressive symptoms in the HIV positive individuals
are significantly higher. Although depressive symptoms may not
be strong enough to warrant a psychiatric diagnosis, but a
careful evaluation of risks were required.31 Depressive symptoms
and suicidal ideation are common amongst HIV positive patients,
occurring at comparable or greater rates than those found in a
variety of other medically ill populations.32 The prevalence of
HIV/AIDS and suicide is difficult to determine specifically.
There has been increasing death in parallel with HIV/AIDS (Table
1 - See above). The percentage of UGH mortality from natural
causes has increased from 15% in 1996 to 25% in 2000 (Fig. 1).
Majority of these suicides were asymptomatic on autopsy.
Figure 3: Click to enlarge There has been an increase in
mortality at Umtata General Hospital since the HIV/AIDS epidemic
started its steep rise (1996-2000) as shown in Fig. 1.
Statistics South Africa is conducting a study into "secondary
causes of death" in an attempt to assess the true impact of
HIV/AIDS. These secondary causes as suggested an alternative
trauma surveillance approach would provide empirical information
about the behaviour of some of the HIV positive population, 33
who prefer to die in motor vehicle accident than to
long-standing-stigmatise-sickness. That could be reason of
uncontrollable state of South African road carnage, and drying
downs the motor vehicle accident funds. Preliminary indications
are that there has been a marked rise in the number of natural
deaths (Table 1 - See above), but non-natural causes -which
includes trauma has not been accounted for. It is expected
co-relation between HIV and mortality due to natural causes at
Umtata General Hospital (Fig. 1).
Among possible outcomes of HIV/AIDS infection are increases in
suicide. Hanging as shown in Table I, is a definitive method of
committing suicide. The increase in hanging deaths from 16% in
1996 to 24% in 2000. HIV/AIDS could be one of the reasons of
this high incidence (Fig. 2), as there were several studies
available indicating that there is increased risk of suicide in
people with HIV/AIDS. Mazruk et al (1988) found that 36%
increase25 and Kazer and colleagues a 21% increase among people
with HIV/AIDS.34 Cote et al (1992) found a 7.4-fold increase
among people with HIV/AIDS as compared to demographically
similar men in the general population.22 Previously, suicide
among South African Blacks was relatively uncommon, but the
picture has changed in recent years.6 Deaths by self-hanging and
by gunshot injuries (which may or may not be suicidal) have each
increased by one and half times as shown in Fig. 2 & 4, while
fatal poisonings have shot up by an alarming five-fold increase
(Fig. 3). In 1993, poisoning was observed 1% female suicide,
have climbed up to 9% in 2001. The poisoning in males also has
increased from 3% to 19% in the similar period. The HIV
seropositivity was 0.8 % in National Survey of women attending
antenatal clinics in 1993. This has increased to 25% in 2001
(Table II - Far below). Young African women are the poorest,
most economically marginalized and least educated sector of the
South African population thus placing them at the bottom the
health pile in this country, and rendering vulnerable to
This nine-fold increase in female fatal poisoning, and
twenty-two times increase in the spread of HIV/AIDS. This could
be possible as in recent years; several right-to-die groups have
advocated that individuals with AIDS use poisoning as a means of
self-inflicted death. However, more than two-thirds of
HIV-positive suicide victims continue to use more violent means
such as hanging, firearms, and other violent methods.4 In a
recent autopsy-based study (under-publication) by the author
found that 82% of the victims died as a result of trauma in this
region. Homicide accounted for 50%. Among the homicides gunshot
injuries were responsible for 24%, stab wounds 17%, and blunt
trauma 9%. There is drastic increase in deaths related to
gunshot.36 There is recent increase in death toll on South
Africa's roads due to motor vehicle accidents has brought the
Government's Arrive Alive campaign in disrepute. The death toll
was at least one quarter higher than the December 2001.37 This
rapid change in empirical death rates could be indicative of the
profound impact of HIV/AIDS, and the startling trends ought to
galvanise efforts to confront the devastation due to the
Figure 4: Click to enlarge Deaths due to firearm injuries have
increased one and half time in last 5 years (1996-2000) as shown
in Table I. In 1996 gunshot related deaths were14%, which has
gone up24% in 2000. It could be a co-incidence that the figures
resemble with HIV/AIDS epidemic (Fig. 4). It is difficult to
estimate the exact number of firearm suicide, but we are
reasonably confident that suicide has been increasing among HIV
positive individuals, and most of these (suicide) deaths were
males in the 20-30 years age group
In the early stage of HIV infection, HIV patients without AIDS
may be prone to depressive symptoms.38In a study carried out
(1995) in UGH mortuary found that 15.5% of the trauma victims
were HIV-seropositive. This was higher than general
population.23 Since the HIV screening in this study was not done
at autopsy, some individuals who committed suicide may not have
even been aware that they were seropositive. In addition, many
individuals who were HIV seropositive undoubtedly had other
risks for suicide such as substance abuse and alcoholism. HIV
serostatus, in itself, could associate, at most, with a modest
elevation in suicide risk.4
There are several risks associated with HIV/AIDS, but the most
important immediate risk, soon after an individual aware of
his/her HIV status, is committing suicide. This is as a result
of sudden unexpected, unprepared disclosure of HIV test result,
lead to mental breakdown i.e. severe acute depression. HIV/AIDS
is a major concern to the health care community and the world
around them. Preventive efforts and education have been the
focus of the fight against AIDS. Regular counselling by
physicians are expected, so that risk of suicide could be
minimized. It is essential to screen, identify, and treat
depression among patients entering care for HIV disease.
