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Background:
Systematic Review

Healthcare Professionals’ Beliefs and Concerns About the Use of Doxycycline Post-Exposure Prophylaxis (doxyPEP): A Systematic Review

by
Molly Spence
1,
Clare Fowler
1,
Saxon Absalom
1,
Tom Roper
1,
Deborah Williams
1 and
Daniel Richardson
1,2,*
1
University Hospitals Sussex NHS Foundation Trust, Brighton BN2 5BE, UK
2
Brighton & Sussex Medical School, Brighton BN1 9PX, UK
*
Author to whom correspondence should be addressed.
Venereology 2026, 5(1), 9; https://doi.org/10.3390/venereology5010009
Submission received: 30 January 2026 / Revised: 24 February 2026 / Accepted: 9 March 2026 / Published: 12 March 2026
Browse Figure
Versions Notes

Abstract

Objective: To explore healthcare professionals’ beliefs and concerns about doxyPEP by systematically reviewing the literature. Method: A systematic review of three bibliographical databases (CINAHL, EMBASE and MEDLINE) and MedRxiv in August 2024, updated in February 2026 explored healthcare professionals’ beliefs and concerns about doxyPEP. Three researchers independently reviewed full-text manuscripts for eligibility and narratively synthesized data. We used the Joanna Briggs Institute toolkit to assess risk of bias. This review was registered on PROSPERO (ID:CRD42024570646). Results: Eight manuscripts were included in the final review: five cross-sectional studies, two qualitative studies, and one mixed method study from the USA (n = 5), Australia (n = 1), Kenya (n = 1), and the UK (n = 1) published between 2020–2025 and including 1840 healthcare professionals. Healthcare professionals recognised the high burden of bacterial STIs and believed that doxyPEP should be made available to MSM. There was a strong willingness to provide doxyPEP to MSM with the support of national guidelines. Healthcare professionals suggest that implementing doxyPEP would be feasible with educational support, but were concerned about antimicrobial resistance, drug–drug interactions, pill burden, cost, implementation logistics and the effect on clinical service demands. They acknowledged the lack of research and access to doxyPEP for other groups, specifically trans people and cis-gendered women. They also highlighted the need for community involvement in the implementation of doxyPEP. Conclusions: This review highlights that healthcare professionals were willing and ready to provide doxyPEP; however, they have concerns including antimicrobial resistance, the effect on service capacity, and the lack of research on cis-gendered women and trans people. Patients and health professionals need to be involved in the implementation of doxyPEP.

1. Introduction

Rates of Treponema pallidum, Chlamydia trachomatis and Neisseria gonorrhoeae have increased significantly in high income settings in men who have sex with men (MSM) [1]. The current interventions of regular screening in MSM using HIV-pre-exposure prophylaxis for T. pallidum, C. trachomatis, and N. gonorrhoeae, promotion of condoms, and health promotion initiatives have not provided effective sexually transmitted infection (STI) control amongst MSM [2,3,4]. The epidemic of Treponema pallidum in MSM is now affecting other populations in high income settings with associated increases in congenital syphilis [5]. Furthermore, antimicrobial resistant N. gonorrhoeae now poses a major public health threat [6]. However, recently, doxycycline 200 mg (doxyPEP) taken within the first 24 h and no later than 72 h after condomless sex has been shown to reduce the rates of T. pallidum, C. trachomatis, and N. gonorrhoeae (to a lesser effect) in MSM [7,8,9]. In a study from the United States of America, rates of T. pallidum, N. gonorrhoeae, and C. trachomatis were reduced by 74%, 55%, and 77% in 174 MSM and transgender women (TGW) living with HIV, and 87%, 55%, and 88% in MSM/TGW using HIV-PrEP [8]. Rates of tetracycline resistant N. gonorrhoeae vary significantly geographically, and therefore doxyPEP has a lesser effect on N. gonorrhoeae than in T. pallidum and C. trachomatis in some parts of the world. Tetracycline resistance in N. gonorrhoeae is estimated to be higher in Asia, Africa, South America, and Europe compared to the USA, which is likely to affect the impact of doxyPEP globally [6].
There remain some concerns over the long-term safety of doxyPEP, such as driving antimicrobial resistance in STIs and other bacteria, including enteric pathogens [10,11,12]. Initially, in 2017, The British Association of Sexual Health and HIV (BASHH) and Public Health England released a joint statement advising extreme caution, stating the unknown risks associated with “widespread, unprescribed, and unmonitored” antibiotic use outweigh the potential benefits of doxyPEP. It has been estimated that between 5–9% of MSM are already using doxycycline to prevent STIs in the UK [13,14]. BASHH released further guidance on how to safety advise patients already using doxyPEP [15]. Current guidance and commissioning of doxyPEP for MSM in the UK is anticipated.
The beliefs and concerns of healthcare professionals working in clinics are important for the implementation of new (sexual) health interventions. Many (sexual) health interventions are co-designed with neither the communities they target, nor the healthcare providers who are expected to deliver these interventions. Previous interventions to prevent HIV and STIs have been, in part, reliant on the offer from healthcare professionals [16]. The aim of this review was to explore the current beliefs and concerns of healthcare professionals regarding doxyPEP by systematically reviewing the literature. Understanding the beliefs and concerns of healthcare professionals can highlight potential barriers and may support strategies to improve the delivery of doxyPEP when it becomes available in publicly funded clinical settings.

