Health Update: Updated Recommendations for Prescribing Doxy-PEP

Situational Update

On October 20, 2022, San Francisco Department of Health (SFDPH) released a health update recommending doxy-PEP for men who have sex with men (MSM) and trans women with a history of chlamydia, gonorrhea or syphilis. In September 2024, SFDPH released a doxy-PEP prescribing guide and updated eligibility criteria to provide better visibility and specificity to prescribing doxy-PEP for trans and other gender-diverse patients.

Recent studies from Japan (1) and Kenya (2) of alternative doxycycline regimens have now demonstrated that doxycycline may help prevent STIs in cis women having vaginal sex. As a result, SFDPH is updating local doxy-PEP recommendations to include eligibility for cis women and others assigned female at birth.

By expanding eligibility for doxy-PEP, SFDPH aims to increase access to doxy-PEP for all who may benefit, including cis women, to promote health for all and bolster congenital syphilis prevention efforts.

Actions requested of SF Clinicians

• Introduce doxy-PEP to all patients who may benefit. Do not wait for patients to learn of doxy-PEP elsewhere. This approach promotes racial and gender equity in sexual health by ensuring all patients who may benefit from doxy-PEP know about it.
• Use the following eligibility criteria for doxy-PEP:
  1. Recommend doxy-PEP to cis men, trans women, and other gender-diverse people who were assigned male sex at birth, who in the past year:
     1. had a bacterial STI, and
     2. had condomless sex (including oral) with ≥ 1 partner who was assigned male sex at birth.
  2. Offer doxy-PEP using shared decision-making to cis men, trans women, trans men, and other gender-diverse patients (of any sex assigned at birth) who in the past year:
     1. had condomless sex (including oral) with ≥ 2 partners assigned male sex at birth, regardless of STI history.
  3. UPDATED: Offer doxy-PEP using shared decision-making to cis women and anyone assigned female at birth who in the past year:
     1. had condomless sex, and
     2. had a bacterial STI, particularly syphilis or recurrent chlamydia, or
     3. report substance use, unstable housing or homelessness, sex work, intimate partner violence, MSM partners, or incarceration.
  4. UPDATED: Providers can consider doxy-PEP for anyone, regardless of gender or gender of sex partners, based on an assessment of their chance of exposure to STIs.

• Doxy-PEP, for all genders, is 200 mg of doxycycline taken as soon as possible after condomless oral, anal, or vaginal/front-hole sex, but no later than 72 hours afterward.
• Counsel patients who could get pregnant not to use doxycycline while pregnant.
• Review our updated Doxy-PEP prescribing guide for San Francisco providers, which includes updated counseling messages.

Additional resources

• SFDPH “About Doxy-PEP” patient handout
• CDC Clinical Guidelines on the Use of Doxycycline Postexposure Prophylaxis for Bacterial Sexually Transmitted Infection Prevention, United States, 2024
• SF City Clinic clinical guidelines and toolkits
• CDC 2021 STI Treatment Guidelines
• Doxy as STI PEP Command Center (National Coalition of STD Directors)
• Doxycycline Use by Pregnant and Lactating Women (FDA)

Abstract citations

1. Seitaro A, et al. (2025) Doxycycline Pre-Exposure Prophylaxis Prevents Sexually Transmitted Infections Without Affecting Vaginal Bacterial Flora in Female Sex Workers. JAC-Antimicrobial Resistance, 7(2), dlaf054.
2. Stewart J, et al. (2025) OA11.06 - Weekly Doxycycline Prophylaxis for Prevention of Sexually Transmitted Infections Among Cisgender Women in Kenya [Conference abstract]. Sexual Health, 22, SHv22n4abs.

Contact information

Alyson Decker, NP
Manager, STI/HIV Training and Technical Assistance
Tel: 628-217-7663
Email: alyson.decker@sfdph.org

To view or sign up for SFDPH Health Alerts, Advisories, and Updates visit: sf.gov/healthalerts