title: Starter packs versus full prescription of antiretroviral drugs for postexposure prophylaxis: a systematic review.
abstract: BACKGROUND
  The provision of starter packs for human immunodeficiency virus postexposure prophylaxis (PEP) is practiced in many settings to facilitate rapid initiation by nonexperts and encourage adherence. However, the impact of starter packs on PEP completion rates has not been systematically assessed. We systematically reviewed the evidence on outcomes associated with starter packs for PEP compared to full prescriptions.
  
  
  METHODS
  Four databases and 2 conference abstract sites were searched up to December 2013; this search was updated in 1 database in June 2014. PEP completion rates, stratified by prescribing practice, were pooled using random-effects meta-analysis.
  
  
  RESULTS
  Fifty-four studies provided data on 11 714 PEP initiations. Thirty-seven studies, including 3 randomized controlled trials (RCTs) and 34 observational cohorts, provided information on starter packs (although none of the RCTs specifically assessed starter packs), and 17 studies, including 2 RCTs and 15 observational cohorts, provided information on full prescriptions. Overall, outcomes were better when participants were offered a full 28-day course of PEP at initial presentation to healthcare, with fewer refusals (11.4% [95% confidence interval {CI}, 5.3%-17.5%] vs 22% [95% CI, 16.7%-28.1%]) and higher completion rates (70% [95% CI, 56.7%-77.3%] vs 53.2% [95% CI, 44.4%-62.2%]). More than a quarter (28% [95% CI, 21.4%-34.5%]) of individuals provided with a PEP starter pack failed to return for their subsequent appointment and therefore defaulted prior to receiving a full course of PEP. The quality of the evidence overall was rated as very low.
  
  
  CONCLUSIONS
  The findings of this review suggest that starter packs do not improve adherence to PEP and may result in lower adherence and completion rates.
authors.affiliation: Department of HIV/AIDS, World Health Organization, Geneva, Switzerland.
authors.forename: Nathan
authors.initials: N
authors.lastname: Ford
authors.affiliation: Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg, South Africa.
authors.forename: Francois
authors.initials: F
authors.lastname: Venter
authors.affiliation: Department of HIV/AIDS, World Health Organization, Geneva, Switzerland.
authors.forename: Cadi
authors.initials: C
authors.lastname: Irvine
authors.affiliation: Department of HIV/AIDS, World Health Organization, Geneva, Switzerland.
authors.forename: Rachel L
authors.initials: RL
authors.lastname: Beanland
authors.affiliation: Department of Infectious Disease Epidemiology, Imperial College London, United Kingdom.
authors.forename: Zara
authors.initials: Z
authors.lastname: Shubber
mesh_terms: D006801:Humans; D019380:Anti-HIV Agents / Q000627:therapeutic use; D011307:Drug Prescriptions; D015658:HIV Infections / Q000517:prevention & control; D055118:Medication Adherence; D064887:Observational Studies as Topic; D056990:Post-Exposure Prophylaxis; D016032:Randomized Controlled Trials as Topic; D014944:World Health Organization
chemical_list: D019380:Anti-HIV Agents
keywords: adherence; completion; full prescriptions; postexposure prophylaxis; starter packs