2. Method

2.1. Search Strategy and Selection

A systematic review of the literature was conducted in August 2024 and updated in February 2026 to explore the attitudes and concerns of healthcare professionals about doxyPEP, which we report following PRISMA guidelines [17]. The February 2026 update was done because some of the initial grey literature had since been published, and to capture any additional manuscripts. Relevant manuscripts were identified by searching three bibliographical databases (CINAHL, EMBASE, and MEDLINE) and the preprint server MedRxiv using the following search terms ((“doxycycline” AND “Post-Exposure Prophylaxis”) OR (“doxy-PEP”) OR (post-exposure prophylaxis or postexposure prophylaxis or post exposure prophylaxis or PEP or doxyPEP)) AND ((health or health care or healthcare) OR (doctor or physician or nurse* or pharmacist, or prescriber or clinician)). The detailed search strategy can be found in Supplementary Material S1. To supplement the small number of articles retrieved in CINAHL, EMBASE, and MEDLINE, the results located through those resources were prospectively citation-searched in Google Scholar. Manuscripts meeting the following criteria were included in the review: those written in English, containing primary data, amd exploring healthcare professionals’ beliefs and concerns about doxyPEP (including the willingness to prescribe). We took a broad view of who a healthcare professional was and included a broad range of professionals such as policy makers, researchers, microbiologists, and advocates, along with frontline clinicians to ensure that anyone who was directly or indirectly involved in the delivery of doxyPEP was included. There was no restriction on the date of publication. We did not limit manuscripts to those where doxyPEP was being considered in non MSM e.g., cis-gendered women. All study types containing primary data were included. Due to the novelty of this research question, we decided to include all types of literature, including conference abstracts and academic degree theses published online, in our initial searches.

2.2. Study Selection and Risk of Bias

A stepwise process was used to select manuscripts from the search results. Citations were uploaded into Microsoft Endnote 2024 (Clarivate, Philadelphia, PA, United States) and duplicates were removed. Initially three researchers (MS, CF, and SA) reviewed the citations and abstracts and then independently reviewed full-text manuscripts against the inclusion criteria to achieve a final set of manuscripts. The reference lists of the final manuscripts were hand searched to seek further eligible manuscripts. Discrepancies between independent authors were resolved by discussion between MS, CF, SA, and DR. The risk of bias was assessed for each manuscript independently by four researchers (MS, CF, SA, and DR) using the Joanna Briggs Institute (JBI) critical appraisal checklists [18]. The risk of bias was assessed for each manuscript including a review of any methods used to account for confounding factors, analysis, and overall risk of bias. Inclusion in the review was not contingent on quality of reporting or risk of bias. Each manuscript was graded as having a low, medium, or high risk of bias. The results were not tempered by the risk of bias in this analysis due to the nature of the manuscripts and data presented.

