SLATE: Simplified algorithm for treatment eligibility

In its 2017 revision of the global guidelines for HIV care and treatment, the World Health Organization called for accelerating the process of initiating antiretroviral therapy (ART) for patients with HIV, whenever possible starting ART on the same day that a patient tests positive for HIV. The goals of this policy are to start treatment earlier, reduce the loss to care of patients who don’t return to the clinic after a positive test, and make the delivery of HIV services more efficient for both providers and patients.

Following on the widely cited RapIT study of rapid ART initiation, DGH researchers and our colleagues in South Africa and Kenya conducted the SLATE I study. SLATE, which stands for Simplified Algorithm for Treatment Eligibility was a pragmatic, individually randomized evaluation of an algorithm that used a self-reported symptoms, medical history, readiness assessment, and brief physical examination to assess whether an adult patient is eligible for immediate same-day treatment initiation. SLATE I follow up was completed in December 2018. The SLATE algorithm increased the proportion of treatment-eligible patients who initiated ART within 28 days by 15% in South Africa and 6% in Kenya. Roughly half of all patients in the intervention arm, however, were found ineligible for same-day initiation, due mostly to having symptoms of TB. Full results of SLATE I have been published, and a summary is available here.

In response to early findings from SLATE I, the SLATE II study was launched in South Africa in March 2018. Like SLATE I, SLATE II is an individually randomized, pragmatic evaluation of a clinical algorithm to reliably determine a patient’s eligibility for immediate ART initiation without waiting for laboratory results or additional clinic visits. Compared to SLATE I, the SLATE II algorithm had fewer reasons for a patient not to be eligible for same-day initiation. In particular, it handled TB symptoms differently, allowing patients without serious, overt TB disease to start ART immediately, rather than automatically delaying ART initiation.

SLATE II follow up was completed in May 2019. The SLATE II algorithm increased the proportion of treatment-eligible patients who initiated ART within 7 days—the new global target—from 64% to 92%. Under SLATE II, 86% of HIV-positive patients walking in the clinic door were eligible for same-day initiation, a marked improvement on SLATE I.

Funded by The Bill & Melinda Gates Foundation, the SLATE studies arose from a 2015 global technical consultation on Models for Accelerating Treatment Initiation, whose recommendations for a research agenda are available here.

Boston University investigators Sydney Rosen (PI), Alana Brennan, Bruce LarsonMatthew Fox
Partner investigators HE2RO: Mhairi Maskew, Lungi Vezi, Francois Venter

KEMRI/Henry Jackson Foundation: Isaac Tsikhutsu, Margaret Bii

Countries South Africa, Kenya
Project period 2015-2020
Funder Bill & Melinda Gates Foundation
Contacts Sydney Rosen, Mhairi Maskew

Publications

2021

Maskew M, Brennan AT, Fox MP, Vezi L, Venter WDF, Rosen S. Retention in care and viral suppression after same-day ART initiation: One-year outcomes of the SLATE I and II individually randomized clinical trials in South Africa. J Int AIDS Soc 2021; 24:e25825.

2020

Maskew M, Brennan AT, Fox MP, Vezi L, Venter WDF, Ehrenkranz P, Rosen S. The SLATE II study: A randomized evaluation of a revised, simplified clinical algorithm for identifying patients eligible for immediate initiation of antiretroviral therapy for HIV. PLOS Medicine 2020; 17: e1003226.

Scott NA, Maskew M, Fong RM, Olson IE, Brennan AT, Fox MP, Vezi L, Ehrenkranz PD, Rosen S. Patient perspectives of quality of the same-day antiretroviral therapy initiation process in Gauteng Province, South Africa: qualitative dominant mixed-methods analysis of the SLATE II trial. Patient 2020; published ahead of print.

Brennan AT, Maskew M, Larson BA, Tsikhutu I, Bii M, Vezi L, Fox MP, Venter WDF, Ehrenkranz P, Rosen S. Prevalence of TB symptoms and symptom profile, TB diagnosis, and TB treatment among HIV-positive adults not yet on ART presenting at outpatient clinics in South Africa and Kenya. BMJ Open 2020; 10:e035794.

