Use of doxycycline prophylaxis among gay and bisexual men in Melbourne
2019; Elsevier BV; Volume: 6; Issue: 9 Linguagem: Inglês
10.1016/s2352-3018(19)30186-9
ISSN2405-4704
AutoresEric P. F. Chow, Christopher K. Fairley,
Tópico(s)Reproductive tract infections research
ResumoIn a recent clinical trial (ANRS IPERGAY) of 232 gay and bisexual men who have sex with men (MSM) taking pre-exposure prophylaxis (PrEP) for HIV, doxycycline taken within 24 h of sex reduced the incidence of chlamydia and syphilis by 70%; incidence of gonorrhoea was not reduced.1Molina JM Charreau I Chidiac C et al.Post-exposure prophylaxis with doxycycline to prevent sexually transmitted infections in men who have sex with men: an open-label randomised substudy of the ANRS IPERGAY trial.Lancet Infecti Dis. 2018; 18: 308-317Summary Full Text Full Text PDF PubMed Scopus (95) Google Scholar Participants had a median of ten partners every 2 months. A mathematical model has predicted that the number of syphilis cases could potentially be reduced by half if 50% of the MSM in the population use doxycycline.2Wilson DP Prestage GP Gray RT et al.Chemoprophylaxis is likely to be acceptable and could mitigate syphilis epidemics among populations of gay men.Sex Transm Dis. 2011; 38: 573-579Crossref PubMed Scopus (28) Google Scholar However, concerns exist about potential for increased antimicrobial resistance with widespread use of doxycycline.3Fairley CK Chow EPF Doxycycline post-exposure prophylaxis: let the debate begin.Lancet Inf Dis. 2018; 18: 233-234Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 4Siguier M Molina JM Doxycycline prophylaxis for bacterial sexually transmitted infections: promises and perils.ACS Infect Dis. 2018; 4: 660-663Crossref PubMed Scopus (7) Google Scholar, 5Peyriere H Makinson A Marchandin H Reynes J Doxycycline in the management of sexually transmitted infections.J Antimicrob Chemother. 2018; 73: 553-563PubMed Google Scholar Several countries, such as the UK, have guidelines against clinicians prescribing doxycycline for prevention of sexually transmitted infections (STIs), whereas others such as Australia do not.6Public Health EnglandBritish Association for Sexual Health and HIVPosition statement on doxycycline as post-exposure prophylaxis for sexually transmitted infections (PHE Publications gateway number: 2017543).https://www.bashhguidelines.org/media/1156/doxy_pep_statement_v5_phe_bashh.pdfDate: 2017Date accessed: August 12, 2019Google Scholar, 7Golden MR Handsfield HH Preexposure prophylaxis to prevent bacterial sexually transmitted infections in men who have sex with men.Sex Transm Dis. 2015; 42: 104-106Crossref PubMed Scopus (10) Google Scholar In Australia, doxycycline prophylaxis is not prescribed through publicly funded sexual health clinics, but prescriptions can be obtained from general practitioners off-label, because doxycycline is not approved for STI prophylaxis. Here we report the first estimate of the use of doxycycline prophylaxis among sexually active Australian MSM who were also taking PrEP. Clients attending Melbourne Sexual Health Centre are invited to complete a questionnaire on sexual practices using computer assisted self-interviewing (CASI) as part of routine clinical care. Men who self-reported having sex with another man in the past 12 months were defined as MSM. Between June and November 2018, we invited all HIV-negative MSM who were taking PrEP for HIV prevention to complete one additional CASI question on doxycycline prophylaxis. The Alfred Hospital Ethics Committee approved the study (number 650/18). 1065 (63·2%) of 1686 men taking PrEP completed the additional question on doxycycline. 105 men (9·9%; 95% CI 8·1–11·8%) reported use of doxycycline prophylaxis in the past month, with a median age of 31 years (IQR 27–37). The univariable analysis showed that men with five or more casual partners in the past 3 months had higher odds of taking doxycycline prophylaxis than those who had less than five casual partners; however, this association disappeared in the multivariable analysis after adjusting for other confounding factors (table). Similarly, condomless anal sex was marginally associated with the use of doxycycline pr ophylaxis in the univariable analysis, but not in the multivariable analysis. After adjusting potential confounding factors, only injecting drug use in the past 3 months was significantly associated with the use of doxycycline prophylaxis. Furthermore, doxycycline prophylaxis use was not associated with demographic characteristics, including age or country of birth, or with having a regular partner.TableFactors associated with the use of doxycycline postexposure prophylaxis among 1065 gay and bisexual men who were taking pre-exposure prophylaxis for HIVMen using doxycycline prophylaxis (%)OR (95% CI)*MSM who attended Melbourne Sexual Health Centre during the study period could participate in the survey more than once. Of 1066 responses, 934 were from unique individuals. ORs were calculated with a logistic regression model with generalised estimating equations to address repeated–measures within individuals. Variables with p<0·10 in the univariable analyses were included in the multivariable analysis.p valueAdjusted OR (95% CI)*MSM who attended Melbourne Sexual Health Centre during the study period could participate in the survey more than once. Of 1066 responses, 934 were from unique individuals. ORs were calculated with a logistic regression model with generalised estimating equations to address repeated–measures within individuals. Variables with p<0·10 in the univariable analyses were included in the multivariable analysis.p valueAge (years)16–2513/173 (7·5%)1 (ref)......26–3562/554 (11·2%)1·53 (0·80–2·94)0·202....