Gonorrhea is the Chink in DoxyPEP's Armor

By: Marcus J. Hopkins, Health Policy Lead Consultant, ADAP Advocacy

Recent studies have shown that DoxyPEP (doxycycline post-exposure prophylaxis) is becoming less effective against the bacterial sexually transmitted infection (STI) gonorrhea. Concerns are rising among certain public health groups, such as the Centers for Disease Control & Prevention and European counterparts, but Doxy-PEP remains regarded as a highly effective prevention method for high-risk groups.

Photo Source: Harvard Health Publishing

For the uninitiated, DoxyPEP is a post-exposure oral medication provided within 72 hours after a sexual encounter that reduces the likelihood of acquiring bacterial STIs, including syphilis, chlamydia, and gonorrhea. In the initial DoxyPEP trial, researchers found that the incidence of syphilis decreased by 87%, chlamydia by 88%, and gonorrhea by 55% (Dall, 2026). After this initial study, the Centers for Disease Control and Prevention (CDC) released clinical guidelines for its utilization in 2024 (Bachmann et al., 2024).

Even in the initial study, the reduced incidence of gonorrhea was modest, at best; subsequent studies have shown that a rapid increase in tetracycline-resistant strains of gonorrhea has greatly reduced or all but eliminated DoxyPEP’s efficacy against the infection.

Research published in JAMA Internal Medicine found that the incidence of STI cases of syphilis and chlamydia in San Francisco, CA, decreased significantly among Men who have Sex with Men (MSM) and transgender women against projected case numbers, while the incidence of gonorrhea increased significantly (Sankaran et al., 2025).

Another study published in Clinical Infectious Diseases suggests that widespread utilization of DoxyPEP may actually be contributing to the increase in tetracycline-resistant gonorrhea strains in King County, Washington state, which has resulted in the county health department revising its guidelines on the utilization of doxycycline to treat other bacterial issues, including skin and soft tissue infections and lower respiratory tract infections (Soge et al., 2025).

A third study published in The Lancet Infectious Diseases similarly suggests that widespread utilization of DoxyPEP may be inadvertently increasing the propagation of multidrug-resistant strains of gonorrhea in southern California (Yechezkel et al., 2026).

Photo Source: emedicinehealth.com

Drug-resistant strains of gonorrhea have been a concern in the United States for some time, and researchers have been sounding the call against overreliance upon DoxyPEP as a harm reduction tool against the STI for just as long. A correspondence published in the New England Journal of Medicine in 2025 warned that multidrug-resistant strains have been spreading globally, including strains that carry resistance to the antibiotic ceftriaxone (Helekal et al., 2025).

Sexual health advocates have been heralding DoxyPEP as one of the first effective methods for preventing STIs transmission since the findings of the initial study, including those at the American Sexual Health Association (ASHA, 2025). There is no doubt that DoxyPEP has clearly been shown to be effective against syphilis and chlamydia; however, ADAP Advocacy recommends that organizations begin having realistic conversations about its efficacy against, as well as the continued increase in propagation of, multidrug-resistant strains of gonorrhea.

These conversations need not be “sex-negative,” focusing on fear and shame-based representations of sexual activity; they do, however, need to be realistic.

Disclaimer: All funders of the ADAP Advocacy Association are publicly listed on our website. 

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

References:

[1] American Sexual Health Association. (2025, May 09). Learn More About Doxy PEP from Three People Who Take It. Research Triangle Park, NC: American Sexual Health Association. https://www.ashasexualhealth.org/learn-more-about-doxy-pep-from-three-people-who-take-it/

[2] Bachmann, L. H., Barbee, L. A., Chan, P., Reno, H., Workowski, K. A., Hoover, K., Mermin, J., & Mena, L. (2024, June 06). CDC Clinical Guidelines on the Use of Doxycycline Postexposure Prophylaxis for Bacterial Sexually Transmitted Infection Prevention, United States, 2024. Morbidity and Mortality Weekly Report Recommendations and Reports, 73(2): 1-8. http://dx.doi.org/10.15585/mmwr.rr7302a1

