HRSA Offers Guidance on Doxy-PEP to Stem the Tide of Rising STIs Among PLWHAs

By: Ranier Simons, ADAP Blog Guest Contributor

According to the Centers for Disease Control & Prevention (CDC), there were 2.5 million reported cases of gonorrhea, chlamydia, and syphilis in the United States in 2022.[1] The rates of sexually transmitted diseases (STIs) have been increasing globally, which is of particular concern for people living with HIV/AIDS (PLWHA). One strategy that is proving highly successful in combatting the spread of STIs is Doxy-PEP (post exposure prophylaxis).

Photo Source: The Washington Post

The presence of HIV in the body can, in some cases, make it harder to treat STIs.[2] Additionally, an STI can increase the HIV viral load in PLWHA who are not on treatment regimens.[3] For those with good antiretroviral adherence, an STI is not likely to change someone from undetectable to detectable. However, the numerous harms STIs inflict on the body make it essential to reduce STIs' impact on PLWHA. The Health Resources & Services Administration (HRSA) recently issued a letter to Ryan White HIV/AIDS Program (RWHAP) colleagues emphasizing their role in lowering the risk of STIs for PLWHA, as well as awareness of new clinical guidelines on the use of doxy PEP in preventing bacterial STIs.[4]

Doxy-PEP is the administration of 200 mg of doxycycline within 24-72 hours of condomless anal, vaginal, or oral sex and should not exceed a maximum of 200mg in any 24hr period.[5] Studies have shown that Doxy-PEP reduces syphilis and chlamydia infections by more than 70% and gonococcal infections by approximately 50%.[5]

Men who have sex with men (MSM) and transgender women (TGW) have been identified as groups disproportionately affected by STIs. Thus, CDC guidelines recommend that medical professionals target MSM and TGW who have had a bacterial STI in the past twelve months to offer education and counseling on the benefits of Doxy-PEP. After counseling and education, if desired, providers should provide prescriptions for Doxy-PEP to be self-administered.[5]

Photo Source: The PrEP Clinic

HRSA’s letter specifically encourages RWHAP recipients to adopt the CDC guidelines and integrate Doxy-PEP into their protocols and clinical programs. The letter also urges state AIDS Drug Assistance Programs (ADAPs) to add Doxy-PEP to their drug formularies to facilitate equitable access and coverage for their eligible populations. In case they are unaware, HRSA reminds RWHAP colleagues that purchasing Doxy-PEP is an allowable cost. “RWHAP Parts A, C, and D recipients may contribute RWHAP funds to ADAPs to purchase medications and/or health care coverage and medication cost sharing for ADAP-eligible clients.”[4]

Proper administration of Doxy-PEP requires STI testing every three to six months, as well as evaluation of the appropriateness of continued utilization of doxy PEP.[5] Increasing the number of those utilizing the antibiotic intervention will also increase the instances of contact with care professionals. Increased contact means more opportunities for strengthening linkages to care and exploration of other points of need. One of the main goals of RWHAP is to improve the health outcomes of PLWHA. Adoption of Doxy-PEP practices and protocols would be another tool to add to comprehensive whole-person care along with established practices such as harm-reduction and risk-reduction counseling, facilitating access to PrEP, and regular STI testing.

Photo Source: The PrEP Clinic

Notably, HRSA’s letter highlighted the RWHAP Part F's AIDS Education and Training Center (AETC) Program and the RWHAP Part F Special Projects of National Significance Addressing STIs: “Ask. Test. Treat. Repeat.” Initiative.[6,7] Both programs provide training and information on the proper implementation of Doxy-PEP and ways to adopt and normalize routine testing of STIs. This letter from HRSAs HIV/AIDS Bureau is more than just an F.Y.I. It is a tangible outreach of support for RWHAP colleagues. 

Ryan White-funded organizations work tirelessly to stretch federal dollars to improve the health and well-being of the vulnerable populations of PLWHA they serve. Clear guidance on Doxy-PEP and the proliferation of educational resources directly acknowledges that the federal government is an active partner with and sees and embraces the efforts of RWHAP recipients.

[1] CDC. (2024, January 30). CDC’s 2022 STI Surveillance Report underscores that STIs must be a public health priority. Retrieved from https://www.cdc.gov/std/statistics/2022/default.htm

[2] U.S. Department of Health & Human Services. (2024, June 27). Sexually Transmitted Infections. Retrieved from https://www.hiv.gov/hiv-basics/staying-in-hiv-care/other-related-health-issues/sexually-transmitted-diseases#:~:text=Many%20STIs%20do%20not%20have,if%20you're%20sexually%20active.

[3] Stanford, A. (2023, September). Undetectable viral load and HIV transmission. Retrieved from https://www.aidsmap.com/about-hiv/undetectable-viral-load-and-hiv-transmission

[4] HRSA. (2024, July 31). Letter to Ryan White HIV/AIDS Program Colleagues. Retrieved from https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/grants/hab-doxy-pep-clinical-guideline-bacterial-sti-prevention.pdf

[5] CDC. (2024, June 6). CDC Clinical Guidelines on the Use of Doxycycline Postexposure Prophylaxis for Bacterial Sexually Transmitted Infection Prevention, United States, 2024. Retrieved from https://www.cdc.gov/mmwr/volumes/73/rr/rr7302a1.htm

[6] AIDS Education and Training Center Program. https://aidsetc.org/topic/sexually-transmitted-infections

[7] TargeyHIV.org. (2024). Addressing STIs: Ask. Test. Treat. Repeat. https://targethiv.org/intervention/addressing-stis-ask-test-treat-repeat?utm_source=bpURL

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.