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. Among facility-level reasons for these losses
are treatment initiation protocols that require multiple clinic visits and long waiting times
before a patient who tests positive for HIV is dispensed an initial supply of medications.
Simpler, more efficient, accelerated algorithms for ART initiation will be needed if "treat
all" is to realize the benefits expected.
Experts have proposed a simplified clinical algorithm to screen patients for eligibility for
immediate ART initiation at a patient's first clinic visit, without the use of point-of-care
laboratory test technologies. The Simplified Algorithm for Treatment Eligibility (SLATE) uses
four screens to assess whether a patient is eligible for same-day treatment initiation: i)
symptom report, ii) medical history, iii) brief physical examination; and iv) readiness
assessment. SLATE is a pragmatic, individually randomized evaluation to determine the
effectiveness of the algorithm in increasing ART initiation among non-pregnant adult
patients. Approximately 960 HIV-infected adult patients not yet on ART will be enrolled
during a routine clinic visit and randomized to receive the intervention or standard care.
Patients in the intervention arm will be administered the SLATE screens; those found eligible
under the algorithm will be offered immediate treatment initiation, while those who are not
eligible will be referred for standard clinic care. Patients in the standard arm will be
referred for ART initiation under standard clinic procedures. All care after the initial
visit will be by the clinic under standard of care. 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.