2.3. Data Extraction and Synthesis

Data were extracted from the manuscripts into a table, including article title, publication year, sample size, study design, population, and the beliefs and concerns about doxyPEP for the prevention of STIs. Data were tabulated and synthesised from the manuscripts, and themes were generated narratively independently by three researchers (MS, CF, and DR) using a process of reading, identifying key words, phrases, and concepts, then coding and identifying recurring patterns and meanings. The narrative synthesis focused on a textual summary to explore beliefs and concerns that healthcare workers have about doxyPEP. Due to methodological heterogeneity, this technique allowed for a thematic, non-statistical aggregation of study results, including contextual interpretation. Initially, a preliminary synthesis was developed by extracting key data—including methodology, population, and intervention outcomes—into structured, standardised tables. Codes were generated through an inductive, iterative, and qualitative process, where reviewers immersed themselves in the findings to identify recurring concepts, patterns, and differences. These codes were subsequently organised into broader, refined, and descriptive themes, which were refined to explain how and why certain interventions were successful. To ensure reliability and minimise subjectivity, consensus was achieved among multiple reviewers through regular, structured meetings where disagreements in coding or theme interpretation were debated until a unanimous decision was reached. Finally, the robustness of the synthesis was assessed by evaluating the strength of the evidence supporting these themes and analyzing the impact of study quality on the overall findings. Following the initial search, which included some grey literature (Masters and PhD theses), these were then published and for transparency, and the searches were repeated to ensure no additional literature had been published in the timeframe. The review protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42024570646).

3. Results

The searches identified 29 manuscripts, from which 14 duplicates were removed, 15 abstracts were screened, and one excluded; 14 full text manuscripts were assessed for eligibility, of which six met the criteria (Figure 1). Two further manuscripts were identified from hand-searching the eligible manuscript reference lists. In total, eight manuscripts were included in the final review: five cross-sectional studies, two qualitative studies, and one mixed method study [19,20,21,22,23,24,25,26] (Table 1). The manuscripts reported were from the United States of America (n = 5), Australia (n = 1), Kenya (n = 1), and the United Kingdom (n = 1), and were published between 2020–2025 [19,21,22,23,26]. Overall, the beliefs and concerns of 1840 healthcare professionals were evaluated. The professionals included clinicians, epidemiologists, microbiologists, researchers, experts in public health & health policy. The risk of bias was determined to be high in two manuscripts, medium in five manuscripts, and low in one manuscript (Supplementary Material S2). All of the manuscripts included were published; no grey literature met our inclusion criteria for the final selection.

3.1. Providing doxyPEP to MSM

Healthcare professionals in this review recognised the high burden of bacterial STIs and believe that doxyPEP should be made available to MSM to reduce rates of T. pallidum, and to a lesser extent to reduce rates of C. trachomatis and N. gonorrhoeae [21,22,25] (Table 2). There was a strong willingness to provide doxyPEP to MSM with the support of national guidelines and recommendations, and healthcare professionals felt that implementing doxyPEP within existing HIV-PrEP services would be feasible [19,20,21,24,25,26]. One manuscript explored the awareness and knowledge of doxyPEP amongst sexual health clinicians in the UK, suggesting that that more educational support was needed for healthcare professionals to be able to deliver doxyPEP in particular being able to counsel patients on the estimated efficacy of doxyPEP [23].

3.2. Concerns About doxyPEP

Healthcare professionals were concerned about antimicrobial resistance which may be driven by doxyPEP in particular for N. gonorrhoeae [19,20,21,22,24,25,26]. In the Australian manuscript, the authors described some disagreement, as some professionals felt strongly that doxyPEP should be considered only for the prevention of syphilis in MSM and that the risk of increasing antimicrobial resistance outweighed any potential benefit from reductions in other bacterial STIs [22,25]. They were also concerned about potential drug-drug interactions, pill burden, cost, implementation logistics and the effect on clinical service demand [21,25,26]. These issues varied considerably by geographical location as cost to patients in an African setting is different from a UK setting where healthcare, including prescription drugs are free at the point of access [21,23,25]. There were concerns from professionals on the implementation of doxyPEP, including clinic flow, electronic record templates, the availability of prescribers and increased waiting times [21,23,25]. The unknown impact on service demands, both increased (accessing doxyPEP) and decreased (effectiveness of doxyPEP causing a reduction in C. trachomatis and T. pallidum) was highlighted as a concern from sexual health clinicians in the UK [23]. Healthcare professionals acknowledge the paucity of research into and therefore access to doxyPEP for other groups, specifically trans people and cis-gendered women [23]. They also highlighted the need for community involvement for the implementation of doxyPEP [21].

