Doxycycline Postexposure Prophylaxis (doxy PEP)

Prevent Bacterial Sexually Transmitted Infections

Use of doxycycline for PEP, known as doxy PEP, is reported to be tolerated and to significantly reduce the acquisition of chlamydia (CT), gonorrhea (GC), and syphilis when taken within 72 hours after condomless oral, anal, or vaginal sex.
The Washington State Department of Health (WA DOH) would like to inform all health care providers and patients of this effective biomedical intervention to prevent bacterial STIs. Refer to the WA DOH Provider Alert: Doxycycline for Postexposure Prophylaxis to Treat Bacterial STI Infection Provider Letter, Guidelines, and Resources (PDF) (7/15/24)

On This Page

Find information and responses to frequently asked questions (FAQs) about doxy PEP. There are three FAQ sections that you can quickly access using the links listed below:

Provider FAQ
The Provider FAQ provides information and resources for health care providers and prescribers.

Patient Navigator FAQ
The Patient Navigator FAQ provides information and resources for agencies who assist community members and patients with accessing sexual health prevention and care, enrolling in Apple Health and health insurance to address cost and access barriers, and coordinate with local programs and community resources.

Patient FAQ
The Patient FAQ provides information and resources for patients prescribed doxycycline for PEP or are interested in learning more about this prevention option.

On June 4, 2024, CDC released The Guidelines for the Use of Doxycycline Post-Exposure Prophylaxis for Bacterial Sexually Transmitted Infection (STI) Prevention. DOH issued a Dear Colleague Letter Provider Alert to increase awareness, promote, and support use of doxy PEP across Washington.  For your convenience, we’ve compiled responses to frequently asked questions below.

Where can I find information on studies that demonstrate the effectiveness of doxy PEP?

The CDC has a compendium of doxy PEP studies that can be referenced at Guidelines for the Use of Doxycycline Post-Exposure Prophylaxis for Bacterial STI Prevention (cdc.gov)

Why is the focus for doxy PEP on gay and bi men and their sexual networks?

Current efficacy data only applies to gay/bisexual men and transgender women. Doxy PEP efficacy in other populations (i.e., cisgender women, cisgender heterosexual men, transgender men, other queer and nonbinary people) remains unclear. Given the lack of supporting data and the contraindications for doxycycline during pregnancy, there is not currently enough evidence to recommend doxy PEP for people who have receptive vaginal sex or who may become pregnant. Doxy PEP should not be used for patients whose medical history or current medications contraindicate the use of doxycycline.

Which form(s) of doxycycline are acceptable to be prescribed as doxy PEP?

Doxycycline hyclate delayed release 200 mg (one tablet) OR doxycycline hyclate or monohydrate immediate release 100 mg (two tablets taken at the same time) are acceptable options. Immediate release doxycycline may be less expensive than delayed release and should be equivalently bioavailable.

What quantity of doses should I prescribe to a patient who is interested in doxy PEP?

Prescribe enough doses (or refills) of doxycycline to last until the next follow-up visit (3-6 months). This will increase the likelihood that patients can take a dose within 24 hours of having sex, reduce the number of trips to and potential questions from their local pharmacy, and still allow opportunities for STI screening. Be sure to elicit a sufficient sexual history from your patient to clarify with what frequency they may used doxy PEP. This can help guide what quantity of doses you prescribe.

What should I tell my patient about side effects and drug interactions for doxy PEP?

Counsel patients about possible drug interactions, risk of sun sensitivity, remaining upright for 30 minutes after taking doxycycline to reduce the risk of pill esophagitis, and the (rare) risk of benign intracranial hypertension. Encourage patients to take doxycycline with a glass of water; take with food if gastric upset occurs. Avoid taking with antacids or dairy products.

What should I be monitoring, in terms of health conditions, while a patient is using doxy PEP?

For patients taking doxy PEP for a prolonged period, consider periodic or annual liver function tests (LFT), renal function tests, and complete blood count (CBC). No severe adverse events were noted in the doxy PEP study.

Can I prescribe both doxy PEP and PrEP to my patient?

