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Doxy-PEP (and Doxy-PrEP)

Doxy-PEP:

Two antibiotic pills taken after sex can stop STIs we often see in queer guys. It’s a simple way to reduce your chances of getting an STI.

Is Doxy-PEP for me?

If you are a queer man or a nonbinary individual with a penis and…

  • use condoms sometimes or not at all,
  • have multiple partners, including partners with a vagina/front hole,
  • had an STI recently, or
  • take HIV PrEP…

then read on – this could be useful to you.

What is Doxy-PEP and how does it work?

“PEP” means post-exposure prophylaxis. It is the technique of using a treatment medication quickly after a possible exposure to an infection to prevent it from developing.

An example of PEP is using HIV medications right after a needle stick injury in a workplace, or right after anal sex with no condom. (This is HIV PEP). There are also PEP techniques for Hepatitis A and B and other potential infections!

“Doxy-PEP” is about using antibiotic medications to prevent exposure to bacteria (in this case chlamydia, gonorrhea, syphilis) from becoming an infection. Specifically, this intervention uses an antibiotic called Doxycycline (“Doxy”) which is normally used to treat STIs after symptoms have appeared. (Doxycycline is used for other issues as well).

Doxy-PEP is simple to use. To reduce the chances of chlamydia, gonorrhea, or syphilis infection after condomless oral, anal, or vaginal/front hole sex:

  • Take two 100mg Doxycycline tablets together,
  • ideally within 24 hours, (but no later than 72 hours), and
  • should be taken with food to reduce nausea.

Important: Understand this is not STI treatment.  You are not waiting for STI symptoms to appear before taking Doxycycline – using it as PEP is about taking it right after sex.

How Effective is it?

Doxy-PEP has proven to be the most effective against:

  • Syphilis – Doxy-PrEP is as high as 88% effective at preventing it; 1
  • Chlamydia – Doxy-PrEP is as high as 87% effective at preventing it.2

Note: Doxy-PEP can prevent syphilis and chlamydia in many cases, but it’s not 99% effective.
Condoms and STI testing should still be part of your tool kit for stopping STIs if you get them a lot or are at increased risk of STIs.

Doxy-PEP is less effective with gonorrhea (which is another STI that disproportionately affects queer men), with some research trials indicating a 50% effectiveness in prevention, while others report no benefit3. Some researchers think this is due to drug resistance in some strains of gonorrhea.

Why is Doxy-PEP Important?

Doxycycline is safe. It’s been used for years to control acne and treat STIs (taken usually for 10 days in a row at 100 mg each day); and it works well in people living with HIV and trans women with no complications around HIV medications or hormones.

Doxycycline is inexpensive.

Given Doxycycline’s safety record and affordability, it’s of interest because:

  • It reduces the risk of syphilis, chlamydia or gonorrhea which are often diagnosed at the same time in queer men.
  • Syphilis, chlamydia and gonorrhea often have no noticeable symptoms in individuals with penises – making them easier to spread.
  • For someone with a vagina or front hole, they can cause some serious health issues, so if someone is having sex with a diversity of people (some of whom have a vagina/front hole) it is a good additional step to protect their sex partners.

Finally, it’s important to consider that while HIV PrEP is getting more popular in the queer community and is good at stopping HIV, HIV PrEP does not stop STIs. Doxy-PEP can help fill this gap, especially if someone on HIV PrEP is not using condoms too much, or not at all.

What is Doxy-PrEP?

Doxy-PrEP (like HIV PrEP) involves taking Doxycycline daily to stop a bacterial sexually transmitted infection (STI) from developing. While this technique appears to work , the medical community is concerned about issues such as drug resistance developing in bacterial infections, especially if people are not taking the medication consistently; as well as who would benefit the most from taking it in this fashion. (For example: What are some unique benefits of taking Doxycycline daily that might benefit a person with which specific set of sexual needs?) As a result, doctors are not widely prescribing Doxy-PrEP in Canada. Still, there is a drug trial currently looking into these types of questions and comparing Doxy-PEP with Doxy-PrEP to help develop guidelines for doctors and satisfy Canadian regulatory processes.

Where to Get Doxycycline in Toronto for STI Prevention:

Doxycycline is on the market to treat bacterial infections and acne in various forms (among other things). Because there are no Canadian guidelines for Doxy PEP and PrEP, Health Canada does not authorize it for preventative use of STIs, meaning doctors would be prescribing it “off-label.”

