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Sexually transmitted infections (STIs) continue to have a significant impact on the lives of adolescents and young adults. According to the Centers for Disease Control and Prevention’s (CDC) 2021 surveillance report, rates of gonorrhea and syphilis in the United States were at their highest since the early 1990s. Chlamydia, one of the most common STIs, had a peak rate in 2019, but more recent rates may have been impacted by the COVID-19 pandemic. In 2021, those 15-24 years of age accounted for 58.5% of all chlamydia infections, 40.4% of all gonorrhea infections, and 18.3% of all syphilis infections in the US.
While pediatricians should discuss sexual health and STI screening with all their adolescent and young adult patients, LGBTQ+ youth are disproportionately impacted by STIs. For example, cisgender men who have sex with men have significantly higher rates of HIV, gonorrhea, and syphilis. These disparities are likely related to unequal access to care, systemic homophobia/transphobia, stigma, and differences in sexual networks and are even more pronounced for those with intersectional minoritized identities such as LGBTQ+ youth of color.1
In the past 12 years, there have been significant advances in HIV prevention methods, including the approval and use of pre-exposure prophylaxis or “PrEP” (a medication regimen that is taken on an ongoing basis to provide highly effective protection against HIV infection) and more widespread use of post-exposure prophylaxis or “PEP” (a medication regimen taken for 1 month after a potential exposure to HIV to prevent HIV from establishing an ongoing infection) outside of the medical setting. While these interventions have the potential to decrease rates of HIV infection, they do not prevent any other STIs.2-3
The current strategies to prevent bacterial STIs include discussions of sexual practices, counseling on risk reduction strategies such as decreased number of partners and condom use, routine screening in those at risk every 3-12 months, and timely diagnosis and treatment of infections in patients and their partners to avoid further transmission.4 Given the increasing rates of bacterial STIs (gonorrhea, chlamydia, and syphilis), additional biomedical prevention methods are greatly needed.
Doxycycline as post-exposure prophylaxis
Doxycycline is a tetracycline antibiotic effective against a wide range of bacteria and is commonly used in the treatment of acne, skin infections, Lyme disease, and STIs, and can also be used in the treatment and prevention of malaria.5 For STIs, doxycycline is currently the recommended treatment for chlamydia and is also an alternate therapy for syphilis in nonpregnant patients when penicillin is not accessible or in those with severe penicillin allergy.4 This medication is often well tolerated with the most common side effects including gastrointestinal irritation and photosensitivity. Doxycycline is contraindicated in pregnancy due to its potential impact on tooth and bone development.5
Given its general tolerability and activity against bacterial STIs, new and emerging studies have examined doxycycline as post-exposure prophylaxis (DoxyPEP: one dose of doxycycline 200 mg PO within 72 hours after unprotected sex) in an attempt to decrease the incidence of new bacterial STIs in populations at risk. Three of the studies cited in the preliminary CDC DoxyPEP guidelines were conducted in cisgender men who have sex with men and transgender women either living with HIV or taking PrEP for HIV prevention. All three studies demonstrated significantly lower risk of chlamydia and syphilis, while two of the studies also showed a significantly lower risk of gonorrhea. One additional study was conducted in cisgender women in Kenya. This study did not show any statistically significant difference in the risk of chlamydia or gonorrhea in the intervention group, but may have been limited by low adherence to the DoxyPEP regimen. There were no serious adverse events reported in any of the studies attributed to doxycycline.6
Avoiding antibiotic resistance
With the increased use of antibiotics, attention must always be paid to the potential for increasing antibiotic resistance. The preliminary CDC DoxyPEP guidelines outline mixed results in the DoxyPEP studies that had limited follow-up timeframes, making it difficult to draw conclusions: “Current data suggest overall benefit of the use of doxycycline PEP, but potential risks related to the development of resistance and impacts on the microbiome will need to be closely monitored after implementation of these guidelines.” Official guideline recommendations from the CDC regarding DoxyPEP are currently pending after a period of public comment on the preliminary drafted guidelines.6 However, the New York State Department of Health AIDS Institute released guidelines for DoxyPEP in September 2023 and several large urban public health departments have also issued their own guidance that largely align with the preliminary CDC guidelines.7
Recommendations currently emphasize that the goal is to allow for implementation of DoxyPEP in those who would benefit the most from the intervention (i.e., cisgender men who have sex with men and transgender women with a history of at least one bacterial STI in the last 12 months with ongoing risk of infection), while also minimizing antibiotic use. It should also be considered for those without a recent infection who have increased likelihood of exposure to bacterial STIs. DoxyPEP is likely to be effective in other populations (e.g., cisgender women, cisgender men who have sex with women, transgender men), but data are currently limited, and the risk/benefit ratio may be different in these populations. The recommended dose for DoxyPEP is doxycycline 200 mg once as soon as possible (within 72 hours) of unprotected oral, vaginal, or anal sex with a maximum of one dose every 24 hours. For those being prescribed DoxyPEP, gonorrhea and chlamydia screening of all anatomic sites of exposure (urine sample or frontal swab, throat swab, and/or rectal swab) should be conducted at baseline and then every 3-6 months in addition to blood testing for syphilis and HIV if indicated.6-7
Another option in our toolkit
DoxyPEP should be viewed as one more option in our toolkit of sexual health services alongside risk reduction strategies (e.g., open discussions with partners, decreased number of partners, and condom use), routine STI screening and treatment, PrEP and PEP for HIV prevention, and pregnancy prevention. Not all of these tools will be relevant to each individual and discussions around sexual health should be patient-centered and focused on their own personal goals. As pediatricians, we should provide guidance to all adolescents and young adults on options to improve their sexual health and empower them to embrace their bodily autonomy.