[3] Dall, C. (2026, May 11). Study shows doxyPEP’s diminished effectiveness against gonorrhea. Minneapolis, MN: University of Minnesota: Research and Innovation Office: Center for Infectious Disease Research and Policy: Antimicrobial Stewardship. https://www.cidrap.umn.edu/antimicrobial-stewardship/study-shows-doxypep-s-diminished-effectiveness-against-gonorrhea

[4] Helekal, D., Mortimer, T. D., & Grad, Y. H. (2025, July 09). Expansion of tetM-Carrying Neisseria gonorrhoeae in the United States, 2018–2024. New England Journal of Medicine, 393(2), 198-200. https://doi.org//10.1056/NEJMc2504010

[5] Sankaran, M., Glidden, D. V., Kohn, R. P., Nguyen, T. Q., Bacon, O., Buchbinder, S. P., Gandhi, M., Havlir, D. V., Liebi, C., Luetkemeyer, A. F., Nguyen, J. Q., Roman, J., Scott, H., Torres, T. S., & Cohen, S. E. (2025, January 06). Doxycycline Postexposure Prophylaxis and Sexually Transmitted Infection Trends. JAMA Internal Medicine, 185(3), 266-272. https://doi.org/10.1001/jamainternmed.2024.7178

[6] Soge, O. O., Thibault, C. S., Cannon, C. A., McLaughlin, S. E., Menza, T. W., Dombrowski, J. C., Fang, F. C., & Golden, M. R. (2025, June). Potential Impact of Doxycycline Post-Exposure Prophylaxis on Tetracycline Resistance in Neisseria gonorrhoeae and Colonization With Tetracycline-Resistant Staphylococcus aureus and Group A Streptococcus. Clinical Infectious Diseases, 80(6), 1,188-1,196. https://doi.org/10.1093/cid/ciaf089

[7] Yechezkel, M., Helekal, D., Kapadia, B., Hong, V., Pomichowski, M. E., Reyes, I. A. C., Davis, G. S., Müller, N. F., Grad, Y. H., Tartof, S. Y., & Lewnard, J. A. (2026, May 07). Durability of doxycycline effectiveness against gonorrhoea after implementation of post-exposure prophylaxis in southern California, USA: a retrospective, test-negative, observational study. The Lancet Infectious Diseases. https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(26)00123-4/fulltext

Putting Politics Ahead of Public Health is Spelling Trouble for Tennessee

By: Ranier Simons, ADAP Blog Guest Contributor

In 2023, Tennessee Governor Bill Lee, rejected nine million dollars in federal HIV funding from the Centers for Disease Control & Prevention (CDC). This meant that the pass-through grant contracts associated with the Integrated HIV Programs for Health Departments to Support Ending the Epidemic in the United States CDC-RFA-PS20-2010 grant and the Tennessee Integrated HIV Surveillance and Prevention Programs for Health Departments CDC-RFA-PS18-1802 grant ended in May of 2023.[1] The decision meant a significant cut in funding for HIV prevention, education, and treatment for public health centers and many community-based organizations. The adverse effects of the decision are materializing, and experts continue to sound the alarm about how devastating the outcomes will impact the state.

Photo Source: The Tennessee Conservative

The governor stated he refused the funds to decrease dependence on federal funds and be more independent as a state. He also expressed that the move was to make it easier for organizations and public health departments to access funding without having to deal with bureaucratic red tape.[2] However, analysis shows that the decision was politically motivated. Lee is on public record expressing disapproval of two organizations that were HIV grant recipients, Planned Parenthood and a task force on transgender health issues.[3] Refusing CDC funding means that the state is no longer required to distribute funding based on science, evidence-based data, and research. The goal of the state was to replace the CDC funds with state funding.

