Differences among diagnostic testing algorithms in the time from HIV diagnosis to care.

BACKGROUND: The association between the type of diagnostic testing algorithm for HIV infection and the time from diagnosis to care has not been fully evaluated. Here we extend an earlier analysis of this association by controlling for patient and diagnosing facility characteristics. STUDY DESIGN: Descriptive analysis of HIV infection diagnoses during 2016 reported to the National HIV Surveillance System through December 2017. Algorithm type: traditional = initial HIV antibody immunoassay followed by a Western blot or immunofluorescence antibody test; recommended = initial HIV antigen/antibody immunoassay followed by HIV-1/2 type-differentiating antibody test; rapid = two CLIA-waived rapid tests on the same date. RESULTS: In multivariate analyses controlling for patient and diagnosing facility characteristics, persons whose infection was diagnosed using the rapid algorithm were more likely to be linked to care within 30 days than those whose infection was diagnosed using the other testing algorithms (p < 0.01). The median time to link to care during a 30-day follow-up was 9.0 days (95% CI 8.0-12.0) after the rapid algorithm, 17.0 days (95% CI 17.0-18.0) after the recommended algorithm, and 23.0 days (95% CI 22.0-25.0) after the traditional algorithm. CONCLUSIONS: The time from HIV diagnosis to care varied with the type of testing algorithm. The median time to care was shortest for the rapid algorithm, longest for the traditional algorithm, and intermediate for the recommended algorithm. These results demonstrate the importance of choosing an algorithm with a short time between initial specimen collection and report of the final result to the patient.

Viral Loads Within 6 Weeks After Diagnosis of HIV Infection in Early and Later Stages: Observational Study Using National Surveillance Data.

BACKGROUND: Early (including acute) HIV infection is associated with viral loads higher than those in later stages. OBJECTIVE: This study aimed to examine the association between acute infection and viral loads near the time of diagnosis using data reported to the US National HIV Surveillance System. METHODS: We analyzed data on infections diagnosed in 2012-2016 and reported through December 2017. Diagnosis and staging were based on the 2014 US surveillance case definition for HIV infection. We divided early HIV-1 infection (stage 0) into two subcategories. Subcategory 0α: a negative or indeterminate HIV-1 antibody test was ≤60 days after the first confirmed positive HIV-1 test or a negative or indeterminate antibody test or qualitative HIV-1 nucleic acid test (NAT) was ≤180 days before the first positive test, the latter being a NAT or detectable viral load. Subcategory 0ß: a negative or indeterminate antibody or qualitative NAT was ≤180 days before the first positive test, the latter being an HIV antibody or antigen/antibody test. We compared median earliest viral loads for each stage and subcategory in each of the first 6 weeks after diagnosis using only the earliest viral load for each individual. RESULTS: Of 203,392 infections, 56.69% (115,297/203,392) were reported with a quantified earliest viral load within 6 weeks after diagnosis and criteria sufficient to determine the stage at diagnosis. Among 5081 infections at stage 0, the median earliest viral load fell from 694,000 copies/mL in week 1 to 125,022 in week 2 and 43,473 by week 6. Among 30,910 infections in stage 1, the median earliest viral load ranged 15,412-17,495. Among 42,784 infections in stage 2, the median viral load declined from 44,973 in week 1 to 38,497 in week 6. Among 36,522 infections in stage 3 (AIDS), the median viral load dropped from 205,862 in week 1 to 119,000 in week 6. The median earliest viral load in stage 0 subcategory 0α fell from 1,344,590 copies/mL in week 1 to 362,467 in week 2 and 47,320 in week 6, while that in subcategory 0ß was 70,114 copies/mL in week 1 and then 32,033 to 44,067 in weeks 2-6. The median viral load in subcategory 0α was higher than that in subcategory 0ß in each of the first 6 weeks after diagnosis (P<.001). CONCLUSIONS: In the 1st week after diagnosis, viral loads in early infections are generally several times higher than those in later stages at diagnosis. By the 3rd week, however, most are lower than those in stage 3. High viral loads in early infection are much more common in subcategory 0α than in subcategory 0ß, consistent with 0α comprising mostly acute infections and 0ß comprising mostly postacute early infections. These findings may inform the prioritization of interventions for prevention.

Trends in testing algorithms used to diagnose HIV infection, 2011-2015, United States and 6 dependent areas.