Dr. Warus is in the division of adolescent and young adult medicine at Children’s Hospital of Los Angeles, where he specializes in care for transgender and gender-nonconforming youth, and LGBTQ health for youth. He is an assistant professor of pediatrics at USC.
Resources
CDC – Sexually Transmitted Infection Treatment Guidelines, 2021
CDC – [Preliminary] Guidelines for the Use of Doxycycline Post-Exposure Prophylaxis for Bacterial Sexually Transmitted Infection (STI) Prevention
New York State Department of Health AIDS Institute – Doxycycline Post-Exposure Prophylaxis to Prevent Bacterial Sexually Transmitted Infections
Los Angeles County Department of Public Health – DoxyPEP for STI Prevention
References
1. Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2021: National Overview of STDs, 2021. Last Reviewed May 16, 2023.
2. Centers for Disease Control and Prevention: US Public Health Service: Preexposure Prophylaxis for the Prevention of HIV Infection in the United States – 2021 Update: A Clinical Practice Guideline. Published 2021.
3. Centers for Disease Control and Prevention: US Department of Health and Human Services: Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV – United States, 2016. Published 2016. .
4. Workowski KA et al. Sexually Transmitted Infection Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):2-10.
5. Patel RS and Parmar M. Doxycycline Hyclate. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Last Updated May 22, 2023.
6. Centers for Disease Control and Prevention. [Preliminary] Guidelines for the Use of Doxycycline Post-Exposure Prophylaxis for Bacterial Sexually Transmitted Infection (STI) Prevention. Published Oct 1, 2023.
7. DiMarco DE, et al. Doxycycline Post-Exposure Prophylaxis to Prevent Bacterial Sexually Transmitted Infections. New York State Department of Health AIDS Institute. Published September 25, 2023.
Sexually transmitted infections (STIs) continue to have a significant impact on the lives of adolescents and young adults. According to the Centers for Disease Control and Prevention’s (CDC) 2021 surveillance report, rates of gonorrhea and syphilis in the United States were at their highest since the early 1990s. Chlamydia, one of the most common STIs, had a peak rate in 2019, but more recent rates may have been impacted by the COVID-19 pandemic. In 2021, those 15-24 years of age accounted for 58.5% of all chlamydia infections, 40.4% of all gonorrhea infections, and 18.3% of all syphilis infections in the US.
While pediatricians should discuss sexual health and STI screening with all their adolescent and young adult patients, LGBTQ+ youth are disproportionately impacted by STIs. For example, cisgender men who have sex with men have significantly higher rates of HIV, gonorrhea, and syphilis. These disparities are likely related to unequal access to care, systemic homophobia/transphobia, stigma, and differences in sexual networks and are even more pronounced for those with intersectional minoritized identities such as LGBTQ+ youth of color.1
In the past 12 years, there have been significant advances in HIV prevention methods, including the approval and use of pre-exposure prophylaxis or “PrEP” (a medication regimen that is taken on an ongoing basis to provide highly effective protection against HIV infection) and more widespread use of post-exposure prophylaxis or “PEP” (a medication regimen taken for 1 month after a potential exposure to HIV to prevent HIV from establishing an ongoing infection) outside of the medical setting. While these interventions have the potential to decrease rates of HIV infection, they do not prevent any other STIs.2-3
The current strategies to prevent bacterial STIs include discussions of sexual practices, counseling on risk reduction strategies such as decreased number of partners and condom use, routine screening in those at risk every 3-12 months, and timely diagnosis and treatment of infections in patients and their partners to avoid further transmission.4 Given the increasing rates of bacterial STIs (gonorrhea, chlamydia, and syphilis), additional biomedical prevention methods are greatly needed.
