Background: The WHO recommends same-day ART initiation for patients who are eligible and ready and ART initiation ≤7 days of diagnosis for all patients. Identifying efficient operational procedures for determining same-day eligibility and readiness is now a priority. The Simplified Algorithm for Treatment Eligibility (SLATE) trial tested a clinical algorithm that allows nurses to determine eligibility for immediate ART dispensing at a patient''s first clinic visit, without laboratory results or delays for other reasons.
Methods: SLATE was an individually randomized trial at public outpatient clinics serving informal settlements in Johannesburg, South Africa. Patients presenting for an HIV test or HIV care but not yet on ART were randomized to the intervention or standard care. The intervention arm was assessed with a symptom self-report, medical history questionnaire, brief physical examination, and readiness questionnaire to distinguish between patients eligible for immediate ART dispensing and those who should have further care, tests, or counseling before initiation. Follow-up was by passive record review. We report the proportion in each arm initiated ≤28 days and retained at 8 months (“28d/8m”) after study enrollment.
Results: From 3/7/17-7/28/17, we enrolled 600 adult, HIV+, non-pregnant patients (median [IQR] age 34 [29-40]; 63% female; median CD4 count 288 [140-487]). Eight-month follow up was completed in April 2018. In the intervention arm, 68% of patients initiated ≤7 days, compared to 40% in the standard arm (risk difference [95% CI] 28% [20-35%]; relative risk (RR) 1.68 [1.43-1.98]). After 8 months'' follow-up, 53% of the intervention arm and 50% of the standard arm achieved 28d/8m outcomes (RR 1.06 95% CI 0.90-1.25) (Table), with no difference in viral suppression rates. Many patients in both arms were > 1 month late for their routine 6-month visit and/or missing viral load results.
Conclusions: The SLATE algorithm, comprising a simplified set of steps for ART initiation, demonstrates that same-day ART initiation for both new and established HIV patients can be offered safely and effectively at primary health centers without delays for laboratory results, additional education or counseling, or other services. It offers a practical model of same-day treatment initiation that can be widely implemented by existing providers.



[Table: SLATE trial primary outcome results]





[Table: SLATE trial primary outcome results]