San Francisco Celebrates Morning-After Pill for STIs. Other Countries Warn of Antibiotic Resistance

When Toler heard there was a morning-after pill for STIs that could solve all these problems, he wanted in. Doxy PEP, or doxycycline post-exposure prophylaxis, is an antibiotic taken within 72 hours of condomless sex to prevent bacterial infections. Toler hasn’t had an STI in the three years since he started taking it.

“I can be as much of a promiscuous person as I possibly can and not have to worry about the ramifications as much,” he said with a wry smile.

Across San Francisco, syphilis rates dropped 24% last year, chlamydia went down 18% and gonorrhea dipped 5%, leading local health officials to celebrate the success of Doxy PEP and their decision to distribute it broadly.

At the same time, doctors around the globe caution that using antibiotics this way could contribute to antibiotic resistance, making it harder to treat a range of bacterial infections down the road.

The tension between reducing STIs and stewarding antibiotics responsibly has led to a range of divergent policies around who should get Doxy PEP and when.

“We need to be thoughtful about how we’re using it,” said Dr. Annie Luetkemeyer, an infectious disease physician and researcher at UCSF. “Antibiotics are an incredible resource. We all worry about antimicrobial resistance.”

Gonorrhea has already built resistance to the class of antibiotics that include doxycycline, and research suggests that Doxy PEP is making it worse, Luetkemeyer said.

She is now leading a five-city study, including Atlanta, Miami, Detroit, Seattle and San Francisco, to examine whether Doxy PEP increases resistance in other bacteria, as well, including strep pneumoniae, which can cause lung infections like pneumonia, and staph aureus, which can cause skin infections. Earlier studies raised this concern.

“In folks who took Doxy PEP, we saw an increase in doxy-resistant staph aureus,” she said. “The numbers were small, but there was a trend in that direction.”

Developing Doxy PEP policy is a balancing act, weighing the benefits of reduced sexually transmitted infections against the risk of cultivating superbugs that are more difficult to treat. San Francisco officials chose to make Doxy PEP widely available and recommended doctors offer it to anyone who might benefit.

Other countries have taken a more conservative approach. The European Centre for Disease Prevention and Control and Australasian Society for Sexual Health Medicine recommended restricting the use of Doxy PEP for the prevention of syphilis only, with a focus on men who have sex with men who have a history of syphilis infection.

Both groups decided against recommending it to prevent gonorrhea or chlamydia because they deemed the benefits did not outweigh the risks.

“I would argue that for gay men, there is no population-level benefit for getting chlamydia rates down,” said Dr. Vincent Cornelisse, a sexual health physician and professor at the University of New South Wales in Sydney.

The consequences of syphilis can be dire: blindness, hearing loss, brain damage. Chlamydia, on the other hand, is more of a nuisance for men, Cornelisse said, uncomfortable, but not dangerous.

The Australian committee decided prescribing Doxy PEP to prevent it was an excessive use of antibiotics.

“I think we need to be a bit tempered in recommending strategies to reduce chlamydia amongst gay men when the strategies themselves might have adverse outcomes,” he said.

At the Strut clinic in the San Francisco Castro neighborhood, nearly half the prescriptions the pharmacy fills are for Doxy PEP. Clinicians offer it to everyone who comes into the clinic.

Medical director, Dr. Hyman Scott, who also does research in the city’s public health department, is firm in his defense of a broad, open policy.

In the early 2010s, San Francisco made serious missteps with the rollout of PrEP, pre-exposure prophylaxis for the prevention of HIV, Scott said, placing a lot of restrictions on who should get it.

The guidelines were so confusing and the medication so hard to access, he added, only a quarter of people who actually needed it were taking it.

“There are a lot of things now we’re trying to undo as a result of the way we did it originally,” Scott said. “We cannot make the same mistakes.”

Health officials learned that they have one shot to make a first impression, positive or negative, and that’s the message that will spread through the community, Scott said.

So they decided to make their message about Doxy PEP simple and straightforward: everyone is eligible, just talk to your doctor.

The science about Doxy PEP moves freely on social media, and by word of mouth, so many San Franciscans who take it are aware of the risk for antimicrobial resistance, both for themselves and the broader population.

“I was very conflicted about it when I started it,” Toler said.

But when he talked to his older friends who lived through the AIDS epidemic, his feelings shifted. Gay activists fought hard for the research and innovation that made PreP and Doxy PEP possible, Toler said, and they want the younger generations to have the sex lives that they couldn’t.

“We need to take advantage of the science that we have right now,” he said, “for the people that weren’t able to take advantage of it.”