Doxycycline as post-exposure prophylaxis
Doxycycline is a tetracycline antibiotic effective against a wide range of bacteria and is commonly used in the treatment of acne, skin infections, Lyme disease, and STIs, and can also be used in the treatment and prevention of malaria.5 For STIs, doxycycline is currently the recommended treatment for chlamydia and is also an alternate therapy for syphilis in nonpregnant patients when penicillin is not accessible or in those with severe penicillin allergy.4 This medication is often well tolerated with the most common side effects including gastrointestinal irritation and photosensitivity. Doxycycline is contraindicated in pregnancy due to its potential impact on tooth and bone development.5
Given its general tolerability and activity against bacterial STIs, new and emerging studies have examined doxycycline as post-exposure prophylaxis (DoxyPEP: one dose of doxycycline 200 mg PO within 72 hours after unprotected sex) in an attempt to decrease the incidence of new bacterial STIs in populations at risk. Three of the studies cited in the preliminary CDC DoxyPEP guidelines were conducted in cisgender men who have sex with men and transgender women either living with HIV or taking PrEP for HIV prevention. All three studies demonstrated significantly lower risk of chlamydia and syphilis, while two of the studies also showed a significantly lower risk of gonorrhea. One additional study was conducted in cisgender women in Kenya. This study did not show any statistically significant difference in the risk of chlamydia or gonorrhea in the intervention group, but may have been limited by low adherence to the DoxyPEP regimen. There were no serious adverse events reported in any of the studies attributed to doxycycline.6
Avoiding antibiotic resistance
With the increased use of antibiotics, attention must always be paid to the potential for increasing antibiotic resistance. The preliminary CDC DoxyPEP guidelines outline mixed results in the DoxyPEP studies that had limited follow-up timeframes, making it difficult to draw conclusions: “Current data suggest overall benefit of the use of doxycycline PEP, but potential risks related to the development of resistance and impacts on the microbiome will need to be closely monitored after implementation of these guidelines.” Official guideline recommendations from the CDC regarding DoxyPEP are currently pending after a period of public comment on the preliminary drafted guidelines.6 However, the New York State Department of Health AIDS Institute released guidelines for DoxyPEP in September 2023 and several large urban public health departments have also issued their own guidance that largely align with the preliminary CDC guidelines.7
Recommendations currently emphasize that the goal is to allow for implementation of DoxyPEP in those who would benefit the most from the intervention (i.e., cisgender men who have sex with men and transgender women with a history of at least one bacterial STI in the last 12 months with ongoing risk of infection), while also minimizing antibiotic use. It should also be considered for those without a recent infection who have increased likelihood of exposure to bacterial STIs. DoxyPEP is likely to be effective in other populations (e.g., cisgender women, cisgender men who have sex with women, transgender men), but data are currently limited, and the risk/benefit ratio may be different in these populations. The recommended dose for DoxyPEP is doxycycline 200 mg once as soon as possible (within 72 hours) of unprotected oral, vaginal, or anal sex with a maximum of one dose every 24 hours. For those being prescribed DoxyPEP, gonorrhea and chlamydia screening of all anatomic sites of exposure (urine sample or frontal swab, throat swab, and/or rectal swab) should be conducted at baseline and then every 3-6 months in addition to blood testing for syphilis and HIV if indicated.6-7
Another option in our toolkit
DoxyPEP should be viewed as one more option in our toolkit of sexual health services alongside risk reduction strategies (e.g., open discussions with partners, decreased number of partners, and condom use), routine STI screening and treatment, PrEP and PEP for HIV prevention, and pregnancy prevention. Not all of these tools will be relevant to each individual and discussions around sexual health should be patient-centered and focused on their own personal goals. As pediatricians, we should provide guidance to all adolescents and young adults on options to improve their sexual health and empower them to embrace their bodily autonomy.
Dr. Warus is in the division of adolescent and young adult medicine at Children’s Hospital of Los Angeles, where he specializes in care for transgender and gender-nonconforming youth, and LGBTQ health for youth. He is an assistant professor of pediatrics at USC.
