The National Association of County and City Health Officials (NACCHO) hosted a virtual consultation, “STI Post-Exposure Prophylaxis with Doxycycline” on December 5th and December 6th, 2022. This meeting was convened by NACCHO with the support of CDC’s Division of STD Prevention (DSTDP) and the National Network of STD Clinical Prevention Training Centers (NNPTCs).

The purpose of this consultation was to gather subject matter experts to share considerations related to implementing doxycycline (doxy) as post-exposure prophylaxis (PEP) (also known as “doxy as PEP”) to prevent STIs. The invite-only consultation included national and global experts in public health, STIs, infectious disease, and antimicrobial resistance. It included overviews of doxy as PEP trial results and discussion of the potential harms, costs, and benefits of using doxy as PEP, and identification of further research needed in these areas.

“NACCHO is proud to have brought together this esteemed group of subject matter experts to discuss the potential of the use of doxycycline as PEP for STIs, as well as potential risks. We hope that this robust conversation will provide important considerations to CDC as they develop future recommendations and national guidance on the use of doxy as PEP,” said Lori Tremmel Freeman, CEO of NACCHO. “Local health departments (LHDs) are on the frontlines of addressing the nation’s growing STI epidemics and we are all eager to see final doxy as PEP results and future guidance from CDC so that LHDs can determine if doxy as PEP will be a new tool in the toolbox to prevent STIs and reduce burden on our communities.”

Together, the subject matter experts explored topics like clinical uses and harms of doxycycline and the possibility of doxycycline resistance developing in STIs or other bacteria. Additionally, there was discussion of questions like “which population(s) would benefit most from doxy as PEP?” and “can doxy as PEP decrease STIs at the population level?”

“This week’s consultation provided an important forum for STI experts around the world to share their thoughts about the promise of doxycycline as PEP, as well as potential risks – factors CDC must carefully consider before issuing national guidance,” said Leandro Mena, M.D., M.P.H., Director of CDC’s Division of STD Prevention. “Our work continues as we await the publication of the DoxyPEP study data, including reviewing information from this week’s consultation and other available research. As the nation’s public health leader, we fully appreciate our immense responsibility to provide evidence-based guidance, that considers all issues.

The doxy as STI PEP consultation highlighted the areas of concern about its potential use, but also areas of hope of what doxy as PEP might do for population-level STI prevalence and for individual patients who see doxy as PEP to take control of their sexual health. A few key takeaways are as follows:

• Doxycycline as PEP for STI has the potential to reduce STIs as shown by recent studies but it must be rolled out equitably and should be provided in the context of culturally competent care and of shared decision making between providers and patients.
• There are real and concerning potential risks to the overuse of antibiotics which include antimicrobial resistance – both for STI pathogens and other important human pathogens – and the human microbiome, which may have long term clinical consequences for individuals. Neither of these risks are yet well-defined for doxy as PEP.
• Determining populations who will benefit from doxy as PEP is not straightforward and may mean making trade-offs between doxy as PEP coverage and overuse of antibiotics.
• Experts attempted to address which patients should be offered doxy as STI PEP and some proposed groups included people with recurrent STIs, or MSM and TGW who have had at least on STI in the past year for doxy as PEP

• Community members cited additional benefits of doxy as PEP in reducing feelings of anxiety and stigma associated with an STI diagnosis or exposing partners to infection
• Regional differences could be impactful when weighing the risk/benefits of doxy as PEP and is especially important to consider when thinking about implementation and determining the appropriate populations for doxy as PEP may not be straightforward so there should be federal guidance with room for localization of the implementation.
• Many of the unknowns about the potential risks of doxy as PEP will not be answered before some areas are ready to implement it as a prevention option – but it is possible to provide some guidelines to patients and physicians even when there is uncertainty.

A brief executive summary with additional takeaways from the meeting is forthcoming. NACCHO will continue to provide updates when new information is available.

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