The World Health Organization (WHO) issued its first recommendation on the use of doxycycline postexposure prophylaxis (doxyPEP) to help prevent bacterial sexually transmitted infections (STIs).

The guidelines recommend using doxyPEP as part of a comprehensive sexual health strategy that complements established prevention measures, including condom use. The WHO advises prioritizing men who have sex with men and transgender women with recent or recurrent bacterial STIs, particularly syphilis, as well as those who belong to sexual networks or settings in which these infections are highly prevalent.

The WHO also recommends monitoring antimicrobial resistance (AMR) as part of doxyPEP implementation. Wherever feasible, surveillance should include both AMR trends and antibiotic use.

“These updated recommendations reflect WHO’s commitment to ensuring that people living with HIV benefit from the most effective, safe, and practical treatment options available,” said Tereza Kasaeva, director of the Department for HIV, Tuberculosis, Hepatitis and STIs of WHO Headquarters in Geneva, Switzerland, in a statement.

The WHO also encouraged countries and implementation partners to work together to ensure that populations at the highest risk have access to evidence-based prevention strategies.

Speaking with El Médico Interactivo, part of the Medscape Professional Network, José Luis Ramón Trapero, MD, a family and community medicine specialist at the Haro Health Center in La Rioja, Spain, and a member of the Spanish Society of Family and Community Medicine’s Infectious Diseases Working Group, described the recommendation as a response to the steady increase in bacterial STIs, particularly syphilis, chlamydia, and gonorrhea.

He noted that in Spain, the incidence of chlamydia and gonorrhea has increased, whereas HIV incidence has stabilized and, according to some datasets, even shown a slight decline.

“Preexposure prophylaxis (PrEP) has likely contributed to this trend,” Trapero said. “The next step is to identify additional preventive strategies. For PEP, single 200-mg dose of doxycycline should be taken within 72 hours after a high-risk sexual exposure, in which a condom was not used correctly.”

According to Trapero, the primary goal is to prevent bacterial STIs after high-risk sexual exposure, thereby reducing transmission among treated individuals and indirectly within the wider population.

“The preventive potential is considerable because previous prevention strategies have already proven highly successful,” he said. “However, inappropriate or excessive use could promote [AMR] and undermine the overall strategy.”

The WHO recommendations primarily target bacterial STIs including syphilis, gonorrhea, and chlamydia.

Implementation

Trapero emphasized that successful implementation should begin with broad educational initiatives directed toward both healthcare professionals and potential users.

“Both groups need to understand the importance of using the strategy appropriately to minimize the risk of [AMR],” he said. “It is a delicate balance. If one side becomes overloaded, the other is affected.”

Before introducing doxyPEP into Spain’s healthcare system, he believes health authorities should estimate the expected demand and ensure an adequate supply of doxycycline for its approved clinical indications.

Implementation should initially focus on STI clinics, specialized centers, and emergency departments before expanding to primary care centers and hospitals.

“Healthcare delivery varies considerably across Spain’s regional health systems,” Trapero said. “A coordinated approach among the autonomous communities will be essential to ensure equitable access.”

Clinical Evidence

The WHO recommendation is supported by randomized clinical trials, including DoxyPEP and ANRS DOXYVAC trials.

Researchers found that doxyPEP reduced the relative risk for infections caused by Chlamydia trachomatis and Treponema pallidum by approximately 70%-80%. However, protection against Neisseria gonorrhoeae was lower, with European studies reporting an efficacy of approximately 50% or less.

Trapero also noted that doxycycline is currently prescribed as a PEP in Spain on an off-label basis, requiring individualized clinical assessment supported by international scientific evidence.

According to the WHO, the next phase will focus on supporting countries, as they implement the recommendation through a series of webinars and updates delivered via the WHO Knowledge Exchange Platform.

The organization also advises national STI programs and other stakeholders to consult with the WHO before introducing doxPEP, in line with the new recommendation.

The WHO has expanded and consolidated the STI guidelines. These resources provide frontline clinicians with the latest evidence-based recommendations and GRADE evidence to strengthen STI prevention, diagnosis, and care

Trapero reported having no relevant conflicts of interest.

This article was translated from El Médico Interactivo on Univadis, part of the Medscape Professional Network.