Maskew M, Brennan AT, Fox MP, Vezi L, Venter WDF, Ehrenkranz PD, Rosen S. A structured algorithm for same-day ART initiation: SLATE II trial primary outcomes. Abstract 1070, 26th Conference on Retroviruses and Opportunistic Infections (CROI 2020), Boston, March 8-11, 2020.

2019

Rosen S, Maskew M, Brennan AT, Fox MP, Vezi L, Larson BA, Tsikhutsu I, Bii M, Venter WDF. Simplified clinical algorithm for identifying patients eligible for same-day HIV treatment initiation (SLATE): results from an individually randomized trial in South Africa and Kenya. PLoS Med 2019; 16: e1002912.

Brennan A, Maskew M, Larson B, Tsikhutsu I, Bii M, Vezi L, Fox M, Venter F, Ehrenkranz P, Rosen S. Who is seeking antiretroviral treatment for HIV now? Characteristics of patients presenting in Kenya and South Africa in 2017-2018J Int AIDS Soc 2019; 22:e25358.

Rosen S, Maskew M, Brennan AT, Fox MP, Vezi L, Larson BA, Tsikhutsu I, Bii M, Venter WDF. The SLATE algorithm for same-day treatment initiation: results of the SLATE trial in South Africa and Kenya. Johannesburg: HE2RO Policy Brief Number 31, Health Economics and Epidemiology Research Office, October 2019.

Brennan AT, Larson BA, Tsikhutsu I, Bii M, Fox MP, Venter WDF, Maskew M, Vezi L, Rosen S. Same-day ART initiation in the SLATE trial in Kenya: preliminary results. Abstract 1018, 25th Conference on Retroviruses and Opportunistic Infections (CROI 2019), Seattle, March 4-7, 2019.

2018

Maskew M, Brennan AT, Fox MP, Venter WDF, Vezi L, Larson B, Tsikihutsu I, Bii M, Rosen S. Same-day ART initiation in the SLATE trial in South Africa: preliminary results. 24th Conference on Retroviruses and Opportunistic Infections (CROI 2018), Boston March 4-7, 2018.

Rosen S, Maskew M, Brennan AT, Fox MP, Vezi L, Larson B, Tsikhutu I, Bii M, Venter WD. Same-day ART initiation without laboratory tests is safe and effective: primary outcomes of the SLATE trial in South Africa. AIDS 2018, Amsterdam, 23-27 July 2018.

Rosen S, Maskew M, Brennan AT, Fox MP, Vezi L, Ehrhenkranz PD, Venter WDF. Improved simplified clinical algorithm for identifying patients eligible for immediate initiation of antiretroviral therapy for HIV (SLATE II): protocol for a randomized evaluationTrials 2018;19:548. PMID: 30305142

2017

Rosen S, Fox MP, Larson BA, Brennan AT, Maskew M, Tsikhutsu I, Bii M, Ehrenkranz PD, Venter WDM. Simplified clinical algorithm for identifying patients eligible for immediate initiation of antiretroviral therapy for HIV (SLATE): protocol for a randomized evaluationBMJ Open 2017;7:e016340. PMID: 28554939

Fox MP, Rosen S. A new cascade of HIV care for the era of “treat all.” PLOS Medicine 2017; 14: e1002268.

Long L, Maskew M, Brennan A, Mongwenyana C, Nyoni C, Malete G, Sanne I, Fox MP, Rosen S. Initiating antiretroviral therapy for HIV at a patient’s first clinic visit: A cost-effectiveness analysis of the RapIT randomized controlled trial. AIDS 2017; 31: 1611-19.

2016

Rosen S, Fox MP, Larson B, et al. Accelerating the uptake and timing of antiretroviral therapy initiation in sub-Saharan Africa: an operations research agenda. PLoS Med 2016; 13: e1002106.

Rosen S, Maskew M, Fox MP, Nyoni C, Mongwenyana C, Malete G, Sanne I, Bokaba D, Sauls C, Rohr J, Long L. Initiating antiretroviral therapy for HIV at a patient’s first clinic visit: the RapIT randomized controlled trial. PLoS Med 2016; 13(5): e1002015.