Can an Algorithm Expedite the Process of ART Initiation?

The World Health Organization (WHO) recommends that treatment with antiretroviral therapy (ART) is initiated same-day for individuals with HIV who are eligible and ready to begin the regimen.

Despite this recommendation, initiating ART typically requires 2 to 4 visits to the clinic and little guidance is provided to clinicians on how to determine whether a patient is eligible and ready to begin treatment and how to provide initiation services in a single visit. Therefore, it is critical to identify procedures that are safe, effective, and feasible for determining same-day eligibility and readiness.

However, a team of investigators may have identified a simplified algorithm that could expedite the process. The findings from their research were published in PLOS Medicine.

The Simplified Algorithm for Treatment Eligibility (SLATE) study evaluated a clinical algorithm that used 4 screening tools to assess eligibility for same-day initiation or refer for further care. The tools included a symptom self-report, a medical history report, a physical examination, and a readiness assessment.

The study was an individual randomized trial that was conducted across 6 clinics, 3 outpatient clinics in urban settlements in Johannesburg, South Africa, and 3 hospital clinics in western Kenya. From March 7, 2017, to April 17, 2018, the trial enrolled 600 patients in South Africa and 477 patients in Kenya.

Participants were adult, non-pregnant, ambulatory patients, with a positive HIV test who presented to the clinic for HIV care (including testing), and were not currently on ART. At enrollment, the participants were randomized to either the SLATE algorithm or standard of care.

The investigators evaluated the primary outcomes of ART initiation <28 days along with initiation <28 days and retention in care <8 months of enrollment. In the intervention arm, 78% of patients initiated ART ≤28 days in South Africa, compared with 68% in the standard-of-care arm (risk difference [RD] 95%, confidence interval [CI] 10% [3%—17%]). In Kenya, 94% of patients in the algorithm arm initiated ART ≤28 days compared with 89% in the standard-of-care arm (6% [0.5%–11%]).

At the 8-month mark, 161 of 298 (54%) intervention-arm patients had initiated ART and were retained in care, compared with 146 of 302 (48%) participants in the standard-of-care arm (6% [2% to 14%]) in South Africa.

In Kenya at the 8-month mark, the corresponding retention outcomes were identical in both arms (137 out of 240 [57%] intervention-arm patients and 136 out of 237 [57%] standard-of-care arm patients).

“In South Africa, the SLATE algorithm increased uptake of ART within 28 days by 10% and showed a numerical increase (6%) in retention at 8 months,” the authors write. “In Kenya, the algorithm increased uptake of ART within 28 days by 6% but found no difference in retention at 8 months.”

The report acknowledges that limitations of the trial include limited geographic representativeness, exclusion of patients who were too ill to participate, missing data of viral load, changes to standard-of-care over the course of the study and others.

Despite limitations, the study found that the simple structured algorithm for same-day treatment initiation procedures is feasible and can increase and accelerate ART uptake but that early retention on treatment remains problematic.

“The SLATE study demonstrates that at least half of all HIV-positive patients who come to clinics and are not yet on HIV treatment are eligible and ready for same-day initiation; initiation can safely be done without waiting for laboratory test results, and the vast majority of patients would like this option.”