R e s e a r c h r e p o r t What is already known on this topic Verbal autopsy is currently the best option for obtaining cause of death information in populations without comprehensive civil registration systems. Verbal autopsy is generally used to assign deaths to broad categories and estimate cause-speciﬁc mortality. What this study adds We demonstrate that verbal autopsy can consistently measure AIDS mortality with a simple set of nine criteria. Surveillance should focus on deaths that occur in the 15e44-year age group for which the method performs reliably. Adding just a handful of questions related to opportunistic infections would enable other widely used verbal autopsy tools to apply this validated method to asses AIDS mortality in areas where HIV testing and hospital records are unavailable or incomplete. the prediction will not be known. Therefore, further validation of the algorithm is recommended. The INDEPTH verbal autopsy is a widely used tool that used a shorter symptom list than ours and does not collect infor- mation to identify herpes zoster, oral candidiasis, abscesses/sores or vaginal tumours.21 These symptoms were commonly reported in our studies and (excluding vaginal tumours) were prevalent in AIDS deaths with a sensitivity of approximately 20% for zoster and abscesses/sores and 40% for oral candidiasis. We found that the INDEPTH shortlist would perform less well and have higher levels of misclassiﬁcation of AIDS deaths.23 The newly released WHO instrument includes signs and symptoms associated with herpes zoster, abscesses/sores and oral candidiasis.4 In general, verbal autopsy have only proved accurate enough to assign cause of death in very broad categories in adults. However, statistical or algorithmic approaches, such as the method used here, have been shown to perform adequately for determining prevalence of a speciﬁc cause, such as HIV. Unfortunately, causes of death other than HIV could not be validated, as neither physician assessment nor diagnostics data were routinely available. Our analyses show that in areas of generalised epidemics, verbal autopsy can consistently measure AIDS mortality. Both studies had HIV prevalence levels exceeding 5%, which is commonly found in eastern and southern Africa. In settings where prevalence is less than 5%, getting AIDS mortality from verbal autopsy may be difﬁcult and will require further valida- tion studies. Even in higher prevalence settings, analyses should be restricted to age groups in which competing causes of mortality, especially other infectious causes, are relatively low. Especially for the Tanzanian population, the verbal autopsy method was much less accurate for deaths over the age of 45 years. Based on our analyses, we recommend surveillance of deaths in populations with severe HIV epidemics be undertaken in the 15e44-year age group. Addition of a handful of questions related to opportunistic infections would enable other widely used verbal autopsy tools (WHO and INDEPTH) to apply this validated method in areas where HIV testing and hospital records are unavailable or incomplete. Contributors BL drafted the manuscript and led data analysis; AC, statistical analysis; JS, statistical analysis; GC, verbal autopsy data collection; MU, study co-ordination; YK, verbal autopsy data collection; RI, data management; CI, physician review of verbal autopsy; JR, physician review of verbal autopsy; MN, demographic surveillance supervision; SG, study design and writing of manuscript; BZ, analysis and writing of manuscript; TB, study design. Funding The comparative study presented here was funded by WHO Health Metrics Network. The Manicaland Study is principally funded by the Wellcome Trust, and the Kisesa study is currently funded by the Global Fund for AIDS, TB and Malaria and by the Wellcome Trust; prior to 2004, it was mainly funded by the Netherlands government through the TANESA programme. Other Funders: Wellcome Trust. Competing interests None. Ethics approval Ethical approval for the DSS and all related procedures (such as the verbal autopsy interviews) was granted by the Tanzanian Medical Research Co-ordinating Committee for the Kisesa study and by the Zimbabwe Medical Research Council for the Manicaland Study. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed. REFERENCES 1. Quigley MA, Chandramohan D, Rodrigues LC. Diagnostic accuracy of physician review, expert algorithms and data-derived algorithms in adult verbal autopsies. Int J Epidemiol 1999;28:1081e7. 2. Soleman N, Chandramohan D, Shibuya K. Verbal autopsy: current pratices and challenges. Bull World Health Organ 2006;84:239e45. 3. Setel PW, Sankoh O, Rao C, et al. Sample registration of vital events with verbal autopsy: a renewed commitment to measuring and monitoring vital statistics. Bull World Health Organ 2005;83:611e17. 4. Baiden F, Bawah A, Biai S, et al. Setting international standards for verbal autopsy. Bull World Health Organ 2007;85:570e1. 5. Porter K, Zaba B. The empirical evidence for the impact of HIV on adult mortality in the developing world: data from serological studies. AIDS 2004;18(Suppl 2):S9eS17. 6. Kamali A, Wagner HU, Nakiyingi J, et al. Verbal autopsy as a tool for diagnosing HIV-related adult deaths in rural Uganda. Int J Epidemiol 1996;25:679e84. 7. Diaz T, Loth G, Whitworth J, et al. Surveillance methods to monitor the impact of HIV therapy programmes in resource-constrained countries. AIDS 2005;19(Suppl 2):31e7. 8. Mathers CD, Fat DM, Inoue M, et al. Counting the dead and what they died from: an assessment of the global status of cause of death data. Bull World Health Organ 2005;83:171e7. 9. Gregson S, Garnett GP, Nyamukapa CA, et al. HIV decline associated with behavior change in eastern Zimbabwe. Science 2006;311:664e6. 10. Mwaluko G, Urassa M, Isingo R, et al. Trends in HIV and sexual behaviour in a longitudinal study in a rural population in Tanzania, 1994-2000. AIDS 2003;17:2645e51. 11. Lopman BA, Barnabas R, Hallett TB, et al. Assessing adult mortality in HIV-1-afﬂicted Zimbabwe (1998e2003). Bull World Health Organ 2006;84:189e97. 12. Lopman BA, Barnabas RV, Boerma JT, et al. Creating and validating an algorithm to measure AIDS mortality in the adult population using verbal autopsy. PLoS Med 2006;3:e312. 13. Ray CS, Mason PR, Smith H, et al. An evaluation of dipstick-dot immunoassay in the detection of antibodies to HIV-1 and 2 in Zimbabwe. Trop Med Int Health 1997;2:83e8. 14. Urassa M, Boerma JT, Isingo R, et al. The impact of HIV/AIDS on mortality and household mobility in rural Tanzania. AIDS 2001;15:2017e23. 15. Ngalula J, Urassa M, Mwaluko G, et al. Health services utilization and household expenditure during terminal illness due to HIV/AIDS in rural Tanzania. Trop Med Int Health 2002;7:873e7. 16. Boerma JT, Urassa M, Nnko S, et al. Sociodemographic context of the AIDS epidemic in a rural area in Tanzania with a focus on people’s mobility and marriage. Sex Transm Infect 2002;78(Suppl 1):i97e105. 17. Boerma JT, Urassa M, Senkoro K, et al. Spread of HIV infection in a rural area of Tanzania. Aids 1999;13:1233e40. 18. INDEPTH Standardised VA questionnaire. Accessed May 2009. http://www. indepth-network.org/ 19. Tollman SM, Kahn K, Garenne M, et al. Reversal in mortality trends: evidence from the Agincourt ﬁeld site, South Africa, 1992e1995. AIDS 1999;13:1091e7. 20. Hosegood V, Vanneste AM, Timaeus IM. Levels and causes of adult mortality in rural South Africa: the impact of AIDS. AIDS 2004;18:663e71. 21. Groenewald P, Nannan N, Bourne D, et al. Identifying deaths from AIDS in South Africa. AIDS 2005;19:193e201. 22. Groenewald P, Bradshaw D, Dorrington R, et al. Identifying deaths from AIDS in South Africa: an update. AIDS 2005;19:744e45. 23. World Health Organization. WHO case deﬁnitions for AIDS surveillance in adults and adolescents. Wkly Epidemiol Rec 1994;69:273e5. 334 J Epidemiol Community Health 2010;64:330e334. doi:10.1136/jech.2008.081554