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Do Starter Packs Improve Outcomes for People Taking HIV Postexposure Prophylaxis?

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Geneva, WHO, 2014

INTRODUCTION: Guidelines for post-exposure prophylaxis (PEP) for people exposed to HIV recommend a 28 day course of antiretroviral (ARV) drugs. The way in which antiretrovirals are prescribed differs by programme and setting. In some instances, people eligible for PEP are given a full 28 day course of treatment; in other instances a partial prescription (sometimes referred to as a starter pack) is provided. The reasons for providing partial or full course of treatment vary. We systematically assessed PEP completion rates according to each approach.

METHODS: We searched Medline via PubMed, EMBASE, the Cochrane Database of Systematic Reviews and LILACS from inception to 1 December 2013, updated in PubMed to 1 June 2014, to identify all studies reporting completion rates for PEP, irrespective of population or exposure type. Completion rates for studies reporting the provision of PEP through partial prescription were compared against studies providing the full 28-day course at initial visit. All outcomes were pooled using random effects meta-analysis.

Characteristics of included studies:We identified 54 studies providing information on PEP prescribing: 37 studies (5997 participants) provided partial prescriptions and 17 studies (5438 participants) provided full prescriptions. Provision of partial prescriptions varied by exposure type, and were more frequently prescribed for nonoccupational
exposures, and less frequently prescribed for occupational exposures. The duration of initial prescription varied from 1 day to 14 days, with the majority (18 studies) providing an initial 3 day course. Study characteristics are summarized in Table 1.

Overall, a higher proportion of people completed a full 28-day course of PEP if they were given a full course of PEP at initial visit (70.0%, 95%CI 56.7-
77.3%) compared to people given an initial starter course (53.2%, 95%CI 44.4-62.2%).
Over a quarter (28%, 95%CI 21.4-34.5%) of people given a partial course of PEP failed to return for the remainder of their prescription.
There were no apparent differences in the proportion who were discontinued during PEP because it was not needed, or because of adverse drug reactions.

CONCLUSIONS: Partial prescriptions may offer advantages in individual circumstances in specific clinical settings. However, there is no evidence that partial prescribing
improves rates of treatment completion, and some indication that partial prescriptions may lead to increased rates of refusal and non-completion of PEP.