NYC Dept. of Health Issues Guidelines on Doxy-PEP for Gay, Bi Men and Trans Women

New York City's Department of Health has jumped on the Doxy-PEP bandwagon, issuing advice on how to prescribe a common antibiotic to men who have sex with men (MSM) and transgender women for morning-after use against a range of STIs.

A Nov. 9 bulletin titled "Doxycycline Post-Exposure Prophylaxis (Doxy-PEP) to Prevent Bacterial Sexually Transmitted Infections," issued by the city's Department of Health and Mental Hygiene, advises health care providers in the city that administration of the antibiotic after unprotected sex "has been shown in studies to reduce the incidence of syphilis, chlamydia, and gonorrhea among cisgender men who have sex with men (MSM) and transgender women with a recent history of these infections."

The practice of prescribing doxycycline within a day or so after unprotected sex to help prevent STIs is known as doxy-PEP, with PEP standing for "post-exposure prophylaxis."

The letter emphasized that "the NYC Health Department wants to ensure that health care providers who care for patients who may benefit from doxy-PEP are aware of the intervention, and that access to doxy-PEP and information about it is equitable."

The bulletin detailed that "Doxy-PEP for bacterial STI prevention consists of 200 mg of doxycycline taken ideally within 24 hours, but no later than 72 hours, after condomless oral, anal, or vaginal/front hole sex," and points to "high and increasing rates of chlamydia, gonorrhea, and syphilis in NYC..."

The bulletin noted that "Doxy-PEP is not for everyone, and initial implementation may be best limited to people at high risk for STIs, especially those who have had and may continue to acquire STIs that lead to substantial antibiotic treatment."

The missive further pointed out that "The U.S. Food and Drug Administration has not approved doxycycline for STI post-exposure prophylaxis and there is no national guidance for its use as STI prevention."

"However, the Centers for Disease Control and Prevention has released proposed guidelines for doxy-PEP as an STI prevention strategy for cisgender MSM and transgender women who have sex with men," the bulletin went on to add.

The CDC's "proposed guidelines" were provided last October, "after studies found some people who took the antibiotic doxycycline within three days of unprotected sex were far less likely to get chlamydia, syphilis or gonorrhea compared with people who did not take the pills after sex," the Associated Press reported at the time.

"The guideline is specific to the group that has been most studied," the AP report added – namely, "gay and bisexual men and transgender women who had a STD in the previous 12 months and were at high risk to get infected again."

One influential study driving the adoption of doxy-PEP, the AP noted, was published by the New England Journal of Medicine. The study "found that gay men, bisexual men and transgender women with previous STD infections who took the pills were about 90% less likely to get chlamydia, about 80% less likely to get syphilis and more than 50% less likely to get gonorrhea compared with people who didn't take the pills after sex."

The CDC's proposed guidelines came a year after "San Francisco's health department began promoting doxycycline as a morning-after prevention measure," the AP added.

But there may be a downside: Some worry that widespread use of doxycycline for morning-after STI prevention could lead to resistant strains of those infections, as has resulted in the past from overuse of antibiotics.

Such a scenario could see the very populations hardest hit that doxy-PEP is intended to help. As the New York Health Department bulletin noted, "increased antibiotic resistance... [is] likely to have the first and greatest impact on cisgender MSM and transgender women who have sex with men, the populations in which doxy-PEP will be most used."

"Evaluations of long-term impacts of doxy-PEP use on antimicrobial resistance and the microbiome are either being planned or are underway," the advisory noted.