In response to Tennessee’s refusal of funding, the CDC decided to try and circumvent the legislature. It decided to directly provide four million dollars in funding to United Way of Greater Nashville.[4] This would allow United Way to distribute funds to nonprofit organizations, such as Planned Parenthood, to continue their HIV prevention efforts. However, four million dollars is only half of the nine million dollars refused.

When the state government replaced the lost CDC funding with state funding, it was mainly local health departments that were guaranteed funding to make up for the cuts.[4] This meant the state health departments could make decisions concerning funding distribution that did not require alignment with CDC requirements. This was eventually followed by an announcement to reallocate funding away from the most at-risk priority communities, such as men who have sex with men, to new groups. The new groups are first responders, pregnant women, and survivors of sex trafficking. Studies are showing that this will result in unnecessary deaths and poor health outcomes because this group is not where the need resides.

Photo Source: Clinical Infectious Diseases

A study published in July of this year in the journal Clinical Infectious Diseases spells out the negative ramifications of Tennessee’s state resource allocation. Men who have sex with men, transgender women, and heterosexual Black women are the evidenced-based identified priority demographic most affected by HIV in Tennessee.[5] The study projected conservative estimates the Tennessee decision would mean 166 preventable HIV transmissions, 190 additional deaths, and 843 life-years lost over 10 years. The study’s more pessimistic or worst-case scenario projections were 1359 preventable HIV transmissions, 712 additional deaths, and 2,778 life-years lost over 10 years.[5] 

Comparatively, this means the reallocation in funding would be prohibitively damaging to the original priority group with negligible benefit for the new priority pivot. “Under Reallocation, MSM would comprise most of the HIV transmissions (77%), followed by TGW (8.6%) and HSBW (6.8%). First responders would contribute 0.5%, pregnant people 0.2%, and SST 6.9% to the total HIV transmissions over 10 years.”[5] The newly suggested priority populations only comprise %1 of all Tennesseans living with HIV compared to the CDC-defined priority populations, which comprise %99 percent.[6]

Funding losses have already begun to negatively affect agencies serving vulnerable populations. Before the change, CDC grant money provided stability for HIV programming for five years at a time. The new state-provided funds happen on a one-year cycle. The one-year budget rides on the auspices of the state legislature, which votes on it each year.[7] Reduced funding means loss of staff for many organizations. According to Amna Osman, CEO of Nashville CARES, “There’s no sustainable grant funding to support these positions…Employees really want some stability.”[7]

Moreover, the new funding plan routes money mainly to metro state health departments and groups associated with them. This translates into a drastic cut to resources for those in rural areas in addition to groups who, under the new reallocation priorities, would not be able to garner funding from the state. 

Photo Source: The New York Times

The motivation behind the original CDC funding was to concentrate efforts on HIV prevention, education, and treatment for those most in need in Tennessee. Prevention requires testing, surveillance, access to PrEP, and more. Before the funding reallocation, a third of those most in need of PrEP did not know where they could access it. Now, issues of access have worsened. Osman states she has heard from community members who say, “Well, I’m hearing there’s no dollars for prevention education for HIV. Then, that means ‘I think there’s no money for me to get a service,”[7] Memphis, Tennessee is second in the nation regarding the rate of new HIV cases. Over 7,500 people in Shelby County alone are living with HIV or AIDS.[8] That number is second only to Miami, Florida.[8]

HIV prevention and testing is not just about HIV. Testing involves STI testing. STI testing benefits the entire community as a public health safeguard as well as a tool in the fight to prevent HIV transmission. People living with HIV do not live in a vacuum, nor do those living with STIs. Effectively focusing funding and infrastructure on the populations that science and health professionals have identified as significantly at risk is the only way to reverse the tide in all of Tennessee’s communities. Only time will tell if voting and continued public and professional outcry, in combination with pressure from the medical community, will result in the legislature changing its course.