Yes- patients who are using PrEP can use doxy PEP. This multilayered prevention strategy is a good approach to reducing the chances your patient will acquire STIs and HIV.

Will my patient’s insurance cover doxy PEP?

 

Most insurance payers will cover doxy PEP. If your patient is concerned about the cost of the drug, or need the medication at a cheaper cost, consider passing along the prescription discount card programs listed below. The average over-the counter price for 60 100 mg capsules, is between $20 and $25 throughout Washington with one of these cards.

Should I still routinely test my patient for STIs if they are using doxy PEP?

To identify and treat existing or breakthrough infections, patients on doxy PEP should be screened at initiation and then every 3-6 months for gonorrhea and chlamydia at all anatomic sites of exposure (urogenital/urine, pharyngeal, and rectal), syphilis, and HIV (if not known to be living with HIV). Patients who are diagnosed with or exposed to an STI while using doxy PEP should be treated according to standard CDC STI Treatment Guidelines.

How could doxy PEP affect syphilis test results in my patient?

A single dose of doxycycline would be unlikely to affect lab results for an established case of syphilis.

My patient tells me that they have been informed that they were exposed to syphilis. Should I treat preventively if the patient has used doxy PEP and tested negative?

Yes, you should. When a patient who uses doxy PEP for STI prevention is notified about a potential STI exposure, they should be tested and preventively treated per the CDC STI treatment guidelines for syphilis, gonorrhea, or chlamydia.

Why is doxy PEP less effective at preventing gonorrhea than it is at preventing syphilis or chlamydia?

Doxy PEP is less effective for gonorrhea prevention because of existing resistance to tetracyclines in some forms of gonorrhea. This means that the use of doxycycline will not prevent all forms of gonorrhea. However, not all forms of gonorrhea are resistant to the tetracycline class of antibiotics, so doxy PEP will still prevent gonorrhea infection for many who use it.

Does WA DOH provide doxy PEP to providers or local health jurisdictions?

DOH does not provide doxy PEP directly to clients, and does not currently supply doxycycline to our partners or to providers for this purpose. However, Washington State’s PrEP Drug Assistance Program (PrEP DAP) can help cover medical and lab costs associated with accessing doxy PEP. However, your client must register in the PrEP DAP program and must go to a PrEP DAP contracted provider. More information on can be found here: Pre-Exposure Prophylaxis (PrEP) | Washington State Department of Health

I’m concerned about antibiotic stewardship. Why should I prescribe doxy PEP if we are trying to use antibiotics less?

Doxy PEP could lead to increased antibiotic resistance, both at the individual and the population level. Specifically, commensal Neisseria (as a potential reservoir for tetracycline resistant plasmids), and Staphylococcus aureus may be affected. Antimicrobial resistant gonococcal infections have been monitored in Washington since 2016 through CDC’s Strengthening the US Response to Resistant Gonorrhea (SURRG) a sentinel surveillance program implemented by Public Health Seattle and King County. It is noted that doxy PEP is not structured as a daily use of the medication, so bacteria are not consistently exposed to the medication, which may somewhat reduce the chance of further antimicrobial resistance emerging from this practice. Additionally, current doxy PEP recommendations are for a very narrow portion of the population, many fewer people than for whom doxycycline is already prescribed in other ways, so it is not expected that this will significantly increase broad use of doxycycline in the population. While antibiotic stewardship is a critical function of public health, the use of doxy PEP can significantly reduce the burden of infections among population disproportionately affected by STIs. Stigma around accessing crucial sexual health care services should not be a barrier for communities trying to access doxy PEP. More information about antimicrobial resistance can be found here Doxycycline Individual Level Harms – Antimicrobial Resistance | CDC Archive. More information around addressing stigma and sexual health can be found here: Structural Stigma and the Health of Lesbian, Gay, and Bisexual Populations » LGBTQIA+ Health Education Center

Where can I find information about discussing sexual orientation and gender identity with patients?

Learning about how patients self-identify as to their sexual orientation and gender identify should occur as early in the provider-patient relationship as possible. This can be accomplished through registration forms, intake forms, and information sharing during the encounter. Providers may want to ask these questions periodically, as sexual and gender identity and sexual attraction can change over the life course. The Fenway Institute and National Coalition for Sexual Health offer extensive information, resources, and support.