Prescribing a medication off-label or using a drug for a purpose for which it was not originally approved happens often in the medical world. In these circumstances, doctors have to take extra time to think about how to prescribe it since there are fewer (if any) established guidelines for this purpose.

It does not mean the drug being prescribed is unsafe, or that it is ineffective.

Basically, Doxy-PEP is being prescribed off-label. The term “off-label” should not prevent you from discussing it with your doctor/nurse practitioner – especially if you find that you have had STIs frequently.

Doxy-PrEP access is much more restricted. Understand that many healthcare professionals might hesitate to prescribe an antibiotic specifically when no actual infection is present or actual exposure because they have concerns about creating drug-resistant strains of bacteria. Researchers were quick to look into this in their Doxy-PEP/PrEP trails and found no marked increase in drug resistance in their trial participants; however, researchers have also been quick to point out they would like to see more long-term monitoring for drug-resistant bacteria emerging as a result of the mass use of Doxycycline.

In either the case of Doxy-PEP or Doxy-PrEP you must: talk to a doctor or nurse practitioner for a prescription. Be prepared to provide them with a list of any other medications you are taking as well as if you have any allergies to the tetracycline class of drugs, are taking birth control, or have any kidney issues.

If you don’t have a doctor/nurse practitioner, consider the following:

  • You can talk to your HIV PrEP provider (clinics and pharmacies) about whether they can get you a prescription for Doxy-PEP with their network of doctors, nurses and pharmacists. If you don’t use HIV PrEP, some (not all) HIV PrEP providers are still willing to connect you with Doxy-PrEP utilizing their interdisciplinary teams or medical connections.
  • If you are living with HIV, some major HIV care clinics are prescribing Doxy-PEP to their patients since many of these groundbreaking trials have included folks living with HIV.

Tip: Because Doxy-PrEP is far less accepted by the medical community:

  1. You may be able to find it being prescribed by doctors with a great deal of sexual health knowledge such HIV PrEP prescribing doctors or even HIV doctors – they need to see you are at risk for these types of STIs.
  2. Consider getting into a drug trial to get access to Doxy-PrEP. Currently, Canadian researchers are running a trial called “disco.” You can find out about it here: www.godisco.ca. Note: getting into a drug trial means you are part of a study with a need to answer questions and attend appointments, and you would be accessing Doxycycline at no cost.

What does Doxy-PEP Cost?

Toronto area pharmacies are reporting a cost of approximately $30 for a typical prescription of 30 pills.

Side Effects of Doxycycline

Most patients taking this have no or mild side effects. Possible side effects include:

  • Gastrointestinal symptoms like stomachache or diarrhea,
  • sensitivity to the sun (common with antibiotics), or
  • pain or discomfort in the chest or throat after swallowing medication (acid reflux).

Tips to Deal with Side Effects and Other Issues:

  • If you are allergic to the tetracycline class of drugs, are on any other medications, have any kidney issues, can get pregnant, or drink a lot of alcohol, tell your healthcare provider before taking Doxycycline. (Note: Doxycycline is in the tetracycline class drug of choice for anyone with a kidney issue, but a physician needs to know what is going on with your body before prescribing.)
  • Do not exceed 200mg of Doxycycline within 24 hours. Follow the directions they gave you when it was prescribed.
  • To reduce feelings of nausea take it with fluids or food.
  • To prevent sunburn, don’t overlook appropriate sunblock or covering yourself.
  • To reduce any pain from acid reflux avoid lying down for 30 minutes after taking Doxycycline4.
  • If you bottom during sex, diarrhea can make things complicated, so you want to see how your system deals with the Doxycycline first before getting into a sexual situation. Keep in mind you are taking it after sex, not before.
  • As with any medication, if you experience any side effects, you should consult a medical professional.
  • Alcohol can reduce the effectiveness of Doxycycline because it increases the absorption of the drug causing it to cycle through the body too quickly, but this is usually in the case of someone being alcohol dependent5. If you regularly drink or party, ask your doctor if you can take Doxycycline in the morning, and then drink at night.
  • Do not take it with antacids, ulcer medications or vitamins that contain calcium, magnesium, zinc, or iron as they can bind with the medication and limit the effectiveness of Doxycycline.6

Doxycycline and Biological Sex

Trans women have been included in these Doxy trials; that population also saw good results.

In contrast, cisgender women have not seen clear research results that Doxycycline helps protect them from these same STIs. Although the reasons for this are not yet clear, a host of issues are being explored, including looking at how Doxycycline concentrates differently in vaginal tissues in comparison to anal tissues.