[1] Talley, P. (2023, January 17). Dear Colleagues Letter. Retrieved from https://wpln.org/wp-content/uploads/sites/7/2023/01/Notification-HIV-Funding-Changes.pdf

[2] Stillman, J. (2023, April 22). Tennessee Rejected HIV Funds From Feds, But The State Was Just Outsmarted. Retrieved from https://www.hivplusmag.com/politics/tennessee-rejected-hiv-funds-from-feds-but-the-state-was-just-outsmarted

[3] Cha, A., Nirallil, F. (2023, Januery 26). HIV at center of latest culture war after Tennessee rejects federal funds. Retrieved from https://www.washingtonpost.com/health/2023/01/26/tennessee-federal-hiv-funding/

[4] Watts, M. (2023, April 17). Federal HIV funding rerouted to nonprofits, bypasses Tennessee health department entirely. Retrieved from https://www.tennessean.com/story/news/local/2023/04/17/hiv-federal-funds-will-reroute-to-tennessee-nonprofits-state-cut-out/70116510007/

[5] Borre, E. D., Ahonkhai, A. A., Chi, K. K., Osman, A., Thayer, K., Person, A. K., Weddle, A., Flanagan, C. F., Pettit, A. C., Closs, D., Cotton, M., Agwu, A. L., Cespedes, M. S., Ciaranello, A. L., Gonsalves, G., Hyle, E. P., Paltiel, A. D., Freedberg, K. A., & Neilan, A. M. (2024). Projecting the potential clinical and economic impact of human immunodeficiency virus prevention resource reallocation in Tennessee. Clinical Infectious Diseases. https://doi.org/10.1093/cid/ciae243

[6] Ridings, M. (2024, July 11). Study Finds That Tennessee’s Shift in HIV Prevention Funding Will Lead to Poorer Health Outcomes for its Residents. Retrieved from https://www.massgeneral.org/news/press-release/tennessee-shift-in-hiv-policy-will-lead-to-poorer-outcomes

[7] Sweeney, C. (2024, October 22). Tennessee replaced its federal HIV funding with state money. Public health experts say the change is causing damage. Retrieved from https://www.wkms.org/health/2024-10-22/tennessee-replaced-its-federal-hiv-funding-with-state-money-public-health-experts-say-the-change-is-causing-damage

[8] Paul, A. (2024, August 13). Memphis ranks second in the nation in highest number of new HIV cases. Retrieved from https://wreg.com/news/memphis-ranks-second-in-the-nation-in-highest-number-of-new-hiv-cases/l

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. 

Could New Research Pave Way for Official Guidelines for the Treatment of Lipohypertrophy

By: Brandon M. Macsata, CEO, ADAP Advocacy Association

There purports to be an "obesity epidemic" in the United States,[1] though strong evidence suggests that people can be healthy at every size.[2] Data shows from 1960-2002, in the United States the average male weighed 25 pounds more and average female weighed 24 pounds more. Putting the debate over obesity aside, undesirable weight gain for many people living with HIV/AIDS is often grudgingly accepted as normal. This paradigm could soon be changing because new research could pave the way for better guidelines for treating HIV-related weight gain — namely, Lipohypertrophy.

Photo Source: myclickfine.com

Research published in the Clinical Infectious Diseases by a panel of international authors (U.S., Canada, Europe) from 12 universities represents a consensus opinion on the diagnosis, clinical consequences and treatment of excess fat in adults with treated HIV infection. The groundbreaking study offers some hope to people living with HIV-infection concerned about facial wasting, belly fat, lipomas, or the dreaded "buffalo hump" on the back of the neck.

The publication, "Practical Review of Recognition and Management of Obesity and Lipohypertrophy in Human Immunodeficiency Virus Infection," concludes, "Both generalized obesity and lipohypertrophy are prevalent among HIV-infected persons on ART. Aggressive diagnosis and management are key to the prevention and treatment of end-organ disease in this population, and critical to the present and future health of HIV-infected persons."