BACKGROUND: In 2014 the Centers for Disease Control and Prevention (CDC) and the Association of Public Health Laboratories (APHL) issued updated laboratory testing recommendations for the diagnosis of HIV infection. OBJECTIVES: To examine trends in the use of HIV diagnostic testing algorithms, and determine whether the use of different algorithms is associated with selected patient characteristics and linkage to HIV medical care. STUDY DESIGN: Analysis of HIV infection diagnoses during 2011-2015 reported to the National HIV Surveillance System through December 2016. Algorithm classification: traditional = initial HIV antibody immunoassay followed by a Western blot or immunofluorescence antibody test; recommended = initial HIV antibody IA followed by HIV-1/2 type-differentiating antibody test; rapid = two CLIA-waived rapid tests on same date. RESULTS: During 2011-2015, the percentage of HIV diagnoses made using the traditional algorithm decreased from 84% to 16%, the percentage using the recommended algorithm increased from 0.1% to 64%, and the percentage using the rapid testing algorithm increased from 0.1% to 2%. The percentage of persons linked to care within 30 days after HIV diagnosis in 2015 was higher for diagnoses using the recommended algorithm (59%) than for diagnoses using the traditional algorithm (55%) (p < 0.05). CONCLUSIONS: During 2011-2015, the percentage of HIV diagnoses reported using the recommended and rapid testing algorithms increased while the use of the traditional algorithm decreased. In 2015, persons with HIV diagnosed using the recommended algorithm were more promptly linked to care than those with diagnosis using the traditional algorithm.

HIV Care and Viral Suppression During the Last Year of Life: A Comparison of HIV-Infected Persons Who Died of HIV-Attributable Causes With Persons Who Died of Other Causes in 2012 in 13 US Jurisdictions.

BACKGROUND: Little information is available about care before death among human immunodeficiency virus (HIV)-infected persons who die of HIV infection, compared with those who die of other causes. OBJECTIVE: The objective of our study was to compare HIV care and outcome before death among persons with HIV who died of HIV-attributable versus other causes. METHODS: We used National HIV Surveillance System data on CD4 T-lymphocyte counts and viral loads within 12 months before death in 2012, as well as on underlying cause of death. Deaths were classified as "HIV-attributable" if the reported underlying cause was HIV infection, an AIDS-defining disease, or immunodeficiency and as attributable to "other causes" if the cause was anything else. Persons were classified as "in continuous care" if they had ≥2 CD4 or viral load test results ≥3 months apart in those 12 months and as having "viral suppression" if their last viral load was <200 copies/mL. RESULTS: Among persons dying of HIV-attributable or other causes, respectively, 65.28% (2104/3223) and 30.88% (1041/3371) met AIDS criteria within 12 months before death, and 33.76% (1088/3223) and 50.96% (1718/3371) had viral suppression. The percentage of persons who received ≥2 tests ≥3 months apart did not differ by cause of death. Prevalence of viral suppression for persons who ever had AIDS was lower among those who died of HIV but did not differ by cause for those who never had AIDS. CONCLUSIONS: The lower prevalence of viral suppression among persons who died of HIV than among those who died of other causes implies a need to improve viral suppression strategies to reduce mortality due to HIV infection.

Associations and Trends in Cause-Specific Rates of Death Among Persons Reported with HIV Infection, 23 U.S. Jurisdictions, Through 2011.

BACKGROUND: Published death rates for persons with HIV have not distinguished deaths due to HIV from deaths due to other causes. Cause-specific death rates would allow better assessment of care needs. METHODS: Using data reported to the US national HIV surveillance system, we examined a) associations between selected decedent characteristics and causes of death during 2007-2011, b) trends in rates of death due to underlying causes among persons with AIDS during 1990-2011, and among all persons with diagnosed HIV infection (with or without AIDS) during 2000-2011. RESULTS: During 2007-2011, non-HIV-attributable causes of death with the highest rates per 1,000 person-years were heart disease (2.0), non-AIDS cancers other than lung cancer (1.4), and accidents (0.8). During 1990-2011, among persons with AIDS, the annual rate of death due to HIV-attributable causes decreased by 89% (from 122.0 to 13.2), and the rate due to non-HIV-attributable-causes decreased by 57% (from 20.0 to 8.6), while the percentage of deaths caused by non-HIV-attributable causes increased from 11% to 43%. During 2000-2011, among persons with HIV infection, the rate of death due to HIV-attributable causes decreased by 69% (from 26.4 to 8.3), and the rate due to non-HIV-attributable causes decreased by 28% (from 10.5 to 7.6), while the percentage of deaths caused by non-HIV-attributable causes increased from 25% to 48%. CONCLUSION: Among HIV-infected persons, as rates of death due to HIV-attributable causes decreased, rates due to non-HIV-attributable causes also decreased, but the percentages of deaths due to non-HIV-attributable causes, such as heart disease and non-AIDS cancers increased.