I have additional questions about doxy PEP. Who should I reach out to?

Please reach out with any questions you may have to Michael Barnes, Infectious Disease Prevention Coordinator: michael.barnes@doh.wa.gov; 360-810-1880.

DOH promotes the use of doxy PEP as a priority intervention to prevent bacterial sexually transmitted infections in Washington. Use these FAQs to promote doxy PEP and engage and support community members and clients.

How much will doxy PEP cost my client? Will insurance cover it?

Doxycycline is a relatively cheap medication but the cost will vary depending on your client’s insurance. A prescription discount card is an option that can provide the medication at a cheaper cost.  The discount card is a digital card that can offer up to 80% savings on medication. There is no membership, age limits, income restrictions, or fees to join.

The discount cards and programs available for doxycycline are showing the average out-of-pocket cost for 60, 100 mg capsules, is between $20 and $25 throughout Washington. The links below provide the enrollment information along with which pharmacy you can get the medication format in your area:

Additionally, Washington State’s PrEP Drug Assistance Program (PrEP DAP) can help cover medical and lab costs associated with accessing doxy PEP. You must go to a PrEP DAP provider that is contracted with DOH to make sure the services are covered. The list of the providers found here.

Where do I refer my client to in order to access doxy PEP?

Most medical providers can prescribe doxy PEP. However, not every medical provider may know about doxy PEP. Additionally, not every medical provider may be willing to prescribe doxy PEP to your client. Washington State’s list of PrEP DAP contracted providers is a great place to start in identifying potential providers in your area: PrEP DAP Contracted Provider Map.

My client’s medical provider is not familiar with doxy PEP. What information can I share with them to help support my client?

On June 4, 2024, CDC released The Guidelines for the Use of Doxycycline Post-Exposure Prophylaxis for Bacterial Sexually Transmitted Infection (STI) Prevention. Additionally, DOH has released Washington State specific guidelines with more local resources for providers.

Does DOH provide doxy PEP?

DOH does not provide doxy PEP directly to clients, and does not currently supply doxycycline to our partners for this purpose. However, Washington State’s PrEP Drug Assistance Program (PrEP DAP) can help cover medical and lab costs associated with accessing doxy PEP. However, your client must register in the PrEP DAP program and must go to a PrEP DAP contracted provider. More information on can be found here: Pre-Exposure Prophylaxis (PrEP) | Washington State Department of Health

Should my client keep testing regularly if they take doxy PEP?

Yes, routine STI testing is important for all patients on doxy PEP as well as routine HIV testing for HIV negative clients. Clients should be screened at initiation and then every 3-6 months for gonorrhea and chlamydia at all anatomic sites of exposure (urogenital/urine, pharyngeal, and rectal), syphilis, and HIV (if not known to be living with HIV).

Can my client take both doxy PEP and PrEP/HIV treatment medications?

Yes, you can take doxy PEP and PrEP/HIV antiretrovirals at the same time. In fact, doxy PEP is a great STI prevention tool to use in addition to PrEP/HIV antiretrovirals as an HIV prevention tool.

What information is available for my client about side effects and drug interactions for doxy PEP?

Most people can take doxycycline without experiencing any problems at all. Side effects that do occur tend to can include stomach upset, a burning feeling in the throat, and sensitivity to light. The good news is that these side effects go away when you aren’t taking the medication, and they tend to be short lived. Additional client-focused resources are available here: Doxy-PEP | San Francisco City Clinic (sfcityclinic.org)

For what kind of client(s) is doxy PEP recommended?

Current efficacy data only applies to gay/bisexual men and transgender women. Doxy PEP efficacy in other populations (i.e., cisgender women, cisgender heterosexual men, transgender men, other queer and nonbinary people) remains unclear. Given the lack of supporting data and the concerns for possible birth defects caused by the use of doxycycline during pregnancy, there is not currently enough evidence to recommend doxy PEP for people who have receptive vaginal sex or who may become pregnant. However, if a client feels that doxy PEP would be a valuable tool for their sexual health, encourage them to talk with their medical provider.