4. Discussion

To our knowledge, this is the first systematic review exploring the beliefs and concerns of healthcare professionals towards doxyPEP. Although limited by the quality and quantity of manuscripts, this review highlights some willingness and readiness to provide doxyPEP to MSM by healthcare professionals. Furthermore, this review has highlighted some important concerns raised by healthcare professionals including the impact of doxyPEP on antimicrobial resistance, the effect on service capacity and the lack of research in other groups such as cis-gendered women and trans people. DoxyPEP is now being recommended in some jurisdictions, and to understand the feasibility and barriers, this review suggests that the implementation of doxyPEP requires a multidimensional approach including input from community voices and healthcare providers [22,24,25,27,28,29].
Healthcare professionals acknowledged the need for innovation (e.g., doxyPEP) to reduce the burden of bacterial sexually transmitted infections in MSM [19,20,21,22,26]. It is also promising that the healthcare professionals in this review believed that implementation of doxyPEP in current services for MSM would be feasible supported by appropriate guidelines [21,26]. Most sexual health services have had to evolve the way in which interventions are delivered (e.g., HIV-PrEP, HPV vaccination, Mpox vaccination) using digital health pathways, home testing, and community partnerships [30,31,32]. To provide equity, national organisations and clinical services need to provide appropriate educational opportunities for healthcare professionals working in clinical services for MSM to improve the offer and uptake of doxyPEP.
Healthcare professionals were concerned about the potential for doxyPEP to drive antimicrobial resistance, including in sexually transmitted bacteria and the microbiome [19,20,22,23,26]. Broadly, the antimicrobial consumption in populations of MSM has increased significantly partly due to the increased testing recommended for monitoring of MSM using HIV-PrEP [11,33]. Antimicrobial resistant sexually transmitted bacteria (N. gonorrhoeae, M. genitalium,) and sexually transmissible enteric bacteria (Shigella sonnei, shigella flexneri, Campylobacter spp., Salmonella spp.) already pose significant public heath challenges globally [6,34,35,36,37,38]. In the UK, isolates of N. gonorrhoeae, and M. genitalium are already resistant to tetracyclines; however, to date there is little evidence of tetracycline resistance in T. pallidum despite considerable use in STI services for the treatment of C. trachomatis and urethritis [39]. A systematic review of seven manuscripts observed modest and transient effects on subgingival, gastrointestinal, and upper respiratory tract flora in individuals taking tetracyclines [40]. The US doxyPEP study demonstrated an increase in tetracycline resistance in commensal Neisseria spp., Staphylococcus. Aureus, and N. gonorrhoeae, and an increase in the abundance of tetracycline resistance genes in the doxyPEP arm.
Doxycycline has been used for malaria prophylaxis and dermatological conditions for decades with little concern from the scientific community about evolving antimicrobial resistance, raising the possibility of prejudice towards doxycycline being used for MSM to prevent sexually transmitted infections [41]. It is important to consider and balance the differences in the prevention of deadly diseases such as malaria and the treatment of a skin condition such as acne with the prevention of sexually transmitted infections, although the potential for doxyPEP to reduce congenital syphilis should not be overlooked. However more work is needed to establish the population impact of doxyPEP use to inform the concerns of healthcare professionals and the communities using this intervention [42]. The unregulated use of antibiotics in agriculture is likely to have an effect on population level antimicrobial resistance, although in general, antimicrobial resistance emerges in core groups exposed to antimicrobials such as MSM using HIV-PrEP [42].
DoxyPEP may also benefit other groups of people who experience high rates of STIs, for example sex workers, cis-gendered women, and trans people [9,43]. The healthcare professionals in this review are concerned about other groups of people in their practice who will not currently be eligible for doxyPEP due to the paucity of clinical research, or, in the case of cis-gendered women, due to adherence as shown in the group of Kenyan women [43]. More work is needed to establish the efficacy and safety of doxyPEP in non-MSM populations.
Sexual health services may need to realign, as they have had to do for the delivery of HPV vaccination, HIV-PrEP, Mpox, and Mpox vaccination, to provide doxyPEP [44]. The delivery of novel interventions should ideally be co-designed with the targeted community to enable timely identification of barriers, and this review also suggests that other stakeholders, such as clinicians asked to provide doxyPEP, should be involved in the service re-design. Co-designed sexual health services targeting people who are unheard by current services can be successful in providing interventions [31,45]. For example in Brighton, UK, the sexual health team have co-designed outreach HIV-PrEP and Mpox vaccination and demonstrated that they have successfully reached unmet populations by working with the community to design services [31,45]. Co-designing HIV-PrEP services for black women living in England has been shown to highlight multilevel barriers experienced by some people, and including black women in the decision making process can reduce equity gaps and improve access [46]. DoxyPEP services and provision requires a multidimensional partnership approach to provide equity, particularly for unmet populations including women and trans people [31].
This review has various limitations, including a small number of manuscripts with significant bias, making the overall results challenging to interpret. It therefore may not be representative of all healthcare professionals’ beliefs and concerns. Apart from one manuscript from Kenya where the surveys were in Kiswahili or Dholuo, all the reviewed data was written in English [21]. Most of the health professionals included in the manuscripts in this review were working in sexual health or MSM health, or were recognised advocates of sexual health, and may not be representative of all healthcare professionals. One study by Park JJ et al., 2021, [19] explored the willingness to prescribe and barriers of both doxyPEP and doxycycline pre-exposure prophylaxis (doxyPrEP) among 76 healthcare facility workers. In this study we focused on doxyPEP due to current changes in health policy and recommendations. This may have introduced some bias into our analysis as some of the respondents may have been considering doxyPrEP in their responses. The data in this review is largely from sexual health specialists working in high income settings (except for a manuscript from Kenya) and may not be representative of other geographical or socioeconomic areas. We took a broad view of who healthcare professionals were in this review. Some of thevmanuscripts included policy makers, researchers, microbiologists and advocates who may not have a direct effect on doxyPEP delivery, and may dilute the implementation process: these data may introduce some bias into the overall findings of this review. Due to the number and quality of the manuscripts in this review, we were unable to safely temper the overall results based on the risk of bias rating.