Mortality Risk After AIDS-Defining Opportunistic Illness Among HIV-Infected Persons--San Francisco, 1981-2012.

OBJECTIVE: To examine whether improved human immunodeficiency virus (HIV) treatment was associated with better survival after diagnosis of AIDS-defining opportunistic illnesses (AIDS-OIs) and how survival differed by AIDS-OI. DESIGN: We used HIV surveillance data to conduct a survival analysis. METHODS: We estimated survival probabilities after first AIDS-OI diagnosis among adult patients with AIDS in San Francisco during 3 treatment eras: 1981-1986; 1987-1996; and 1997-2012. We used Cox proportional hazards models to determine adjusted mortality risk by AIDS-OI in the years 1997-2012. RESULTS: Among 20 858 patients with AIDS, the most frequently diagnosed AIDS-OIs were Pneumocystis pneumonia (39.1%) and Kaposi sarcoma (20.1%). Overall 5-year survival probability increased from 7% in 1981-1986 to 65% in 1997-2012. In 1997-2012, after adjustment for known confounders and using Pneumocystis pneumonia as the referent category, mortality rates after first AIDS-OI were highest for brain lymphoma (hazard ratio [HR], 5.14; 95% confidence interval [CI], 2.98-8.87) and progressive multifocal leukoencephalopathy (HR, 4.22; 95% CI, 2.49-7.17). CONCLUSIONS: Survival after first AIDS-OI diagnosis has improved markedly since 1981. Some AIDS-OIs remain associated with substantially higher mortality risk than others, even after adjustment for known confounders. Better prevention and treatment strategies are still needed for AIDS-OIs occurring in the current HIV treatment era.

Disparities among US states in HIV-related mortality in persons with HIV infection, 2001-2007.

OBJECTIVE: To examine interstate variation in US HIV case-fatality rates, and compare them with corresponding conventional HIV death rates. DESIGN: Cross-sectional analysis using data on deaths due to HIV infection from the National Vital Statistics System and data on persons 15 years or older living with HIV infection in 2001-2007 in 37 US states from the national HIV/AIDS Reporting System. METHODS: State rankings by age-adjusted HIV case-fatality rates (with HIV-infected population denominators) were compared with rankings by conventional death rates (with general population denominators). Negative binomial regression determined case-fatality rate ratios among states, adjusted for age, sex, race/ethnicity, year, and state-level markers of late HIV diagnosis. RESULTS: On the basis of 3,096,729 HIV-infected person-years, the overall HIV case-fatality rate was 20.6 per 1000 person-years [95% confidence interval (CI) 20.3-20.9]. Age-adjusted rates by state ranged from 9.6 (95% CI 6.8-12.4) in Idaho to 32.9 (95% CI 29.8-36.0) in Mississippi, demonstrating significant differences across states, even after adjusting for race/ethnicity (P < 0.0001). Many states with low conventional death rates had high case-fatality rates. Nine of the 10 states with the highest case-fatality rates were located in the southern United States. CONCLUSION: Case-fatality rates complement and are not entirely concordant with conventional death rates. Interstate differences in these rates may reflect differences in secondary and tertiary prevention of HIV-related mortality among infected persons. These data suggest that state-specific contextual barriers to care may impede improvements in quality and disparities of healthcare without targeted interventions.

Trends in Diseases Reported on US Death Certificates That Mentioned HIV Infection, 1996-2006.

