DoxyPEP Beyond the Guidelines: Turning Evidence Into Equitable Access 

_{By Leandro Mena, MD, MPH, FIDSA}

August 2026

For decades, we have relied on a relatively small set of tools to prevent bacterial sexually transmitted infections (STIs). Condoms, screening, timely treatment, partner services, and counseling remain essential, but the continuing burden of syphilis, gonorrhea, and chlamydia makes clear that we need additional options.

Doxycycline postexposure prophylaxis, commonly called DoxyPEP, is one of the most important recent advances in STI prevention. I find the evidence encouraging, but its value will depend on much more than a clinical recommendation. It will depend on access, community trust, and the diagnostic and surveillance capacity needed to use it responsibly.

At AIDS 2026 in Rio de Janeiro, I attended the session, WHO clinical, service delivery and surveillance updates: new recommendations for HIV and sexually transmitted infections, where two presentations approached these issues from different perspectives. Remco Peters from World Health Organization (WHO) reviewed the evidence supporting the new WHO DoxyPEP recommendation. Midnight Poonkasetwattana of the Asia Pacific Coalition on Male Sexual Health (APCOM) discussed what the recommendation means for gay, bisexual, and other men who have sex with men and for transgender women in their communities.

The presentations described different parts of the same challenge. Evidence tells us what is possible. Implementation determines who benefits.

A meaningful addition to STI prevention 

DoxyPEP involves taking 200 mg of doxycycline within 72 hours after sex. Across three large randomized trials, it reduced syphilis and chlamydia by more than 70 percent and gonorrhea by approximately half. The lower and less consistent protection against gonorrhea matters because it reflects, at least in part, differences in tetracycline resistance across settings. Recent observational data from Southern California also suggest that effectiveness against gonorrhea may decline as resistance increases.

The WHO recommendation supports offering DoxyPEP to men who have sex with men and transgender women at increased risk of bacterial STIs. Peters emphasized that this should not become a rigid eligibility checklist. Risk changes over time as relationships, practices, and life circumstances change. Decisions about starting, continuing, or stopping DoxyPEP should therefore be revisited through ongoing shared decision making.

Our role as clinicians is not to police sexual behavior. It is to provide clear information and help each person decide whether DoxyPEP is appropriate for their needs and priorities.

DoxyPEP should also not be treated as an isolated prescription. It should be provided as part of comprehensive sexual health care that may include HIV testing, HIV pre-exposure or post-exposure prophylaxis, STI screening and treatment, vaccination, reproductive health care, condoms, and counseling.

Choice, not judgment

Poonkasetwattana’s presentation made the community implications very clear. People need options. No single prevention approach will work for everyone or at every point in a person’s life.

DoxyPEP should be presented as an additional choice, not as a punishment for having an STI, a requirement linked to certain sexual practices, or a substitute for condoms. Communities have too often received sexual health messages shaped by fear, shame, and assumptions about how people should behave. We should not repeat those mistakes.

People need honest and understandable information about what DoxyPEP can and cannot do. They should know that it works best against syphilis and chlamydia, that its effectiveness against gonorrhea varies, and that it does not replace routine STI testing and continued clinical care. They also need practical information about adverse effects, safe use, and antimicrobial resistance.

These conversations should be confidential and free of judgment. The purpose is to support informed decisions that reflect each person’s health, relationships, and quality of life.

A recommendation does not create access 

Publishing a recommendation does not put medication into anyone’s hands. Meaningful access requires affordable doxycycline, reliable testing, trained providers, and services that people trust. It may also require delivery outside traditional clinics through community organizations, HIV programs, pharmacies, mobile services, and other models that reflect local needs.

Communities need to be involved from the beginning. They can help shape how eligibility is discussed, where services are offered, which words are used, and who delivers the message. APCOM’s experience translating regional HIV prevention information into 15 languages, with community participation from the start, offers a useful example.

This is especially important for migrants, sex workers, people without insurance or identification documents, people living in criminalizing environments, and those who cannot afford medication, testing, transportation, or clinic fees. Without deliberate planning, DoxyPEP could primarily reach people who already have the greatest access to care.

The diagnostic gap cannot be ignored 

In many parts of the world, STIs continue to be managed syndromically. People are treated based on symptoms because laboratory testing is unavailable, unaffordable, or too slow to guide care.

Syndromic management has an important role where diagnostic options are limited, but it misses many asymptomatic infections and can result in both overtreatment and undertreatment. It also makes it difficult to know which infections are circulating, whether DoxyPEP is preventing them, whether breakthrough infections are occurring, or whether treatment is beginning to fail.

This creates a serious mismatch. Countries are being asked to monitor the effect of DoxyPEP on antimicrobial resistance while many still lack the capacity to routinely identify the organism causing an infection.

Antimicrobial resistance requires action and investment 

Concern about antimicrobial resistance is legitimate. It should not be used to delay access indefinitely, but it also cannot be treated as a minor issue. Responsible implementation requires monitoring resistance patterns, prescribing practices, medication use, and potential effects on organisms beyond the STIs DoxyPEP is intended to prevent.

Surveillance is only as strong as the diagnostic infrastructure beneath it. Meaningful monitoring requires etiologic diagnosis, quality assured molecular testing, gonococcal culture and susceptibility testing, specimen transport, trained laboratory personnel, and systems that link laboratory findings with clinical and epidemiologic information.

A global recommendation that calls for surveillance must be accompanied by a global commitment to finance that capacity. Governments, donors, manufacturers, and global health agencies should invest in affordable STI diagnostics, including rapid tests that can be used at the point of care, stronger reference laboratories, culture and susceptibility testing, data systems, and the workforce needed to sustain them.

These investments would improve much more than DoxyPEP. They would strengthen STI diagnosis and treatment, antimicrobial stewardship, and outbreak detection.

Surveillance must also be transparent and developed with communities. People should understand what information is being collected, why it is needed, and how findings may affect recommendations. Monitoring should improve care. It should never become another way to blame, stigmatize, or exclude communities.

Moving from recommendation to impact 

The two presentations left me optimistic, but also clear about the work ahead. DoxyPEP is a meaningful addition to STI prevention, but its impact will depend on informed choice, affordable and trusted services, community leadership, accurate diagnosis, responsible surveillance, and a willingness to adjust implementation as the evidence evolves.

We should not allow uncertainty about resistance to paralyze implementation. We also should not allow enthusiasm for a new intervention to minimize legitimate questions about equity, access, and long-term effects.

Science has given us an important new tool. Our responsibility now is to build the services, partnerships, diagnostic systems, and surveillance capacity needed to ensure that the people who could benefit from DoxyPEP are actually able to do so.

About the Author
Leandro A. Mena, MD, MPH, FIDSA, is an infectious diseases physician, researcher, educator, and public health practitioner whose work focuses on HIV and STI prevention, treatment, implementation science, and health equity. He is Professor of Medicine in the Division of Infectious Diseases at Emory University and Chief Medical Officer of NMAC. Dr. Mena previously served as Director of the Division of STD Prevention at the U.S. Centers for Disease Control and Prevention and was the founding chair of the Department of Population Health Science at the University of Mississippi Medical Center. Throughout his career, he has worked to expand culturally responsive sexual health services and address inequities affecting communities disproportionately impacted by HIV and other STIs. He is board certified in infectious diseases and a Fellow of the Infectious Diseases Society of America.

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