5. Conclusions

Although it should be acknowledged that this review contained data mainly from high income settings, these data can be used at both local and national levels to guide the implementation of doxyPEP. Healthcare professionals were in general willing and ready to provide doxyPEP. However there remain some concerns amongst healthcare professionals about doxyPEP including antimicrobial resistance, the effect on service capacity and the lack of research in other groups for example cis-gendered women and trans people. Patients and health professionals need to be involved in future clinical research and in the implementation of doxyPEP.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/venereology5010009/s1, Supplementary Material S1: Search strategies. Supplementary Material S2: Risk of bias assessment.

Author Contributions

Conceptualization, D.R., M.S., C.F.; Methodology, M.S., C.F.; Validation, D.R., T.R., D.W.; Formal Analysis, M.S., C.F., D.R.; Investigation, T.R.; Resources, T.R.; Data Curation, M.S., C.F., S.A., D.R.; Writing—Original Draft Preparation, D.R., M.S.; Writing—Review & Editing, M.S., C.F., S.A., T.R., D.W., D.R.; Supervision D.R.; Project Administration, D.R. & M.S. All authors have read and agreed to the published version of the manuscript.

Funding

The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Data Availability Statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Conflicts of Interest

None of the authors have any conflict of interest.

References

  1. Geretti, A.M.; Mardh, O.; de Vries, H.J.C.; Winter, A.; McSorley, J.; Seguy, N.; Vuylsteke, B.; Gokengin, D. Sexual transmission of infections across Europe: Appraising the present, scoping the future. Sex. Transm. Infect. 2022, 98, 451–457. [Google Scholar] [CrossRef] [Scilit]
  2. Kenyon, C. Screening is not associated with reduced incidence of gonorrhoea or chlamydia in men who have sex with men (MSM); an ecological study of 23 European countries. F1000Research 2019, 8, 160. [Google Scholar] [CrossRef] [Scilit]
  3. Roberto Queiroz, P.; Dos Santos, M.M.; Lopes, A.K.B.; da Silva, J.A.; Aranha Filho, B.; Costa, T.G.; Bezerra, A.C.N.; Lima, K.C. Prevalence and factors associated with syphilis among men who have sex with men in Brazil. Front. Public Health 2025, 13, 1465799. [Google Scholar] [CrossRef] [Scilit] [PubMed]
  4. Hu, H.; Chen, Y.; Shi, L.; Liu, X.; Xu, Z.; Sun, L.; Zhao, X.; Zhou, Y.; Lu, J.; Zhang, Z.; et al. Prevalence of syphilis and Chlamydia trachomatis infection among men who have sex with men in Jiangsu province, China: A cross-sectional survey. Front. Public Health 2022, 10, 1006254. [Google Scholar] [CrossRef] [Scilit] [PubMed]
  5. Gilmour, L.S.; Walls, T. Congenital Syphilis: A Review of Global Epidemiology. Clin. Microbiol. Rev. 2023, 36, e0012622. [Google Scholar] [CrossRef] [Scilit] [PubMed]
  6. Hooshiar, M.H.; Sholeh, M.; Beig, M.; Azizian, K.; Kouhsari, E. Global trends of antimicrobial resistance rates in Neisseria gonorrhoeae: A systematic review and meta-analysis. Front. Pharmacol. 2024, 15, 1284665. [Google Scholar]
