Taking Doxycycline After Sex Reduces STI Risk, Study Finds :: Bay Area Reporter

Taking the antibiotic doxycycline as post-exposure prophylaxis (PEP) after sex can reduce the risk of gonorrhea, chlamydia and syphilis, according to a study presented at the recent International AIDS Conference in Montreal. San Francisco health experts discussed the findings and local implementation at the Sept. 22 meeting of the Getting to Zero Consortium.

The DoxyPEP trial showed that gay and bisexual men and transgender women who were living with HIV or on PrEP reduced their risk of getting the three most common bacterial sexually transmitted infections by more than 60% if they took doxycycline within 72 hours of having sex without a condom.

“The use of doxycycline after condomless sex has the potential to be an effective strategy to significantly reduce sexually transmitted infections in targeted populations with high rates of STIs,” the study researcher said. , Dr. Annie Luetkemeyer of UCSF, to the Bay Area Reporter.

“It’s not for everyone,” Luetkemeyer said at an AIDS news conference. “But there are populations that are really suffering from the STI epidemic, and it’s time to act on the data and really think about incorporating it into guidance and rolling it out in a safe and thoughtful way.”

As is often the case with LGBTQ health, San Francisco is taking the lead in implementing doxycycline PEP.

Current guidelines from the federal Centers for Disease Control and Prevention do not recommend for or against doxycycline PEP, but some providers are already offering it on a case-by-case basis, said the medical director of the City of San Francisco clinic. , Dr. Stephanie Cohen, at the Getting to Zero conference. Meet.

The San Francisco Department of Public Health is developing interim guidelines on who is eligible for doxycycline PEP. Restricting eligibility might reduce access and increase disparities, but it would minimize unnecessary antibiotic use. DPH aims to build provider capacity, promote doxycycline PEP in appropriate communities, and roll it out in settings that serve people with high rates of STIs, Cohen said. Going forward, the agency will monitor the impact on the incidence of STIs and antibiotic resistance.

“We’re grappling with the risk-benefit ratio. There are benefits to taking a broader use approach and there are downsides as well. We’re trying to find the sweet spot,” Cohen said. In the meantime, “it’s helpful for patients and providers to have a conversation and make the choice that’s right for them with the information we have.”

Results of the DoxyPEP study

The DoxyPEP study recruited more than 500 transgender men and women who have sex with men from public health clinics in San Francisco and Seattle. About a third were living with HIV and the rest were taking PrEP. A majority had been diagnosed with an STI in the past year and they reported a median of nine recent sexual partners.

Participants were randomly assigned to receive a single dose of oral doxycycline as post-exposure prophylaxis within 72 hours after condomless sex or the standard of care, which is regular testing and treatment after an STI diagnosis. . They were tested for gonorrhea, chlamydia and syphilis every three months.

The study was scheduled to last until May 2023, but was halted a year earlier after an interim analysis showed that doxycycline PEP significantly reduced the incidence of STIs.

In people living with HIV, doxycycline reduced the odds of being diagnosed with one of these STIs by 62% per trimester compared to standard of care (incidence 12% versus 31%, respectively). The incidence of gonorrhea decreased by 57%, that of chlamydia by 74% and that of syphilis by 77%.

An even greater risk reduction was seen in HIV-negative participants on PrEP. In this group, there was an overall 66% reduction in quarterly STI incidence compared to the standard care group (11% vs. 32%). Gonorrhea fell by 55%, chlamydia by 88% and syphilis by 87%.

In both groups, doxycycline PEP was safe and well tolerated. However, doxycycline can cause side effects, including gastrointestinal symptoms, esophageal irritation, and sun sensitivity. Overall grip was good. Just over half of participants reported taking less than 10 doses of doxycycline per month, about a third took 10 to 20 doses, and 16% took more than 20 doses.

Supporters welcomed the findings and urged rapid implementation.

“These are the kinds of innovations that clinicians, patients, and communities desperately need to fight the epidemic of STIs in the United States,” said David Harvey, executive director of the National Coalition of STD Directors, in a press release. “Our conclusion to draw from the DoxyPEP study is that we are headed for a future where symptomatic infection and community spread may be entirely unnecessary for some of our most at-risk neighbors and patients.”

Doxy PEP Concerns

Preventive use of doxycycline is not without concern. The first is that overuse of antibiotics can lead to drug resistance. But doxycycline is not usually used to treat gonorrhea or syphilis, which means people who develop resistance will have other treatment options. Additionally, a lower daily dose of doxycycline is used for weeks or months to prevent malaria in travelers without promoting resistance.

Another potential concern is whether frequent antibiotic use will disrupt the microbiome, the ecosystem of healthy bacteria that normally live in the gut, vagina, and elsewhere in the body. Resistance and microbiome analyzes are in progress.

Leutkemeyer noted that people in the standard care group had STIs so often that they spent a significant portion of their time on doxycycline treatment anyway. But using doxycycline as PEP instead of treatment reduces suffering and decreases the length of time people can transmit STIs.

As happened with PrEP for HIV, some worry that doxycycline PEP will encourage people to have more sex without a condom. “When PrEP came out, we saw a lot of shame and stigma — why not just use a condom? — but we need multiple tools,” Leutkemeyer said. “I hope it doesn’t come with the shame and blame that came with the first cycle of PrEP.”

Equitable access will also be an issue. Inexpensive generic versions of doxycycline are widely available, but the cost could add up if people take it frequently. And everyone who could potentially benefit may not have access to sex-positive providers who know about the new intervention and will offer it without stigma.

A decade after its approval, black and Latino men, gay and bisexual men, and cisgender women are still not using PrEP for HIV as much as white gay men, and advocates fear the same is happening with PEP to doxycycline. The preventive doxycycline might also work for cisgender women and transgender men, but it has not yet been studied in these populations. Dr. Connie Celum of the University of Washington said a study of doxycycline PEP for cisgender women is currently underway in Kenya.

The CDC is “encouraged” by the DoxyPEP data, according to a statement issued in response to the study results. “It will be essential to provide advice that will maximize the effectiveness of STI prevention, while minimizing individual and potential public health risks,” the agency said. “[I]It is our public health imperative to develop responsible guidance based on careful consideration of all available data and public health risks and benefits – we cannot take shortcuts when it comes to health people.

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