Doxycycline post-exposure prophylaxis (DoxyPEP) has emerged as a promising intervention to combat the rising rates of sexually transmitted infections (STIs). As its use gains traction, experts are stressing the need for equitable implementation strategies that prioritize community involvement and address disparities in access. With individuals already adopting DoxyPEP independently, health professionals are pushing for careful, thoughtful integration to avoid exacerbating existing inequalities.1
On November 28, 2024, the University of Edinburgh hosted a roundtable discussion that brought together researchers, clinicians, activists, and users to explore how DoxyPEP could be implemented in the UK. The conversation, which has since been published in The Lancet Infectious Diseases, highlighted the need to ensure that the benefits of DoxyPEP extend beyond STI prevention. Experts argue that, when used appropriately, DoxyPEP can enhance sexual wellbeing, reduce anxiety, and offer holistic benefits that go beyond just disease prevention.1
Experts agree that DoxyPEP is more than just a tool for STI prevention—it has the potential to improve sexual wellbeing and reduce anxiety. These benefits extend beyond the physical aspects of sexual health, aligning with calls for a more holistic approach to sexual health interventions that address both the psychological and emotional aspects of well-being.1
In an interview with author Jaime Garcia-Iglesias, PhD, researcher at the University of Edinburgh's Centre for Biomedicine, Self and Society, we discussed the key issues surrounding DoxyPEP's implementation. Garcia-Iglesias emphasized the importance of balancing the benefits and risks, particularly in relation to AMR. He noted, “It’s not about being blind to the risks, but contextualizing them in relation to the many benefits DoxyPEP can provide. At the same time, it’s also about not exaggerating the risks: Doxycycline is currently used for things like malaria and acne, and those applications don’t cause as much debate. Finally, it’s about being aware that the main sources of AMR are sectors like intensive farming, not individuals.”
A core element of the discussion centered on the importance of community involvement in DoxyPEP's rollout. Garcia-Iglesias further elaborated on how community-prescribing models, such as those used during the mpox outbreak, could be adapted to improve access and reduce stigma. He said, “Any plans for implementation should be developed in collaboration with communities. Community-focused interventions have worked very well for mpox vaccination among underserved communities. Community organizations have the capacity to build links and develop trust with communities that facilitate the kind of conversations needed for people to understand the benefits and risks of DoxyPEP. They will be best placed to provide guidance as to what modes of prescribing people prefer: similar to PrEP in the UK (sexual health clinic-based), or different models.”
The lessons learned from the rollout of HIV pre-exposure prophylaxis (PrEP) also provided valuable insights for DoxyPEP’s potential implementation. Garcia-Iglesias reflected on the importance of addressing underlying health inequalities and structural barriers to healthcare access, which he believes were crucial in the uneven distribution of PrEP. He stated, “What we have found with PrEP is that, no matter how efficacious a drug is, it is no fix for structural and social inequalities.” This is particularly important for ensuring that marginalized groups and low-income communities are not left behind in the effort to expand access to DoxyPEP.
In addition to AMR concerns, experts at the roundtable discussed the need for a balanced, evidence-based conversation around the antibiotic’s use. They cautioned against overemphasizing the risks associated with DoxyPEP when compared to other common uses of doxycycline, such as for acne or malaria treatment. Public health messaging should frame DoxyPEP within a broader conversation on AMR, which includes the significant antibiotic burden from industrial farming and environmental sources.
Equity is also a critical theme in DoxyPEP's implementation. Experts emphasize that, like PrEP, DoxyPEP should not only be focused on high-risk groups such as cisgender gay and bisexual men but should be inclusive of other populations, including transgender individuals and people in low-resource settings. Expanding the evidence base to address these gaps will be crucial for ensuring that DoxyPEP benefits are distributed fairly across all populations.
The panel also discussed how DoxyPEP could be integrated into existing sexual health frameworks. Community-prescribing models, which provide users with more autonomy over their healthcare, are seen as a promising solution. These models, which empower people and reduce pressure on clinical systems, could make DoxyPEP more accessible to underserved populations while fostering greater trust within communities. Collaboration with experts in infectious disease, sexual health, and social science will be vital in developing and maintaining these systems.
What You Need To Know
DoxyPEP’s implementation must balance its benefits in enhancing sexual wellbeing with the risks of AMR, contextualizing these risks in relation to the broader use of doxycycline.
Community involvement, especially through community-prescribing models, is essential to ensure equitable access and reduce stigma around DoxyPEP.
Addressing structural health inequalities and ensuring that marginalized groups benefit from DoxyPEP is crucial, as evidenced by the lessons from HIV PrEP’s rollout.
Garcia-Iglesias emphasized that any implementation plan for DoxyPEP must take a holistic approach, integrating this intervention into a broader sexual health strategy. He stressed the importance of balancing DoxyPEP with other approaches, “DoxyPEP should be part of a broader suite of interventions, including vaccinations, home testing kits, and structural reforms. Framing DoxyPEP as one component of a comprehensive approach will ensure its benefits are maximized without overburdening existing infrastructures.”
A recent retrospective cohort study published in JAMA examined the effectiveness of DoxyPEP in preventing STIs among individuals using HIV PrEP. The study found reductions in chlamydia (79%) and syphilis (80%), with a more modest reduction in gonorrhea (12%). These findings are closely related as both highlight the potential of doxyPEP in STI prevention.2
This piece offers broader strategy for equitable implementation of doxyPEP, including the need for community involvement and addressing AMR, while the JAMA study provides specific evidence of doxyPEP’s efficacy in a population of HIV PrEP users. Both pieces emphasize the importance of expanding access to doxyPEP beyond high-risk groups. Garcia-Iglesias’ article stresses inclusive, community-centered approaches, while this study demonstrates doxyPEP’s effectiveness in a predominantly male cohort with a history of STIs. Together, they contribute to a growing body of evidence supporting doxyPEP as a valuable tool in STI prevention, while underscoring the need for thoughtful, equitable implementation strategies.
Reference
1. Garcia-Iglesias J, Ledina C, Gilmore J, et al. DoxyPEP: thinking towards implementation. Lancet Infect Dis. February 18, 2025. Accessed February 24, 2025. doi:10.1016/S1473-3099(25)00077-5
2. Traeger MW, Leyden WA, Volk JE, et al. Doxycycline Postexposure Prophylaxis and Bacterial Sexually Transmitted Infections Among Individuals Using HIV Preexposure Prophylaxis. JAMA Intern Med. January 06, 2025. Accessed February 24, 2025. doi:10.1001/jamainternmed.2024.7186