  7. Molina, J.M.; Charreau, I.; Chidiac, C.; Pialoux, G.; Cua, E.; Delaugerre, C.; Capitant, C.; Rojas-Castro, D.; Fonsart, J.; Bercot, B.; et al. Post-exposure prophylaxis with doxycycline to prevent sexually transmitted infections in men who have sex with men: An open-label randomised substudy of the ANRS IPERGAY trial. Lancet Infect. Dis. 2018, 18, 308–317. [Google Scholar] [CrossRef] [Scilit]
  8. Luetkemeyer, A.F.; Donnell, D.; Dombrowski, J.C.; Cohen, S.; Grabow, C.; Brown, C.E.; Malinski, C.; Perkins, R.; Nasser, M.; Lopez, C.; et al. Postexposure Doxycycline to Prevent Bacterial Sexually Transmitted Infections. N. Engl. J. Med. 2023, 388, 1296–1306. [Google Scholar] [CrossRef] [Scilit]
  9. Szondy, I.; Meznerics, F.A.; Lőrincz, K.; Kemény, L.V.; Walter, A.; Mohammed, A.A.; Hegyi, P.; Kiss, N.; Bánvölgyi, A. Doxycycline prophylaxis for the prevention of sexually transmitted infections: A systematic review and meta-analysis of randomized controlled trials. Int. J. Infect. Dis. 2024, 147, 107186. [Google Scholar] [CrossRef] [Scilit]
  10. Mason, L.C.E.; Richardson, D.; Charles, H.; Simms, I.; Mitchell, H.D.; Manuel, R.; Godbole, G.; Jenkins, C.; Baker, K.S. Using demographics of patients to inform treatment of shigellosis in England. Lancet Microbe 2024, 6, 101026. [Google Scholar] [CrossRef] [Scilit]
  11. Kenyon, C.; Baetselier, I.; Wouters, K. Screening for STIs in PrEP cohorts results in high levels of antimicrobial consumption. Int. J. STD AIDS 2020, 31, 1215–1218. [Google Scholar] [CrossRef] [Scilit]
  12. Vanbaelen, T.; Manoharan-Basil, S.S.; Kenyon, C. Doxy-PEP could select for ceftriaxone resistance in Neisseria gonorrhoeae. Lancet Infect. Dis. 2025, 25, e316. [Google Scholar] [CrossRef] [Scilit] [PubMed]
  13. O’Halloran, C.; Croxford, S.; Mohammed, H.; Gill, O.N.; Hughes, G.; Fifer, H.; Allen, H.; Owen, G.; Nutland, W.; Delpech, V.; et al. Factors associated with reporting antibiotic use as STI prophylaxis among HIV PrEP users: Findings from a cross-sectional online community survey, May–July 2019, UK. Sex. Transm. Infect. 2021, 97, 429–433. [Google Scholar] [CrossRef] [Scilit] [PubMed]
  14. Ringshall, M.; Cooper, R.; Rawdah, W.; Perera, S.; Bannister, A.; Nichols, K.; Fitzpatrick, C.; Richardson, D. Chemsex, sexual behaviour and STI-PrEP use among HIV-PrEP users during the COVID-19 pandemic in Brighton, UK. Sex. Transm. Infect. 2022, 98, 312. [Google Scholar] [CrossRef] [Scilit] [PubMed]
  15. Kohli, M.; Medland, N.; Fifer, H.; Saunders, J. BASHH updated position statement on doxycycline as prophylaxis for sexually transmitted infections. Sex. Transm. Infect. 2022, 98, 235–236. [Google Scholar] [CrossRef] [Scilit]
  16. Nadarzynski, T.; Smith, H.E.; Richardson, D.; Ford, E.; Llewellyn, C.D. Sexual healthcare professionals’ views on HPV vaccination for men in the UK. Br. J. Cancer 2015, 113, 1599–1601. [Google Scholar] [CrossRef] [Scilit]
  17. Page, M.J.; McKenzie, J.E.; Bossuyt, P.M.; Boutron, I.; Hoffmann, T.C.; Mulrow, C.D.; Shamseer, L.; Tetzlaff, J.M.; Akl, E.A.; Brennan, S.E.; et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ 2021, 372, n71. [Google Scholar] [CrossRef] [Scilit]
  18. Moola, S.; Munn, Z.; Sears, K.; Sfetcu, R.; Currie, M.; Lisy, K.; Tufanaru, C.; Qureshi, R.; Mattis, P.; Mu, P. Conducting systematic reviews of association (etiology): The Joanna Briggs Institute’s approach. Int. J. Evid. Based Healthc. 2015, 13, 163–169. [Google Scholar] [CrossRef] [Scilit]