≥3630/338 (8·9%)1·21 (0·60–2·46)0·597....Country of birthOverseas36/411 (8·8%)1 (ref)......Australia63/617 (10·2%)1·25 (0·79–1·97)0·340....Unknown6/37 (16·2%)2·20 (0·83–5·81)0·112....Injecting drug in the past 3 monthsNo94/1018 (9·2%)1 (ref)..1 (ref)..Yes10/36 (27·8%)3·82 (1·76–8·25)0·0013·26 (1·50–7·08)0·003Unknown1/11 (9·1%)0·82 (0·09–7·31)0·8570·80 (0·09–7·22)0·840Had a regular male partnerNo64/667 (9·6%)1 (ref)......Yes40/385 (10·4%)1·15 (0·75–1·77)0·508....Unknown1/13 (7·7%)0·92 (0·12–7·28)0·938....Number of casual male partners in the past 3 months<536/496 (7·3%)1 (ref)..1 (ref)..≥569/569 (12·1%)1·74 (1·13–2·67)0·0111·49 (0·96–2·30)0·075Condom use in the past 3 months†Consistent condom use was defined as men who used condoms at every sex act in the past 3 months; inconsistent condom use was defined as men who did not always use or never used condoms in the past 3 months.Consistent2/70 (2·9%)1 (ref)..1 (ref)..Inconsistent102/950 (10·7%)4·37 (0·98–19·53)0·0543·57 (0·80–16·04)0·097Unknown1/45 (2·2%)0·82 (0·07–9·80)0·8740·87 (0·07–10·41)0·913* MSM who attended Melbourne Sexual Health Centre during the study period could participate in the survey more than once. Of 1066 responses, 934 were from unique individuals. ORs were calculated with a logistic regression model with generalised estimating equations to address repeated–measures within individuals. Variables with p<0·10 in the univariable analyses were included in the multivariable analysis.† Consistent condom use was defined as men who used condoms at every sex act in the past 3 months; inconsistent condom use was defined as men who did not always use or never used condoms in the past 3 months. Open table in a new tab Our data suggest that MSM injecting drugs are more likely to use doxycycline prophylaxis and that sexual practices, such as number of partners and condom use, are not related to its use. Because doxycycline was not prescribed by the clinicians at our clinic, we were unable to determine whether the participants used it daily or on-demand; and whether doxycycline was taken after or before exposure. Our response rate was only 63%, so if those who did not respond were systematically different to those who did in relation to doxycycline use, our results might be biased. Ours is the first estimate of the use of doxycycline prophylaxis among MSM taking PrEP in Australia. Our data are similar to those from large sexual health clinic in London estimating that 8% of 106 MSM taking PrEP were also taking doxycycline prophylaxis.8Carveth-Johnson T Stingone C Nwokolo N Whitlock G Doxycycline use in MSM taking PrEP.Lancet HIV. 2018; 5: e482Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar These estimates were much lower than those for acceptability of doxycycline for STI prophylaxis in studies of sexually active MSM, which was 53% in Australia2Wilson DP Prestage GP Gray RT et al.Chemoprophylaxis is likely to be acceptable and could mitigate syphilis epidemics among populations of gay men.Sex Transm Dis. 2011; 38: 573-579Crossref PubMed Scopus (28) Google Scholar and 84% in the USA.9Spinelli MA Scott HM Vittinghoff E Liu AY Coleman K Buchbinder SP High interest in doxycycline for sexually transmitted infection post-exposure prophylaxis (doxycycline-PEP) in a multi-city survey of men who have sex with men (MSM) using a social-networking app.Sex Transm Dis. 2019; 46: e32-e34Crossref PubMed Scopus (10) Google Scholar The high acceptance rate but low actual use rate of doxycycline prophylaxis might be a result of limited access to doxycycline prophylaxis. Further research will be needed to explore not only the benefits of doxycycline prophylaxis on STI prevention but also the potential harm in terms of antimicrobial resistance.10Chow EPF Grulich AE Fairley CK Epidemiology and prevention of sexually transmitted infections in men who have sex with men at risk of HIV.Lancet HIV. 2019; 6: e396-e405Summary Full Text Full Text PDF PubMed Scopus (89) Google Scholar EPFC and CKF designed the study. EPFC performed the data analysis and wrote the first draft of the manuscript. EPFC and CKF contributed to data interpretation, critically revised it for important intellectual content and approved the final version of the manuscript. We acknowledge Afrizal Afrizal for his assistance with data extraction. Ethical approval was obtained from the Alfred Hospital Ethics Committee, Melbourne, Australia (number 650/18). EPFC was supported by the Early Career Fellowship from the Australian National Health and Medical Research Council (NHMRC; 1091226). The funder of the study had no role in study design, data collection, analysis, or interpretation or the writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication. EPFC has received consultant fees from Gilead Sciences, and research funding from Gilead Sciences, Merck & Co., and Seqirus Australia. CKF has no conflicts of interest to declare. Post-exposure prophylaxis with doxycycline to prevent sexually transmitted infections in men who have sex with men: an open-label randomised substudy of the ANRS IPERGAY trialDoxycycline PEP reduced the occurrence of a first episode of bacterial STI in high-risk men who have sex with men. Full-Text PDF
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