OBJECTIVE: We examined trends during 1996-2006 in diseases reported on death certificates that mentioned HIV infection. METHODS: We analyzed multiple-cause mortality data compiled from all US death certificates with any mention of HIV to determine the annual percentages of deaths with various diseases. RESULTS: Deaths reported with HIV during 1996-2006 decreased from 35 340 to 13 750. Standardized percentages of death certificates reporting AIDS-defining opportunistic infections also decreased: pneumocytosis (6.3% to 5.1%), nontuberculous mycobacteriosis (5.5% to 1.8%), cytomegalovirus (5.7% to 1.2%). Non-Hodgkin's lymphoma rose from 4.8% in 1996 to 6.4% in 1997 and declined to 5.0% in 2001, while Kaposi's sarcoma declined from 3.7% in 1996 to 1.7% in 2001; these AIDS-defining cancers had stable percentages after 2001. All other cancers increased during 1996-2006 (2.7% to 7.3%). The percentage of deaths with diseases not specifically attributable to HIV increased: liver disease (5.8% to 13.0%), kidney disease (7.9% to 12.0%), and heart disease (4.9% to 10.2%). CONCLUSION: Among deaths reported with HIV, the percentages reported with HIV-attributable diseases decreased, while the percentages reported with other diseases increased. Consequently, these other life-threatening diseases need more attention in the management of HIV-infected persons.

Comparing the National Death Index and the Social Security Administration's Death Master File to ascertain death in HIV surveillance.

OBJECTIVES: New York City (NYC) maintains a population-based registry of people with human immunodeficiency virus (HIV) infection to monitor the epidemic and inform resource allocation. We evaluated record linkages with the National Death Index (NDI) and the Social Security Administration's Death Master File (SSDMF) to find deaths occurring from 2000 through 2004. METHODS: We linked records from 32,837 people reported with HIV and not previously known to be dead with deaths reported in the NDI and the SSDMF. We calculated the kappa statistic to assess agreement between data sources. We performed subgroup analyses to assess differences within demographic and transmission risk subpopulations. We quantified the benefit of linkages with each data source beyond prior death ascertainment from local vital statistics data. RESULTS: We discovered 1,926 (5.87%) deaths, which reduced the HIV prevalence estimate in NYC by 2.03%, from 1.19% to 1.16%. Of these, 458 (23.78%) were identified only from NDI, and 305 (15.84%) only from SSDMF. Agreement in ascertainment between sources was substantial (kappa = [K] 0.74, 95% confidence interval [CI] 0.72, 0.76); agreement was lower among Hispanic people (K = 0.65, 95% CI 0.62, 0.69) and people born outside the U.S. (K = 0.60, 95% CI 0.52, 0.68). We identified an additional 13.62% of deaths to people reported with HIV in NYC; white people and men who have sex with men were disproportionately likely to be underascertained without these linkages (p < 0.0001). CONCLUSION: Record linkages with national databases are essential for accurate prevalence estimates from disease registries, and the SSDMF is an inexpensive means to supplement linkages with the NDI to maximize death ascertainment.

Characteristics of HIV infection among Hispanics, United States 2003-2006.

BACKGROUND: Hispanic subgroups of varied national origin differ culturally; overall, Hispanics in the United States are disproportionately affected by HIV infection. METHODS: We analyzed cases of HIV infection that were diagnosed among Hispanics in 33 states and US-dependent areas during 2003-2006 and reported to the Centers for Disease Control and Prevention through June 2007. We used Poisson regression to calculate the estimated annual percent change in the number and rate of HIV diagnoses and used logistic regression to analyze the association between birthplace and a short (<12 months) HIV-to-AIDS interval. RESULTS: HIV infection was diagnosed among 30,415 Hispanics. Of 24,313 with reported birthplace, 61% were born outside the continental United States. The annual number of diagnoses increased among Mexican-born males [estimated annual percent change = 8.8%; 95% confidence interval (CI) = 3.5 to 14.5] and Central American-born males (18.6%; 95% CI = 9.4 to 28.6) and females (24.6%; 95% CI = 8.8 to 42.7) but decreased among US-born Hispanic females (-8.2%; 95% CI = -13.3 to -2.8). A short HIV-to-AIDS interval was more common among Mexican-born Hispanics than among US-born Hispanics. DISCUSSION: Diagnosis trends and HIV-to-AIDS intervals varied by place of birth. To decrease the incidence of HIV infection among Hispanics, prevention programs need to address cultural differences.

Trends in perimortal conditions and mortality rates among HIV-infected patients.

