Doxy PrEP

(About the author/contact. 5/30/18)

[For more on the state-of-the-science of doxy PrEP/doxy PEP, feel free to peruse the uptodate-as-of -2020 rundown/review by Grant et al that lists a who’s-who of recent-, ongoing-, and planned STI PrEP/PEP trials, including Klausner, who reported in 2015, Molina, who reported in 2017, and Grennan just in 2020. The review also includes a table (screenshotted below) just for the ongoing and planned doxy-prophylaxis trials large and small. Fascinatingly, IPERGAY trial principal investigator Molina’s nested (PRÉVENIR HIV/STI PrEP) study called DOXYVAC includes a Bexsero–meningitis-vaccine-as-Gonorrhea-vaccine test-of-concept study. These planned-/pending-/ongoing studies, in addition to exploring antibiotic impacts on gut microbes, will look at antibiotic resistance since the data are few, not robust, and mixed on that in the context of STI transmission.]

Table 2. Key Characteristics of Studies in Progress or Development on Doxycycline Prophylaxis for Sexually Transmitted Infections, March 2019

Just needed to park a few anxieties somewhere, so here goes…

I went to the doctor’s office a few weeks ago for my quarterly PrEP checkup and had to see a different care provider since mine had had scheduling issues.

The stand-in had an intern with him. ‘No problem,’ I thought magnanimously, ‘I’m all for keeping it light, patient, and real. They can learn a lot from that.’

We started going through the usual questions:

“Are you still on PrEP,” he asked.

“Yes,” I answered.

“And are you taking it every day,” he pressed further.

“I’m doing 4 doses per week,” I explained, ready to deploy my rationale and supporting research if needed.

“That’s the IPERGAY dosing schedule [for anal exposures],” he offered in an aside to the intern.

This was my opportunity. I launched into it anxious but at full throttle. “Well, it’s more like the finding from IPREX that no one who took four pills per week got HIV.”

“I need to look that up right quick,” he admitted, bowing his head and setting to type on his laptop.

I didn’t relent. “I only have one kidney, and I was actually supposed to talk with my doctor about seeing a kidney specialist…”

“…A nephrologist…” he interjected, regaining his focus.

“…Yes… and because I do a lot of prevention research, I was just in Baltimore at Hopkins for a microbicide study and the researcher there said he knows a nephrologist who deals with HIV a lot and he might be a good person to consult with, but I was worried about cost and networks for my insurance. Do you know if I could get that covered?” I kind of wanted to shift the topic to make clear that my dosing practices weren’t up for discussion and evaluation herein.

“Oh, we don’t know about networks and plans, you’d have to talk to your insurance.” His hands were cleaned metaphorically speaking with that comment it seemed.

“Oh, maaaan! Ok.” I was keeping it light but I thought ‘Great! Now I’ll have to bushwhack through the bureaucracy … AGAIN!’

(How I finally got on PrEP is a long story. Maybe I’ll tell it in this space some day. Suffice it to say for now I had months of this kind of run-around between potential providers, the insurance company, and myself.)

Fast forward to the part about other recent meds and conditions as well as condom use. I proffered that I don’t use condoms much, opting instead for things like bottoming less than topping, getting tested about every 6 weeks, and preferring to biomed-sort for others on PrEP or Treatment-as-Prevention (TasP).

Likely to encourage me to rethink my reliance on TasP, he cautioned that people who are poz-undetectable with STIs CAN still transmit HIV. I felt like I was supposed to challenge him, but instead, I just said ‘ok’ and noted in my head that he was at odds with the science that I know from the U=U campaign. He seemed to really push doxycycline STI prophylaxis (taking small daily pre-exposure doses or slightly higher post-exposure doses of the antibiotic to help prevent chlamydia, gonorrhea, and/or syphilis, doxy PrEP and PEP respectively). He explained “Oh, I’m putting ALL my slutty friends on doxy PrEP …” likely to normalize the procedure and with a laugh to soften the blow of the judgement embedded in his joke, adding “There’s a big push from the health commissioner…”

Now, granted, I did have a syphilis diagnosis in the fall and have had other bacterial STIs before/since. And I did also concede that I was amenable to doxy PEP. I mean, I’ve been keen to the idea since folks in Cali and the French started publishing data among cis MSM back in 2015 (Indeed, I wish expedited partner services/treatment were implemented locally.) but I just hate a hard sell.

