In its 2015 revision of the global guidelines for HIV care and treatment, the World Health Organization called for initiating lifelong antiretroviral treatment (ART) for all patients testing positive for HIV, regardless of CD4 cell count. As countries adopt the new recommendation, known as “treat all,” millions of additional patients are becoming eligible for ART worldwide. In sub-Saharan Africa, where most of these patients are located, studies continue to document high losses of treatment-eligible patients from care before they receive their first dose of antiretroviral medications (ARVs). If patients are not retained in care after testing positive for HIV, the potential benefits of “treat all” will not be realized.
In sub-Saharan Africa, one reason for losing patients before they start treatment is that treatment initiation typically requires multiple clinic visits and long waiting times before a patient who tests positive for HIV is dispensed an initial supply of medications. In South Africa, for example, patients usually have to visit the clinic five or six times. Simpler, more efficient, accelerated algorithms for ART initiation are needed.
The Simplified Algorithm for Treatment Eligibility (SLATE) uses four screens to assess whether a patient is eligible for immediate (same-day) treatment initiation: i) symptom report, ii) medical history, iii) readiness assessment, and iv) brief physical examination. SLATE is a pragmatic, individually randomized evaluation to determine the effectiveness of the algorithm in increasing ART initiation, compared to standard care, among non-pregnant adult patients. We will enroll a total of approximately 960 HIV-infected adult patients not yet on ART in South Africa and Kenya during a routine clinic visit and randomize them to receive the intervention or standard care. Patients in the intervention arm will be administered the SLATE screens; those who “screen in” under the algorithm will be dispensed ARVs on the spot, while those who “screen out” will be referred for follow up care to address the reason for screening out. Patients in the standard arm will be referred for ART initiation under standard clinic procedures. We will then estimate the proportion of patients in each arm who (i) initiate treatment within 28 days; and (ii) initiate within 28 days and are retained care eight months after study enrollment, an interval that captures the routine six-month clinic visit and viral load test.
If successful, SLATE will offer a standardized approach to collecting and interpreting a minimum set of patient data that will avoid delaying treatment initiation for the majority of patients who are eligible for immediate ART, while deferring initiation in the minority who should not start immediately.
The following publications emanate from this project:
HE2RO staff involvedDr. Alana Brennan Professor Sydney Rosen Dr. Matthew Fox Dr Mhairi Maskew Michael Mothapo
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