PEP in your step - the public health politics of Doxycycline STD prophylaxis for unprotected sexual activity

From the article:

Since their popularization during the outbreak of the AIDS crisis, condoms have, ironically enough, given birth to an array of sexual freedoms, among them the ability to have sex without risk of pregnancy or infection. Yet, as freeing as they can be, condoms have also, for many, been just as limiting—tethering sex, especially sex outside of monogamous, heterosexual, reproductive relationships, to a frankly unsexy public health imperative for latex prophylaxis.

The condom doctrine is often untenable, especially where mishap, misadventure, drunkenness, forgetfulness, or coercion collides with even the most devout of condom-carriers. And for those it has most frequently been thrust upon, the informal prohibition of condomless sex fuels persistent stigma and anxieties about “contagion,” and inhibits erotic fantasies about the pleasures of bodily fluids and skin touching skin. In this way, condoms have answered one question—how to have sex in the presence of a range of biological risks—and posed another: namely, how to have sex without them.

In 2023, a new tool is furthering the possibilities of safer sex without condoms. Like HIV PrEP, a pill that is close to 100 percent effective at preventing an HIV-negative person from acquiring HIV, doxycycline post-exposure prophylaxis, or DoxyPEP, is a dosing regimen that can drastically reduce the chances of someone becoming infected with a bacterial STI. Clinical trials in both HIV-positive and HIV-negative transgender women and gay, bisexual, and other men who have sex with men (GBMSM) have demonstrated that DoxyPEP, taken within seventy-two hours of sex without condoms, may be capable of preventing over 80 percent of infections by chlamydia and syphilis and upwards of 50 percent of gonorrhoea infections, which are all rapidly rising across the United States. Yet, despite evidence of efficacy and real-world benefit, outside of a handful cities—including San Francisco, Seattle, and Chicago—few jurisdictions, and none outside of the United States, have officially approved DoxyPEP as an “on-label” use of doxycycline.

I'd prefer not to see this essay link moved to ~lgbt, even though LGBTQ+ concerns and homophobic opposition to stereotyped gay "promiscuity" are central themes in the article. This is an article about public health for humans doing what humans do in real life. Further, it engages with the question of what "responsibility" means in a time of drastically inequitable access to healthcare, particularly by race and for injectable drug users and sex workers.

We like sex, and generally engage in it wherever, whenever, and however possible, as often as our complicated social relations, religious taboos, economic status, and other conditions will permit. Even though bacteria, viruses, fungi, and parasites have taken advantage of our predilections for direct intimate contact, we're at war with them, not each other. The article makes note that condoms are not generally objects of desire. They're just an available, not always acceptable or accessible, means of preventing STIs.

I'd rather see sex made as safe as possible for everyone, taking into account real-world conditions, than under the capricious control of religious or other sorts of authoritarians. With respect to DoxyPEP for chylamidia, syphilis, and gonorrhea prevention, even the superficially plausible concerns about antibiotic resistance raised by public health authorities become questionable given the drug's widespread, continuous use for livestock and some human diseases. It's time they confess to morality bias rather than public health concern.

Ideally, we'll have vaccines for some of the pathogens spread by sexual contact within the next decade, but don't hold your breath for any urgency in their testing and distribution until we can get the old-fashioned taboo mindset out of the way. The HPV vaccine, known to nearly eliminate cervical and other cancers from the major strains of oncogenic HPV, only has about 60% coverage of people in what's considered the at-risk age group (age 11 to age 45, and I beg to differ about that upper limit) in the U.S., with lower adoption outside major metropolitan areas.