Encouragement in joining support groups is a reasonable
component of a addressing this common condition.39
Figure 5: Click to enlarge Critical psychosocial stressors of
HIV/AIDS including social stigma, discrimination, isolation,
lack of support from family and friends, and social devaluation,
enhance suicide risk. Substantial number of primary care
physicians is not trained enough in the area of psychosocial
aspects of health care, and therefore missing important
opportunities to prevent HIV transmission not adequately
assessing patients' risks and not providing necessary risk
reduction counselling during their physician-patient
encounters.40 In a study carried out in Uganda (1997) reported
that 29% of health workers never discussed HIV prevention with
patients, 26% had never referred patients for HIV counselling
and 31% had never advised patients suspected of HIV infection to
be tested. Hospital based health workers are missing important
opportunities for AIDS prevention education with their
More than one third of physicians reported feeling uncomfortable
talking about patients' sexual preferences and practices. To
identify patients at risk and to help prevent AIDS, methods must
be found to make physicians more comfortable discussing sexual
issues with their patients.42 Primary care physicians play an
increasingly important role in the care of persons with HIV/AIDS
due to the rising number and changing geographic distribution of
persons infected with HIV/AIDS.43 Family physicians are caring
for an increasing number of those with human deficiency virus
(HIV) infection, those at risk, and those concerned about HIV
disease. They need to take a more active role in educating and
counselling patients about HIV disease.44 There are 50% patients
visits to General Practitioners are usually due to some sort of
mental problem. The WHO predicts that by the year 2020
depression as a single disease, causing disability and death in
the world. The World Bank has also predicted, depression to be
number one disease by 2020.8
Table II: Click to enlarge Currently, HIV/AIDS is the commonest
cause of acute depression. Primary care physicians with little
experience treating HIV infection are providing care for large
number of HIV-infected persons.45 Individuals with HIV /AIDS are
subject to disease specific stressors and to a greater number of
general suicide risk factors.46 A quality counselling to the
HIV-positive patients could avoid acute depression, therefore,
an attempt of committing suicide. There is a need for increased
training and education of primary care physicians about AIDS
related suicide prevention.47 HIV infection is associated with
an increased risk of suicidal behaviour.48 Suicidal acts seem to
be more frequent in AIDS patients than in the general
population.49 Health care professional must be aware of the
potential for suicidal thoughts and suicidal behaviours in
HIV-positive patients to enable them to provide the necessary
support.50 Ironically, it is difficult to provide support as
many areas in the former Transkei can best be described as
deep-rural with poor roads, poor water supply, limited
electricity, few telephone connections and very limited access
to transport and health services.
This study suggests that suicide rates have risen in parallel to
the rise in mortality due to HIV/AIDS over the same period.
Accurate estimation of suicide in relation to HIV/AIDS is
necessary in measuring the costs of the epidemic and for
effective strategic planning. A more careful follow up study is
needed to understand the non-natural deaths in association with
Evidence underlying conclusions made in the present study may be
circumstantial, but its credibility is enhanced by the fact that
the observed mortality trends are similar to data for the whole
country recently reported by the Medical Research Council.17
My special thanks to the HIV/AIDS victims, who have died in the
discriminatory, and stigmatised environment of the community. I
would like to thank 'South African Anxiety and Depression
Support group' and to Professor Antoon Leenaar for their
encouragement to write this work.
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*Corresponding author and requests for clarifications and
Dr. BL Meel ,
Head, Department of Forensic Medicine, Faculty of Health
University of Transkei P/bag X1 UNITRA,
Umtata 5100, South Africa,
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