The CDC Perspective on Advanced HIV Disease with Dr. Elfriede Agyeman

Dec 22, 2022

Elfriede Agyemang, MD, MPH, is the Morbidity and Mortality Team lead for the U.S. Centers for Disease Control’s (CDC) HIV Care and Treatment Branch and a subject matter expert in advanced HIV disease, HIV coinfections, and comorbidities. Dr. Agyemang joined the recent CQUIN annual meeting in Durban, South Africa. In this Q&A, she talks about the CDC’s approach to AHD and what countries can look forward to in COP 23, among other key issues.

How does your team at CDC Atlanta work to support countries as they roll out programs to address Advanced HIV Disease?

We approach advanced HIV disease (AHD) on multiple fronts. First, we work directly with our CDC country offices globally, supporting them with technical assistance to roll out the WHO package of care with ministries of health. We think through the resources they have and how we can optimally roll out the package of care. In addition, we have a CDC AHD working group, which is a collaboration between the HIV Care and Treatment Branch, the Maternal and Child Health Branch, and colleagues from the International Laboratory Branch, who help us with diagnostics support. We also work closely with colleagues from the Mycotic Diseases Branch within the NCEZID, the CDC center that focuses on fungal diseases. We work collaboratively, exchanging ideas on the support we give countries. In the inter-agency space, we work on the short-term task team that has members from USAID and OGAC, and we collaborate with other stakeholders like CHAI on different topics.

How has PEPFAR’s support for AHD services evolved over the past few years?

That is a great question. Early on, PEPFAR changed its stance to focus on viral load monitoring. Over the past couple of years, we’ve shifted towards expanding CD4 access. Initially, we had focused more on populations that had a higher prevalence of AHD, detected through the “PHIAs,” and other surveillance projects. However, last year and this year, we’ve focused more on CD4 testing across the board but focused more on priority groups. The three priority groups are people who are initiating care, people who are re-engaging in care after treatment interruption for 12 months or more, and people who have documented biological failure, which is defined as two consecutive viral loads greater than a thousand taken at least three months apart, with the second one being after enhanced adherence counseling. Those are the policies, and we’ve been pushing that.

In addition to that, the international laboratory branch has been leading the focus on CD4 network assessments to see where the CD4 testing resources are, looking at turnaround time and additional details to try to identify gaps where we can advocate for more resources for CD4 testing, whether it be the point of care testing or strengthening laboratory testing. We hope that it will give us the programmatic detail we need on the burden of AHD and use it as a way to advocate for additional resources for other opportunistic infections like cryptococcal screening and treatment. In addition to that, through our colleagues at USAID, we’ve been in different discussions trying to advocate for reduced prices for some of the medications so they can be affordable for lower to middle-income countries.

What will PEPFAR AHD support services for countries look like in COP23?

I think it is going to increase. Everybody is talking about AHD. We are pushing for CD4 network assessment, and we’ll get the truth about the burden of advanced HIV disease. Through that, we should advocate for additional resources. That said, we know that PEPFAR has a flat budget, so whatever we’re looking for, we know that something will have to give. So really, it is about thinking through how we can be efficient in our programs so we can re-allocate resources. For instance, if we strengthen DSD models, it doesn’t mean the cadres in the clinics need to be laid off, but they will now have more time to focus on patients who need more care, like people living with AHD.

What topics do you think the CQUIN AHD Community of Practice should focus on in the upcoming year?

I really like that CQUIN has a capability maturity model for advanced HIV disease. I think we will need to think through strengthening the monitoring and evaluation aspect of AHD, and I’m glad we’ve started that discussion. I think in the future, we need to talk about commodities and specifically try to bring prices down for medications that are cost-effective for our programs. We also need to focus on the link between in-patient and outpatient care for people with advanced HIV disease as they move from one care setting to the other. I think we also need to think about people with lower CD4 counts who may be clinically well and what sort of less-intensive or community models we can make available to them because part of the reason they might have AHD is because they can’t get to the health facility at a particular frequency. I know there are smart minds in CQUIN, so there will definitely be solutions.

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