How would you recommend that I inform a client that they may be a candidate for doxy PEP?

Talking to a client about  kinds of sex, the frequency of sex they may be having, and their prior diagnoses or exposures to STIs will help clarify if they would benefit from doxy PEP. Remember that doxy PEP has been shown to benefit certain groups of people more than others. These include men who have sex with men and transgender women who’ve had an STI within the past 12 months (1 year). It may also benefit people with multiple sexual partners.

I have additional questions about doxy PEP. Who should I reach out to?

Please reach out with any questions you may have to Michael Barnes, Infectious Disease Prevention Coordinator: michael.barnes@doh.wa.gov; 360-810-1880.

DOH promotes the use of doxy PEP as a priority intervention to prevent bacterial sexually transmitted infections in Washington. Use the FAQ for Patients to learn about doxy PEP and getting connected to doctors, doxy PEP, navigation support, and other community resources for sexual health and prevention.

What is doxy PEP?

Doxycycline Post-Exposure Prophylaxis (Doxy-PEP) is a new way to take an old medication. The term is a combination of two phrases, doxycycline and PEP (Post-Exposure Prophylaxis).  It means taking the antibiotic doxycycline after sex, to prevent getting an STI. It is similar to emergency contraception, but for STIs.

What does doxy PEP prevent?

Recent studies have shown that taking doxy PEP can reduce your chance of getting syphilis and chlamydia by about three quarters and gonorrhea by about half.

What does doxy PEP NOT prevent?

Doxy PEP does not prevent HIV, hepatitis A, B, or C, Mpox (monkeypox), HPV, or herpes. Although doxy PEP can prevent bacterial STIs, and that is why it is recommended, it may not prevent all bacterial STIs, so you should still get tested regularly.

Who is doxy PEP for?

Doxy PEP has been shown to benefit certain groups of people more than others. These include men who have sex with men (MSM) and transgender women (TGW) who’ve had an STI within the past 12 months (1 year). It may also benefit people with multiple sexual partners.

When should I take doxy PEP?

Take 200 mg (two 100 mg pills) of doxycycline within 24 hours (for greatest effect) but no later than 72 hours after condomless sex. “Condomless sex” means oral, anal, vaginal, or front-hole sex when a condom is not used for the entire time. If you have sex again within 24 hours of taking doxycycline, you can take another dose 24 hours after your last dose. You can take doxycycline as often as once every day. However, do not take more than 200 mg (two 100 mg pills) per day.

How should I take doxy PEP?

Take doxycycline with a full glass of water or something else to drink so that it does not get stuck when you swallow. If your stomach is upset by doxycycline, taking it with food may help. Avoid dairy products (milk, cheese, etc.), calcium, antacids, or vitamins for 2 hours before and 2 hours after taking doxycycline.  Some people are more sensitive to the sun when they take doxycycline, so wear sunscreen.

What are the side effects of doxy PEP?

Most people can take doxycycline without experiencing any problems at all. Side effects that do occur tend to can include stomach upset, a burning feeling in the throat, and sensitivity to light. The good news is that these side effects go away when you aren’t taking the medication, and they tend to be short lived.

Will doxy PEP interact with my other medications?

Doxycycline is safe and well tolerated with few indications of interactions with other drugs. Doxycycline has been prescribed safely for long term use for other medical indications (e.g. acne treatment or malaria prophylaxis). Talk to your doctor about the other medications you may be taking.

Where can I get doxy PEP?

Most medical providers can prescribe doxy PEP. However, not every medical provider may know about doxy PEP. Additionally, not every medical provider may be willing to prescribe doxy PEP to you. Washington State’s list of PrEP DAP contracted providers is a great place to start in identifying potential providers in your area: PrEP DAP Contracted Provider Map.

How much will doxy PEP cost?

Doxycycline is a relatively cheap medication but the cost will vary depending on your client’s insurance. A prescription discount card is an option that can provide the medication at a cheaper cost.  The discount card is a digital card that can offer up to 80% savings on medication. There is no membership, age limits, income restrictions, or fees to join.