  19. Park, J.J.; Stafylis, C.; Pearce, D.D.; Taylor, J.; Little, S.J.; Kojima, N.; Gorin, A.M.; Klausner, J.D. Interest, Concerns, and Attitudes Among Men Who Have Sex With Men and Health Care Providers Toward Prophylactic Use of Doxycycline Against Chlamydia trachomatis Infections and Syphilis. Sex. Transm. Dis. 2021, 48, 615–619. [Google Scholar] [CrossRef] [Scilit]
  20. Pearson, W.S.; Emerson, B.; Hogben, M.; Barbee, L. Use of Doxycycline to Prevent Sexually Transmitted Infections According to Provider Characteristics. Emerg. Infect. Dis. 2024, 30, 197–199. [Google Scholar] [CrossRef] [Scilit]
  21. Mogaka, F.O.; Kwach, B.; Odira, A.; O’Malley, G.; Hearst, M.; Bukusi, E.A.; Stewart, J. Stakeholder perspectives on integrating doxycycline postexposure prophylaxis into Kenyan HIV PrEP programmes. Sex. Transm. Infect. 2025, 056535, Online First. [Google Scholar] [CrossRef] [Scilit] [PubMed]
  22. Cornelisse, V.J.; Riley, B.; Medland, N.A. Australian consensus statement on doxycycline post-exposure prophylaxis (doxy-PEP) for the prevention of syphilis, chlamydia and gonorrhoea among gay, bisexual and other men who have sex with men. Med. J. Aust. 2024, 220, 381–386. [Google Scholar] [CrossRef] [Scilit] [PubMed]
  23. Phillips, C.; Vinuesa, M.; Fowler, C.; Soni, S.; Richardson, D. Doxycycline postexposure prophylaxis (doxyPEP): Sexual health clinicians’ knowledge and readiness. Sex. Transm. Infect. 2025, 101, 132. [Google Scholar] [CrossRef] [Scilit] [PubMed]
  24. Allan-Blitz, L.T.; Traeger, M.; Gitin, S.; Smith, K.; Mayer, K.H.; Khan, T. Facilitators and Barriers to the Rollout of Doxycycline Postexposure Prophylaxis for Sexually Transmitted Infections in a Boston Community Health Center. Sex. Transm. Dis. 2025, 52, 585–590. [Google Scholar] [CrossRef] [Scilit]
  25. Imerlishvili, E.; Lake, J.; Todorovic, S.; Gonzalez, C.; Boos, E.M.; Hart-Malloy, R. Doxycycline post-exposure prophylaxis for preventing bacterial sexually transmitted infections (STIs): Are clinical providers supportive? Int. J. STD AIDS 2025, 36, 297–303. [Google Scholar] [CrossRef] [Scilit]
  26. Perkins, R.; Beima-Sofie, K.; Christopoulos, K.; Cohen, S.E.; Dright, A.; Dombrowski, J.C.; Gougougui, A.; Kohler, P.; Luetkemeyer, A.F.; Pintye, J.; et al. Another Tool for the Sexual Health Toolkit: US Health Care Provider Knowledge and Attitudes About Doxycycline Postexposure Prophylaxis to Prevent Bacterial Sexually Transmitted Infections Among Men Who Have Sex With Men. Sex. Transm. Dis. 2025, 52, 129–134. [Google Scholar] [CrossRef] [Scilit]
  27. Bachmann, L.H.; Barbee, L.A.; Chan, P.; Reno, H.; Workowski, K.A.; Hoover, K.; Mermin, J.; Mena, L. CDC Clinical Guidelines on the Use of Doxycycline Postexposure Prophylaxis for Bacterial Sexually Transmitted Infection Prevention, United States, 2024. MMWR Recomm. Rep. 2024, 73, 1–8. [Google Scholar] [CrossRef] [Scilit]
  28. Sherrard, J.; Gokengin, D.; Winter, A.; Marks, M.; Unemo, M.; Jensen, J.S.; Cusini, M.; Mårdh, O. IUSTI Europe position statement on use of DoxyPEP: June 2024. Int. J. STD AIDS 2024, 35, 1087–1089. [Google Scholar] [CrossRef] [Scilit]