Whether this is also true for trans men is unknown as they are not explicitly mentioned in the data around effectiveness. They have not been explicitly mentioned in these research trials.

Background Info – The Research that drew attention to Doxycycline in early 2024:

According to NAM AIDSmap (a respected HIV knowledge clearinghouse from the UK), the DoxyPrEP study that happened in the US involving gay and bisexual men, trans women, and people living with HIV was getting such good results it had to be stopped and redesigned. It was later reported at the 2022 International AIDS Conference as having “reduced the risk of acquiring chlamydia by 74%, and syphilis by 77% for people with HIV.”7 (This is impressive considering people living with HIV may sometimes have compromised immune systems; therefore, a tough sample group of people to demonstrate better infection resistance.)

Studies of Doxy-PEP and DoxyVac, found that among people who were also taking HIV PrEP there were reductions of:
87% for syphilis,
88% for chlamydia, and
55% for gonorrhea.

and for people living with HIV, there were reductions of:
77% for syphilis,
74% for chlamydia, and
57% for gonorrhea.8

Note: the French IPERGAY study involving Doxy-PEP did not result in a decrease in gonorrhea, researchers are suggesting this is likely because of the high prevalence of Doxycycline-resistant gonorrhea in the population they studied. Other research studies have found moderate reductions.9

Citations

  1. Prescribing Doxy-PEP after STI diagnosis is more efficient than targeting specific groups of people. Andy Carstins. Retrieved Dec 29, 2023 from: https://www.aidsmap.com/news/feb-2023/prescribing-Doxy-PEP-after-sti-diagnosis-more-efficient-targeting-specific-groups . ↩︎
  2. Prescribing Doxy-PEP after STI diagnosis is more efficient than targeting specific groups of people. Andy Carstins. Retrieved Dec 29, 2023 from: https://www.aidsmap.com/news/feb-2023/prescribing-Doxy-PEP-after-sti-diagnosis-more-efficient-targeting-specific-groups . ↩︎
  3. Prescribing Doxy-PEP after STI diagnosis is more efficient than targeting specific groups of people. Andy Carstins. Retrieved Dec 29, 2023 from: https://www.aidsmap.com/news/feb-2023/prescribing-Doxy-PEP-after-sti-diagnosis-more-efficient-targeting-specific-groups . ↩︎
  4. Doxycycline Post-Exposure Prophylaxis (Doxy-PEP) to Prevent Bacterial Sexually Transmitted Infections. NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE. Retrieved Feb 8, 2024 from: https://www.nyc.gov/assets/doh/downloads/pdf/std/dear-colleague-doxy-PEP-to-prevent-bacterial-STI-11092023.pdf ↩︎
  5. Fact versus Fiction: a Review of the Evidence behind Alcohol and Antibiotic Interactions. Antional Library of medicine. (Published online 2020 Feb 21). Retrieved may 28, 2024. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7038249/ ↩︎
  6. Medication Information Doxycycline. Hamilton Health Sciences. 2019. Retrieved May 28, 2024. https://www.hamiltonhealthsciences.ca/wp-content/uploads/2019/08/Doxycycline-trh.pdf ↩︎
  7. Taking antibiotic after sex cuts STIs by two-thirds, ‘Doxy-PEP’ study finds . Gus Cairns. Retrieved dec 28, 2023 from: https://www.aidsmap.com/news/jul-2022/taking-antibiotic-after-sex-cuts-stis-two-thirds-Doxy-PEP-study-finds .
    https://www.nyc.gov/assets/doh/downloads/pdf/std/dear-colleague-doxy-PEP-to-prevent-bacterial-STI-11092023.pdf ↩︎
  8. Doxycycline Post-Exposure Prophylaxis (Doxy-PEP) to Prevent Bacterial Sexually Transmitted Infections. NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE. Retrieved Feb 8, 2024 from: https://www.nyc.gov/assets/doh/downloads/pdf/std/dear-colleague-doxy-PEP-to-prevent-bacterial-STI-11092023.pdf ↩︎
  9. Doxycycline Post-Exposure Prophylaxis (Doxy-PEP) to Prevent Bacterial Sexually Transmitted Infections. NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE. Retrieved Feb 8, 2024 from: https://www.nyc.gov/assets/doh/downloads/pdf/std/dear-colleague-doxy-PEP-to-prevent-bacterial-STI-11092023.pdf ↩︎