Resources
CDC – Sexually Transmitted Infection Treatment Guidelines, 2021
CDC – [Preliminary] Guidelines for the Use of Doxycycline Post-Exposure Prophylaxis for Bacterial Sexually Transmitted Infection (STI) Prevention
New York State Department of Health AIDS Institute – Doxycycline Post-Exposure Prophylaxis to Prevent Bacterial Sexually Transmitted Infections
Los Angeles County Department of Public Health – DoxyPEP for STI Prevention
References
1. Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2021: National Overview of STDs, 2021. Last Reviewed May 16, 2023.
2. Centers for Disease Control and Prevention: US Public Health Service: Preexposure Prophylaxis for the Prevention of HIV Infection in the United States – 2021 Update: A Clinical Practice Guideline. Published 2021.
3. Centers for Disease Control and Prevention: US Department of Health and Human Services: Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV – United States, 2016. Published 2016. .
4. Workowski KA et al. Sexually Transmitted Infection Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):2-10.
5. Patel RS and Parmar M. Doxycycline Hyclate. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Last Updated May 22, 2023.
6. Centers for Disease Control and Prevention. [Preliminary] Guidelines for the Use of Doxycycline Post-Exposure Prophylaxis for Bacterial Sexually Transmitted Infection (STI) Prevention. Published Oct 1, 2023.
7. DiMarco DE, et al. Doxycycline Post-Exposure Prophylaxis to Prevent Bacterial Sexually Transmitted Infections. New York State Department of Health AIDS Institute. Published September 25, 2023.
Sexually transmitted infections (STIs) continue to have a significant impact on the lives of adolescents and young adults. According to the Centers for Disease Control and Prevention’s (CDC) 2021 surveillance report, rates of gonorrhea and syphilis in the United States were at their highest since the early 1990s. Chlamydia, one of the most common STIs, had a peak rate in 2019, but more recent rates may have been impacted by the COVID-19 pandemic. In 2021, those 15-24 years of age accounted for 58.5% of all chlamydia infections, 40.4% of all gonorrhea infections, and 18.3% of all syphilis infections in the US.
While pediatricians should discuss sexual health and STI screening with all their adolescent and young adult patients, LGBTQ+ youth are disproportionately impacted by STIs. For example, cisgender men who have sex with men have significantly higher rates of HIV, gonorrhea, and syphilis. These disparities are likely related to unequal access to care, systemic homophobia/transphobia, stigma, and differences in sexual networks and are even more pronounced for those with intersectional minoritized identities such as LGBTQ+ youth of color.1
In the past 12 years, there have been significant advances in HIV prevention methods, including the approval and use of pre-exposure prophylaxis or “PrEP” (a medication regimen that is taken on an ongoing basis to provide highly effective protection against HIV infection) and more widespread use of post-exposure prophylaxis or “PEP” (a medication regimen taken for 1 month after a potential exposure to HIV to prevent HIV from establishing an ongoing infection) outside of the medical setting. While these interventions have the potential to decrease rates of HIV infection, they do not prevent any other STIs.2-3
The current strategies to prevent bacterial STIs include discussions of sexual practices, counseling on risk reduction strategies such as decreased number of partners and condom use, routine screening in those at risk every 3-12 months, and timely diagnosis and treatment of infections in patients and their partners to avoid further transmission.4 Given the increasing rates of bacterial STIs (gonorrhea, chlamydia, and syphilis), additional biomedical prevention methods are greatly needed.
