Early Implementation of Doxycycline Postexposure Prophylaxis at an Infectious Diseases Clinic in the Southern United States

Doxycycline postexposure prophylaxis (DoxyPEP) is an emerging strategy to prevent bacterial sexually transmitted infections (STIs) among men who have sex with men (MSM) and transgender women (TGW). We evaluated early DoxyPEP implementation in a university-affiliated infectious diseases clinic providing HIV and pre-exposure prophylaxis (PrEP) care in Durham, North Carolina. This retrospective study included two overlapping cohorts: (1) patients prescribed DoxyPEP through December 31, 2024, to characterize early prescribing and follow-up with contextual clinic comparison; and (2) MSM and TGW diagnosed with a bacterial STI between July 1, 2023, and December 31, 2024, in whom factors associated with DoxyPEP receipt were evaluated using mixed-effects logistic regression. Among 219 patients prescribed DoxyPEP, 41% had a bacterial STI in the preceding year, more frequently among people with HIV (PWH) than PrEP users (51% vs. 30%, p = 0.002). Although PWH comprised 90% of the clinic population, they accounted for 53% of DoxyPEP recipients, signaling disproportionate adoption by HIV status. Among 276 MSM/TGW patients with a bacterial STI during the study period, 26% were prescribed DoxyPEP during a median follow-up of 11 months (interquartile range: 6–14). PrEP use (adjusted odds ratio [aOR]: 11.1, 95% confidence interval [CI]: 2.97–41.2) and encounters after Centers for Disease Control and Prevention guideline release (aOR: 2.46, 95% CI: 1.03–5.83) were associated with DoxyPEP receipt. Recurrent bacterial STI incidence prior to DoxyPEP initiation was 51 per 100 person years. Despite increasing uptake over time, missed opportunities for DoxyPEP prescribing were observed following STI diagnoses, particularly among PWH. Targeted strategies are needed to support integration of DoxyPEP into routine HIV care.