The discount cards and programs available for doxycycline are showing the average out-of-pocket cost for 60, 100 mg capsules, is between $20 and $25 throughout Washington. The links below provide the enrollment information along with which pharmacy you can get the medication format in your area:

Additionally, Washington State’s PrEP Drug Assistance Program (PrEP DAP) can help cover medical and lab costs associated with accessing doxy PEP. You must go to a PrEP DAP provider that is contracted with DOH to make sure the services are covered. The list of the providers can be found here.

Washington State also has prevention service navigators available to support you in accessing doxyPEP. More information can be found here: Prevention Service Navigation Providers (wa.gov).

Should I still get tested if I’m taking doxy PEP?

You will still need to get tested for STIs every 3 months and whenever you have symptoms. Talk to your healthcare provider if you are experiencing any STI symptoms.

Can I take doxy PEP if I have HIV?

Yes- doxy PEP can be taken regardless of your HIV status.

Can I take doxy PEP and PrEP at the same time?

Yes, you can take doxy PEP and PrEP at the same time. In fact, doxy PEP is a great STI prevention tool to use in additional to PrEP as an HIV prevention tool.

Do I still need to use condoms if I take doxy PEP?

Condoms are an additional tool in reducing STIs and HIV. Using condoms while on doxy PEP is a great best practice.

Why doesn’t doxy PEP prevent gonorrhea as well as it prevents chlamydia or syphilis?

Some strains of gonorrhea have developed resistance to doxycycline and that is why doxycycline is no longer recommended as treatment when people test positive for gonorrhea. Because drug resistant strains of gonorrhea exist, doxycycline is not as effective at reducing transmission of gonorrhea when used as PEP.

I’m not a male who as sex with men or a transgender woman who has had an STI in the past 12 months and I would like to try doxy PEP. Why can’t I get it?

A study conducted with cisgender women did not show a benefit to using doxy PEP. More research needs to be done to see if doxycycline can help prevent STIs after vaginal sex. People who are already pregnant or may become pregnant should not take doxy PEP.

What are other ways I could support my sexual health?

There are a variety of immunizations that can also be used to support your sexual health.

The monkeypox virus (MPXV) is the virus that causes mpox and can be transmitted through close contact with a symptomatic person, which can often happen during sex or intimate contact. JYNNEOS vaccine is available for both prevention of mpox and post-exposure prophylaxis for people exposed to mpox. JYNNEOS is a two dose series, so consider starting or finishing your mpox vaccine series to lower your risk of developing mpox.

Human papilloma virus (HPV) is the virus that causes genital warts and can be transmitted through skin-to-skin contact which often happens during sex. HPV can also cause cervical, anorectal, and oral/throat cancers. Consider starting or finishing your HPV vaccine series to lower your risk of developing HPV and HPV related cancers.

Hepatitis A virus is a virus that can cause severe liver disease and can be transmitted fecal-orally, which can sometimes occur during sex. Check with your provider to see if you need to start your Hepatitis A series or receive a Hepatitis A booster shot. Hepatitis B virus is another virus that can cause severe liver disease and can be transmitted when bodily fluids (like blood and semen) from one person enters the body of another. This can occur during sex. Check with your provider to see if you need to start your Hepatitis B series or need a Hepatitis B booster shot. There is also an option to get vaccinated and boosted with a vaccine for both Hepatitis A virus and Hepatitis B virus to lower your risk of becoming infected with both Hepatitis A virus and Hepatitis B virus. Ask your provider about your vaccine options.

Meningococcal bacteria are a bacterium that causes meningitis, which is an infection that affects the brain and spinal cord. Meningococcal bacteria are transmitted through lengthy contact of respiratory and throat secretions (like saliva), which occurs when kissing during sex or intimate contact. Consider getting boosted or starting your meningococcal vaccine series to lower your risk of developing meningitis.

For more information on adult immunization schedule and to learn more about adult immunizations please visit the CDC’s website.

I have additional questions about doxy PEP. Who should I reach out to?

Please reach out with any questions you may have to Michael Barnes, Infectious Disease Prevention Coordinator: michael.barnes@doh.wa.gov; 360-810-1880.