(For more on the state-of-the-science of doxy PrEP/doxy PEP, feel free to peruse the uptodate-as-of -2020 rundown/review by Grant et al that lists a who’s-who of recent-, ongoing-, and planned STI PrEP/PEP trials, including Klausner, who reported in 2015, Molina, who reported in 2017, and Grennan just in 2020. The review also includes a table (screenshotted below) just for the ongoing and planned doxy-prophylaxis trials large and small. Fascinatingly, IPERGAY trial principal investigator Molina’s nested (PRÉVENIR HIV/STI PrEP) study called DOXYVAC includes a Bexsero–meningitis-vaccine-as-Gonorrhea-vaccine test-of-concept study. These planned-/pending-/ongoing studies, in addition to exploring antibiotic impacts on gut microbes, will look at antibiotic resistance since the data are few, not robust, and mixed on that in the context of STI transmission.)

I’m also iffy because I’d like to see more data on doxy PrEP and needed to find out the cost of a prescription because I might not have been able to cover it. ‘I’m also concerned about the impact on gut flora’ I told him. And after making my reservation known, I accepted what I felt like was an executive decision on his part as a prescriber.

I must admit though that I am curious if it will have any effect on the low level residual/adult acne I get since some people take a daily dose for acne management. I’d also love to have to do less of the “Hey, I tested positive for … “ heads-up texts, especially if/when/as I launch out of dry spells into greater volumes of sex and/or exploring kinks more.

I’ve learned a few other interesting tidbits about using doxy regularly. For instance, because some experience sun sensitivity during doxy use, there’s a recommendation to wear a strong sun screen. Doxy can also create irritating esophagitis. So, it’s suggested that the pill be taken when the user is in an upright position (and staying upright for at least 90 seconds after swallowing), with ample water for swallowing (at least 100mL), and at least 30 minutes before lying down to rest. Doxy-related stomach upset can also be managed by eating food with pill-taking (but could reduce absorption slightly). Additionally, it can also trigger diarrhea (the so-called post-pill fast flush, particularly on an empty stomach). However, on the positive side, doxy is also used as a prophylactic against malaria and a prophylactic against Lyme disease, so there’s that too!

Obviously, you’d also have to consider with your doctor any doxy interactions with other drugs you’re already taking if you’d like to try it since YMMV.

In any event, it turned out that my prescription was covered, and the copay was just $4. I took my first two 100mg doxy PEP pills last Saturday. (You can take one 100mg pill daily as doxy PrEP or two 100mg pills upto 72hrs after any likely exposure, preferably within 24, for doxy PEP.) I’m still thinking through it since I felt it was sprung on me (we didn’t even discuss dosing or what to expect from side-effects) but deployments after group, anonymous sex, with new partners, or “in the window” if/when I get heads up are likely contexts … In addition to any heads-up I get within 24-72hrs of any potential exposure (which is VERY rare, sadly, compared to how much and how often in the way of notice I give). So far, not much out of the ordinary in GI reactions (some loose stool, gas, and feeling a bit bloated but that happens regardless given my general diet) and no photosensitivity or dizziness yet and only time and population data will tell with gut flora impacts and/or antibiotic resistance to this prevention approach.

One other concern came up in my consideration and information-gathering around doxy PrEP. That is the question of what implications there are of doxy PrEP in HIV prevention research. Indeed, STI prevalence data represents just about the best proxy we have right now for comparing and quantifying HIV risk exposures among various groups of trial participants, and doxy’s STI prevention capability will likely mask some such evidence of HIV exposure risk contexts. In other words, as more data comes out on doxy PrEP efficacy and as more people start using it, researchers will have to consider that use in their effort to gauge just how much HIV acquisition was prevented based on how much other STI acquisition (via pelvic orifice principally) there was still acquired if doxy PrEP is preventing some of those other STIs as well.

As for me, I have my next STI check in about 2wks. I wonder how often I’ll need/want to do this.

Wish me luck!