Among the research findings, management of HIV-related weight gain includes lifestyle changes in diet and exercise, though there was "insufficient data to support any specific dietary or exercise strategy in patients with HIV and abdominal obesity."[3] Changes in anti-retroviral therapy is also suggested, since some of the new medications have less side-effects.[4] Medical interventions are also identified as viable options — including Growth Hormone (GH) Axis Therapy and Metformin.[5] Finally, surgical interventions are also included in the options identified by the authors.[6]

The research findings are already gaining attention in respected HIV news publications, too.

The ADAP Advocacy Association sees promise in the report findings for patients suffering from a condition for which treating physicians are paying little attention, and in many cases where payors — including many State ADAPs — are excluding coverage for treatment options approved by the U.S. Food & Drug Administration. In late 2016, we urged the Health Resources and Services Administration ("HRSA") to update to the Guide for HIV/AIDS Clinical Care. The national sign-on letter wasn't an endorsement of a specific product or treatment, but rather an attempt to afford patients suffering from HIV-associated lipodystrophy syndrome the opportunity to access the available treatment options (all of which were identified in the aforementioned research).

HRSA now has a template for updating its treatment guidelines. It is up to the federal agency to respond to the needs to the patients!



Read our related blogs on this topic:

• Despite Treatment Improvements, Patients Remain Concerned about Lipo (published January 27, 2017)
• Why HIV Medical Treatment Guidelines Matter (published on October 28, 2016)
• Mandating Treatment for HIV-Related Lipodystrophy: The Massachusetts experience and a call for national action (published on August 25, 2016)
• HIV-Related Belly Fat: More Than Just an Appearance Issue (published on June 23, 2016)

__________
[1] Rauh, Sherry (2010); Is Fat the New Normal? A rise in average body weight may be changing how we see ourselves. WebMD. Retrieved from http://www.webmd.com/diet/obesity/features/is-fat-the-new-normal#1.
[2] Bacon, Linda (2010, May 4); Health At Every Size: The Surprising Truth About Your Weight; BenBella Books. Retrieved from https://lindabacon.org/health-at-every-size-book/.
[3] Lake, Jordan E., et. al (2017, February 24); Clinical Infectious Diseases; Practical Review of Recognition and Management of Obesity and Lipohypertrophy in Human Immunodeficiency Virus Infection; Oxford University Press. Retrieved from https://academic.oup.com/cid/article-abstract/doi/10.1093/cid/cix178/3051856/Practical-Review-of-Recognition-and-Management-of?redirectedFrom=fulltext.
[4] Lake, Jordan E., et. al (2017, February 24); Clinical Infectious Diseases; Practical Review of Recognition and Management of Obesity and Lipohypertrophy in Human Immunodeficiency Virus Infection; Oxford University Press. Retrieved from https://academic.oup.com/cid/article-abstract/doi/10.1093/cid/cix178/3051856/Practical-Review-of-Recognition-and-Management-of?redirectedFrom=fulltext.
[5] Lake, Jordan E., et. al (2017, February 24); Clinical Infectious Diseases; Practical Review of Recognition and Management of Obesity and Lipohypertrophy in Human Immunodeficiency Virus Infection; Oxford University Press. Retrieved from https://academic.oup.com/cid/article-abstract/doi/10.1093/cid/cix178/3051856/Practical-Review-of-Recognition-and-Management-of?redirectedFrom=fulltext.
[6] Lake, Jordan E., et. al (2017, February 24); Clinical Infectious Diseases; Practical Review of Recognition and Management of Obesity and Lipohypertrophy in Human Immunodeficiency Virus Infection; Oxford University Press. Retrieved from https://academic.oup.com/cid/article-abstract/doi/10.1093/cid/cix178/3051856/Practical-Review-of-Recognition-and-Management-of?redirectedFrom=fulltext.