Doxycycline as post-exposure prophylaxis
Doxycycline is a tetracycline antibiotic effective against a wide range of bacteria and is commonly used in the treatment of acne, skin infections, Lyme disease, and STIs, and can also be used in the treatment and prevention of malaria.5 For STIs, doxycycline is currently the recommended treatment for chlamydia and is also an alternate therapy for syphilis in nonpregnant patients when penicillin is not accessible or in those with severe penicillin allergy.4 This medication is often well tolerated with the most common side effects including gastrointestinal irritation and photosensitivity. Doxycycline is contraindicated in pregnancy due to its potential impact on tooth and bone development.5
Given its general tolerability and activity against bacterial STIs, new and emerging studies have examined doxycycline as post-exposure prophylaxis (DoxyPEP: one dose of doxycycline 200 mg PO within 72 hours after unprotected sex) in an attempt to decrease the incidence of new bacterial STIs in populations at risk. Three of the studies cited in the preliminary CDC DoxyPEP guidelines were conducted in cisgender men who have sex with men and transgender women either living with HIV or taking PrEP for HIV prevention. All three studies demonstrated significantly lower risk of chlamydia and syphilis, while two of the studies also showed a significantly lower risk of gonorrhea. One additional study was conducted in cisgender women in Kenya. This study did not show any statistically significant difference in the risk of chlamydia or gonorrhea in the intervention group, but may have been limited by low adherence to the DoxyPEP regimen. There were no serious adverse events reported in any of the studies attributed to doxycycline.6
Avoiding antibiotic resistance
With the increased use of antibiotics, attention must always be paid to the potential for increasing antibiotic resistance. The preliminary CDC DoxyPEP guidelines outline mixed results in the DoxyPEP studies that had limited follow-up timeframes, making it difficult to draw conclusions: “Current data suggest overall benefit of the use of doxycycline PEP, but potential risks related to the development of resistance and impacts on the microbiome will need to be closely monitored after implementation of these guidelines.” Official guideline recommendations from the CDC regarding DoxyPEP are currently pending after a period of public comment on the preliminary drafted guidelines.6 However, the New York State Department of Health AIDS Institute released guidelines for DoxyPEP in September 2023 and several large urban public health departments have also issued their own guidance that largely align with the preliminary CDC guidelines.7
Recommendations currently emphasize that the goal is to allow for implementation of DoxyPEP in those who would benefit the most from the intervention (i.e., cisgender men who have sex with men and transgender women with a history of at least one bacterial STI in the last 12 months with ongoing risk of infection), while also minimizing antibiotic use. It should also be considered for those without a recent infection who have increased likelihood of exposure to bacterial STIs. DoxyPEP is likely to be effective in other populations (e.g., cisgender women, cisgender men who have sex with women, transgender men), but data are currently limited, and the risk/benefit ratio may be different in these populations. The recommended dose for DoxyPEP is doxycycline 200 mg once as soon as possible (within 72 hours) of unprotected oral, vaginal, or anal sex with a maximum of one dose every 24 hours. For those being prescribed DoxyPEP, gonorrhea and chlamydia screening of all anatomic sites of exposure (urine sample or frontal swab, throat swab, and/or rectal swab) should be conducted at baseline and then every 3-6 months in addition to blood testing for syphilis and HIV if indicated.6-7
Another option in our toolkit
DoxyPEP should be viewed as one more option in our toolkit of sexual health services alongside risk reduction strategies (e.g., open discussions with partners, decreased number of partners, and condom use), routine STI screening and treatment, PrEP and PEP for HIV prevention, and pregnancy prevention. Not all of these tools will be relevant to each individual and discussions around sexual health should be patient-centered and focused on their own personal goals. As pediatricians, we should provide guidance to all adolescents and young adults on options to improve their sexual health and empower them to embrace their bodily autonomy.
Dr. Warus is in the division of adolescent and young adult medicine at Children’s Hospital of Los Angeles, where he specializes in care for transgender and gender-nonconforming youth, and LGBTQ health for youth. He is an assistant professor of pediatrics at USC.
Resources
CDC – Sexually Transmitted Infection Treatment Guidelines, 2021
CDC – [Preliminary] Guidelines for the Use of Doxycycline Post-Exposure Prophylaxis for Bacterial Sexually Transmitted Infection (STI) Prevention
New York State Department of Health AIDS Institute – Doxycycline Post-Exposure Prophylaxis to Prevent Bacterial Sexually Transmitted Infections
Los Angeles County Department of Public Health – DoxyPEP for STI Prevention
References
1. Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2021: National Overview of STDs, 2021. Last Reviewed May 16, 2023.
2. Centers for Disease Control and Prevention: US Public Health Service: Preexposure Prophylaxis for the Prevention of HIV Infection in the United States – 2021 Update: A Clinical Practice Guideline. Published 2021.
3. Centers for Disease Control and Prevention: US Department of Health and Human Services: Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV – United States, 2016. Published 2016. .
4. Workowski KA et al. Sexually Transmitted Infection Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):2-10.
5. Patel RS and Parmar M. Doxycycline Hyclate. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Last Updated May 22, 2023.
6. Centers for Disease Control and Prevention. [Preliminary] Guidelines for the Use of Doxycycline Post-Exposure Prophylaxis for Bacterial Sexually Transmitted Infection (STI) Prevention. Published Oct 1, 2023.
7. DiMarco DE, et al. Doxycycline Post-Exposure Prophylaxis to Prevent Bacterial Sexually Transmitted Infections. New York State Department of Health AIDS Institute. Published September 25, 2023.