OBJECTIVES: To describe trends in perimortal conditions (pathological conditions causing death or present at death but not necessarily the reported cause of death) during three periods related to the availability of HAART, pre-HAART (1992-1995), early HAART (1996-1999), and contemporary HAART (2000-2003); annual mortality rates; and antiretroviral therapy (ART) prevalence during 1992-2003. DESIGN: Multicenter observational clinical cohort in the United States (Adult/Adolescent Spectrum of HIV Disease [ASD] project). METHODS: Proportionate mortality for selected perimortal conditions, annual mortality rates, and ART prevalence were standardized by sex, race/ethnicity, age at death, HIV transmission category, and lowest CD4 cell count of ASD decedents. Multivariable generalized linear regression was used to estimate trends in proportionate mortality, as linear trends through all three HAART periods, mortality rates, and ART prevalence. RESULTS: Of 9225 deaths, 58.6% occurred during 1992-1995, 29.5% during 1996-1999, and 11.9% during 2000-2003. Linear trends in proportionate mortality for noninfectious diseases (e.g., liver disease, hypertension, and alcohol abuse) increased significantly; proportionate mortality for AIDS-defining infectious diseases (e.g., pneumocystosis, nontuberculous mycobacterial disease, and cytomegalovirus disease) decreased significantly. Mortality rates decreased from 487.5/1000 person-years in 1995 to 100.6 in 2002. Of 36 256 patients from ASD, 75.7% (standardized average) were prescribed ART annually. CONCLUSIONS: Among HIV-infected patients, the majority of whom were prescribed ART, the increasing trend in common noninfectious perimortal conditions support screening and treatment for these conditions in order to sustain the trend in declining mortality rates.

Characteristics of persons with heterosexually acquired HIV infection, United States 1999-2004.

OBJECTIVES: In the United States a growing proportion of cases of heterosexually acquired HIV infections occur in women and in persons of color. We analyzed the association between race/ethnicity, whether diagnoses of HIV infection and AIDS were made concurrently, and the survival after diagnosis of heterosexually acquired AIDS. METHODS: We used data from 29 states that report confidential name-based HIV/AIDS cases to the Centers for Disease Control and Prevention to calculate estimated annual percentage change in the number of actual diagnoses and analyzed the association between race/ethnicity and concurrent diagnoses of HIV and AIDS. We adjusted for reporting delays and absence of information about HIV risk factors. RESULTS: During 1999 to 2004, diagnoses of heterosexually acquired HIV were made for 52 569 persons in 29 states; 33 554 (64%) were women. Among men and women, 38 470 (73%) were non-Hispanic Black; 7761 (15%), non-Hispanic White; and 5383 (10%), Hispanic. The number of persons with heterosexually acquired HIV significantly increased: 6.1% among Hispanic men (95% confidence interval=2.7, 9.7) and 4.5% among Hispanic women (95% confidence interval=1.8, 7.3). The number significantly decreased (-2.9%) among non-Hispanic Black men. Concurrent HIV and AIDS diagnoses were slightly more common for non-Hispanic Whites (23%) and Hispanics (23%) than for non-Hispanic Blacks (20%). CONCLUSIONS: To decrease the incidence of heterosexually acquired HIV infections, prevention and education programs should target all persons at risk, especially women, non-Hispanic Blacks, and Hispanics.

This place is killing me: a comparison of counties where the incidence rates of AIDS increased the most and the least.

BACKGROUND: The objective of this study was to identify the socioeconomic and health characteristics of communities with the largest proportional increases in incidence rates of acquired immunodeficiency syndrome (AIDS). METHODS: Reported AIDS cases (1981-1990 and 1995-1999) were used for a comparison between 20 US counties with the largest proportional increases in incidence rates of AIDS and 20 US counties with the smallest increases. Data were obtained from Community Health Status Indicators Reports of the Health Resources and Services Administration (HRSA) and from the US Census Bureau. RESULTS: Counties with the largest increases in the incidence of AIDS had lower levels of income, education, and literacy; higher incidence rates of syphilis, age-adjusted mortality (all causes), and infant mortality; more low-birth-weight infants; and higher levels on all 9 specific mortality measures in the HRSA reports. CONCLUSIONS: The incidence of AIDS increased the most in areas where many other health problems occurred. Research is needed to identify and address the root causes of ill health.

