Opinion Paper

Doxycycline post-exposure prophylaxis for sexually transmitted infections in South Africa

Remco P.H. Peters, James A. McIntyre, Nigel Garrett, Adrian J. Brink, Connie L. Celum, Linda-Gail Bekker
Southern African Journal of HIV Medicine | Vol 24, No 1 | a1510 | DOI: https://doi.org/10.4102/sajhivmed.v24i1.1510 | © 2023 Remco P.H. Peters, James A. McIntyre, Nigel Garett, Adrian J Brink, Connie L Celum, Linda-Gail Bekker | This work is licensed under CC Attribution 4.0
Submitted: 09 June 2023 | Published: 28 September 2023

About the author(s)

Remco P.H. Peters, Research Unit, Foundation for Professional Development, East London Department of Medical Microbiology, University of Pretoria, Pretoria Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
James A. McIntyre, Anova Health Institute, Johannesburg School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
Nigel Garrett, Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
Adrian J. Brink, Division of Medical Microbiology, University of Cape Town, Cape Town National Health Laboratory Services, Groote Schuur Hospital, Cape Town Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
Connie L. Celum, Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, United States
Linda-Gail Bekker, Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa

Abstract

South Africa has a large burden of bacterial sexually transmitted infections (STIs) with high rates among men who have sex with men (MSM). Randomised controlled trials have recently demonstrated high effectiveness of doxycycline post-exposure prophylaxis (PEP) for prevention of bacterial STIs in MSM, with 70% – 85% reductions in Chlamydia trachomatis infection and syphilis, and approximately 50% reduction in Neisseria gonorrhoeae infection. Doxycycline PEP was not demonstrated to be effective in reducing C. trachomatis and N. gonorrhoeae infection among Kenyan cisgender women. Although no worrisome trends in antimicrobial resistance (AMR) were observed in the trials, important concerns remain about doxycycline PEP and AMR development in STIs, other pathogens, commensals, and the microbiome. Tetracycline resistance in N. gonorrhoeae is already widespread in South Africa, but emergence of AMR in other STIs would be concerning. Larger sample sizes of doxycycline PEP users with longer follow-up time are needed to understand the impact that doxycycline PEP may have on AMR at individual and population level. In this opinion article, we weigh the benefits of doxycycline PEP for prevention of bacterial STIs against the existing AMR concerns and data gaps in the South African context. Based on the current evidence, we conclude that it would be reasonable to offer doxycycline PEP to high-risk MSM on a case-by-case basis, provided that it is offered by experienced sexual health clinicians in settings that have access to diagnostic STI testing and ongoing AMR surveillance.

Keywords

doxycycline; STI prevention; men who have sex with men; antimicrobial resistance; Chlamydia trachomatis; Neisseria gonorrhoeae; syphilis

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