Community health sometimes goes faster than doctors. According to a recent investigation carried out in the Netherlands and published in Eurosurveillancenearly a quarter of transgender and men with sex with other men (HSH) would already use doxyprep, that is to say the regular taking of doxycycline in pre-exposure prophylaxis of sexually transmitted infections (IST), or at Doxypep for post-exhibition. A totally informal, without prescription and uncontrolled use which makes the authors fear the emergence of bacterial resistance and microbiota disorders.
Of the 1,633 people who answered an online questionnaire between the end of February and early May 2024, 22 % claimed to have already used informally and without prescription at the Doxypep or the DoxyPrep, 15 % even said it had been recourse recently, and 65 % declared to have the firm intention to take it. Between 2021 and 2022, a similar investigation had been carried out in Amsterdam. By comparing the results of the two works, the authors note in their analysis a substantial increase in the informal use of the Doxypep/PREP between 2022 and 2024. Users lived more frequently than the others with HIV and more often practiced chemsex.
Of the 246 responders who claim to have used doxycycline, 114 used it in post-exhibition prophylaxis (PEP), 71 in post-exposition prophylaxis (PREP) and 61 combined both. Doxypep users have used it on average 2 to 4 times in the last 6 months, each time for 2 consecutive days in the median.
A use that lends the flank to criticism
Interviews conducted as part of this study “Show that the informal use of the Doxypep/Prep can be influenced by non -medical opinions, which implies possible bad decision -making, for lack of necessary knowledge”specify the authors. These data “Underline the need for recommendations, information campaigns and individualized explanations”, they add.
Although the majority, doxycycline was not the only drug used. Other antibiotics, such as azithromycin, ciprofloxacin and amoxicillin, have also been used. In some cases, users did not remember the antibiotic taken. “It’s a bad idea, Reacts Professor Jean-Michel Molina, main investigator of Anrs Ipergay and Doxyvac tests. Doxycycline must only be used which poses fewer tolerance problems. The other antibiotics have more impact on the microbiota and have more risk of resistance because they are also more widely used in other indications. This is the reason why you have to accompany things rather than leaving people without a benchmark. »»
The interest of the Doxypep/Prep has been demonstrated in several studies. France has been a pioneer in this area: the first data demonstrating an efficiency of the Doxypep comes from a sub-study of the IPERGAY trial in HSH using a PREP in HIV prevention. In the 116 participants in Doxypep (200 mg within 24 hours of exposure), the risk of STI was reduced by 47 % compared to the control group without prophylaxis. In detail, the Doxypep reduced the risks of syphilis (-73 %) and Chlamydia (-70 %) more than that of Gonorrhea (-17 %).
These results were then confirmed in the Anrs Doxyvac study which evaluated in HSH both the use of the Doxypep (200 mg within 24 to 72 hours of an unprotected sexual intercourse) and vaccination against type B meningococcus (4Cmenb, supposed then being able to protect from the infection by gonococcus). After 14 months of follow -up, the doxypep was associated with a decrease of 83 % of the risk of syphilis and/or chlamydia, and with a only 33 % drop in gonorrhea, while vaccination by 4Cmenb was not associated with a significant reduction in the risk of gonorrhea. In the United States, the Doxypep study has reached similar results, which led the control and prevention centers of American diseases (CDC) to recommend its use.
However, questions remain on the supposed risks of this strategy. Also, most European countries, apart from Great Britain, have not spoken to date, even if the European Company against AIDS (EACS) recommends Doxypep in PREP HIV users. A group of experts from the World Health Organization (WHO) and the European Center for the Control and Prevention of Diseases (ECDC) is currently hard at work to produce a report that could encourage the various national guardianships to take the plunge.
In France too, the Doxypep progresses
The Dutch government recently published a text in which it specified not to recommend the doxyprep or the doxypep. However, to reduce the risk linked to not supervised, the Doxypep can be prescribed on a case -by -case basis, accompanied by advice and information. In France, the High Authority for Health (HAS) is roughly on the same line in post-exhibition: no recommendation but an authorization for a practice which must remain “Exceptional”.
Like their counterparts in the Netherlands, the populations exposed of France also began to seize the doxycycline in pre-exhibition prophylaxis, indicates to the Daily Dr. Bruno Spire, researcher at SESSTIM. “Some doctors consider that the risk of STI is serious enough to justify prescribing doxycycline in prevention, he explains. Even if there is no consensus to know who to offer it. »»
The main risks mentioned about the DoxyPrep/PEP are of two orders: the risk of emergence of bacterial resistance and the disturbance of the microbiota. “These risks do not prevent offering doxycycline for several months to patients who suffer from inflammatory acnenotes Dr. Spire. On the other hand, the subject of the resistance of gonococci is a real problem. »» A concern that Professor Molina is not entirely sharing: “In vitro exposure to doxycycline does not induce resistance in Treponema Pallidum or Chlamydia which remain sensitive to this antibiotic used for over 50 years. It only generates resistance in gonococcus, but it is already considered that 80 to 90 % of the strains are already. In France, this antibiotic has not been used for a long time to treat gonococcus infections. »»
Reassuring data to confirm
” On the other hand, warns Professor Molina, You have to be cautious about the fact that we do not increase the risk of crossed resistors of gonococci to other antibiotics such as cephalosporins. »» Some researchers also point to the risk of emergence of resistance in bacteria not targeted by PEP. In the Doxypep study, the use of doxycycline in post-exposure prophylaxis was associated with a decrease in oral portage of golden staphylococci, but also with a slight increase in the proportion of resistant strains.
Regarding the microbiota, “We were a little late in France, recognizes Professor Molina. But two recent publications (one in nature communications and the other in nature medicine, editor’s note) show that there is little impact on the bacterial composition of the microbiota ”.
If Dr. Bruno Spire judges the data currently available insufficient to establish recommendations, Professor Molina is not completely of this opinion. “In the STIs, we have only few effective strategies, other than condoms and saying that you have too many partners”explains the latter. According to him, the efficiency and safety data are already sufficient to recommend the use of the doxypep in a framed manner: “It is a tool, maybe not the best, but it is important that people can take it. »» The infectiologist of the University of Paris Cité recommends limiting the use to a maximum taking per week, in people with frequent STIs.
“As a researcher close to users, I think what we need is a gonococcus vaccine in addition to the doxypep, judge Dr. Bruno Spire. It has been even a long time since we should have one, because we already have a vaccine against meningococcal when it is practically the same bacteria. The only reason we just start to develop this type of vaccine is because it did not interest firms until recently. »» Professor Molina also considers very important to develop vaccines against bacterial IST, but this is much more complex than expected with many so far unsuccessful attempts.