Changes in deaths reported with human immunodeficiency virus infection among United States children less than thirteen years old, 1987 through 1999.

BACKGROUND: With implementation of highly active antiretroviral therapy during 1995 through 1999, deaths reported in adults with HIV infection decreased 67%, and the proportions of those accompanied by various opportunistic infections decreased, whereas their proportions with possibly unrelated conditions (e.g. diseases of liver, kidneys and heart) increased. OBJECTIVE: To examine changes among deaths of children with HIV infection. METHODS: We analyzed multiple-cause death certificate data with any mention of HIV infection for all US deaths at ages <13 years from 1987 through 1999. We examined changes in the numbers and rates of deaths and the proportions reported with various diseases. RESULTS: The annual number of children who died with HIV infection increased from 274 in 1987 to 511 in 1994 and then decreased by 81% to 97 in 1999. The median age at death increased from 1 year in 1987 to 5 years in 1999. During the periods 1987 through 1991 (1652 deaths), 1992 through 1995 (1906 deaths) and 1996 through 1999 (762 deaths), the proportion of deaths with pneumocystosis decreased from 19.0% to 9.9% and 7.5%, respectively. In a comparison of 1992 through 1995 with 1996 through 1999, no significant change occurred in the proportions of deaths with nontuberculous mycobacteriosis (5.6% to 6.0%), cytomegalovirus disease (3.2% to 4.4%), heart disease (10.8% to 11.7%), kidney disease (5.0%), liver disease (3.9% to 4.1%) or wasting/cachexia (4.0% to 5.0%). CONCLUSIONS: Deaths with HIV infection among children have decreased substantially, probably because of both highly active antiretroviral therapy and prevention of perinatal HIV transmission. The decrease after 1995 was greater proportionally among children than among adults, but fewer changes in disease proportions occurred among children.

Increase in deaths caused by HIV infection due to changes in rules for selecting underlying cause of death.

With implementation of the (ICD-10), for U.S. vital statistics in 1999, the criteria for selecting HIV infection as the underlying cause of death were expanded. To estimate the effect of ICD-10 rules on the number of deaths attributed to HIV infection, we applied a simplified version of ICD-10 rules to data on causes of death from all U.S. death certificates for 1998 (previously classified by rules of the 9th revision of ICD [ICD-9]) and calculated the resulting increase in deaths for which HIV infection was selected as the underlying cause. Of the 17,186 deaths in 1998 with any mention of HIV infection on the death certificate, ICD-10 rules selected HIV infection as the underlying cause for 15,145, which was 1,719 (13%) more than the 13,426 for which it had been selected by ICD-9 rules. The proportional increase differed by demographic group, being less among non-Hispanic blacks (9%) and Hispanics (13%) than among non-Hispanic whites (18%). Thus, comparison of deaths attributed to HIV infection in 1999 or later with those in 1998 or earlier should take into account the changes in ICD rules for selecting the underlying cause of death.

Trends in diseases reported on U.S. death certificates that mentioned HIV infection, 1987-1999.

To examine trends in the proportions of deaths with various diseases among deaths with HIV infection, we analyzed multiple-cause death certificate data for all deaths in the United States from 1987 through 1999. Disease proportions were adjusted to control for demographic changes. Deaths reported with HIV infection increased from 15,331 in 1987 to 47,977 in 1995 and then decreased to 16,061 in 1999. Among these reported deaths, new trends during the period from 1995 through 1999 included decreases in the proportions with cytomegalovirus disease (from 6.8% to 2.8%), wasting/cachexia (9.8% to 6.8%), and dementia/encephalopathy (6.3% to 3.9%) and increases in the proportions with septicemia/septic shock (from 9.2% to 13.4%) and diseases of the liver (4.9% to 11.6%), kidney (6.3% to 9.1%), and heart (4.2% to 6.9%). Continuations of pre-1995 trends included decreases in the proportions with nontuberculous mycobacteriosis (7.1% to 3.1%) and Kaposi sarcoma (5.3% to 2.6%). Advances in antiretroviral therapy probably caused deaths due to HIV infection to decrease after 1995. Consequently, the proportions of deaths with HIV that were caused by other conditions increased. Improved prophylaxis or treatment of some opportunistic infections could also have reduced the proportions of deaths with those diseases, whereas antiviral drug toxicity could have contributed to increases in the proportions with noninfectious organ diseases.