Starter Packs Versus Full Prescription of Antiretroviral Drugs for Postexposure Prophylaxis: A Systematic Review

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 highercompletion 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.