  29. Werner, R.N.; Schmidt, A.J.; Potthoff, A.; Spornraft-Ragaller, P.; Brockmeyer, N.H. Position statement of the German STI Society on the prophylactic use of doxycycline to prevent STIs (Doxy-PEP, Doxy-PrEP). J. Dtsch. Dermatol. Ges. 2024, 22, 466–478. [Google Scholar] [CrossRef] [Scilit]
  30. Fitzpatrick, C.; Richardson, D.; Sherriff, N.; Whetham, J. Pilot evaluation of PrEP EmERGE—A novel digital health innovation designed to support sexual health clinics and HIV-PrEP users. HIV Med. 2023, 24, 502–506. [Google Scholar] [CrossRef]
  31. Tweed, M.; Fortescue-Talwar, K.; Finn, R.; Buonsenno, L.; Nichols, K.; Frem, J.; Darking, M.; Nicholson, S.; Williams, D.; Richardson, D. Delivering a community-based monkeypox vaccination programme in partnership. Int. J. STD AIDS 2023, 34, 427–429. [Google Scholar] [CrossRef] [Scilit] [PubMed]
  32. Nadarzynski, T.; Frost, M.; Miller, D.; Wheldon, C.W.; Wiernik, B.M.; Zou, H.; Richardson, D.; Marlow, L.A.V.; Smith, H.; Jones, C.J.; et al. Vaccine acceptability, uptake and completion amongst men who have sex with men: A systematic review, meta-analysis and theoretical framework. Vaccine 2021, 39, 3565–3581. [Google Scholar] [CrossRef] [Scilit] [PubMed]
  33. Vanbaelen, T.; Kenyon, C. Primum non-nocere: Is it time to stop screening for Neisseria gonorrhoeae and Chlamydia trachomatis in men who have sex with men taking HIV pre-exposure prophylaxis? Sex. Transm. Infect. 2024, 100, 337–338. [Google Scholar] [CrossRef] [Scilit] [PubMed]
  34. Pitt, R.; Unemo, M.; Sonnenberg, P.; Alexander, S.; Beddows, S.; Cole, M.J.; Clifton, S.; Mercer, C.H.; Johnson, A.M.; Ison, C.A.; et al. Antimicrobial resistance in Mycoplasma genitalium sampled from the British general population. Sex. Transm. Infect. 2020, 96, 464–468. [Google Scholar] [CrossRef] [Scilit]
  35. O’Flanagan, H.; Siddiq, M.; Llewellyn, C.; Richardson, D. Antimicrobial resistance in sexually transmitted Shigella in men who have sex with men: A systematic review. Int. J. STD AIDS 2023, 34, 374–384. [Google Scholar] [CrossRef] [Scilit]
  36. Wahab, N.; Dubey, V.; Sivachandran, V.; Llewellyn, C.; Richardson, D. Campylobacter spp. in men who have sex with men: A systematic review. Int. J. STD AIDS 2024, 35, 1094–1102. [Google Scholar] [CrossRef] [Scilit]
  37. Frem, J.A.; Russell, A.; Fitzpatrick, C.; Williams, D.; Richardson, D. Gastrointestinal Escherichia coli in men who have sex with men: A systematic review. Int. J. STD AIDS 2025, 36, 176–184. [Google Scholar] [CrossRef] [Scilit]
  38. Sivachandran, V.; Wahab, N.; Dubey, V.; Richardson, D.; Llewellyn, C. Demographic, Behavioural, and Biological Factors Seen in Men Who Have Sex with Men with Salmonella spp.: A Systematic Review. Venereology 2024, 3, 162–171. [Google Scholar] [CrossRef] [Scilit]
  39. Jensen, J.S.; Unemo, M. Antimicrobial treatment and resistance in sexually transmitted bacterial infections. Nat. Rev. Microbiol. 2024, 22, 435–450. [Google Scholar] [CrossRef] [Scilit]
  40. Truong, R.; Tang, V.; Grennan, T.; Tan, D.H.S. A systematic review of the impacts of oral tetracycline class antibiotics on antimicrobial resistance in normal human flora. JAC Antimicrob. Resist. 2022, 4, dlac009. [Google Scholar] [CrossRef] [Scilit]
  41. Kohli, M.; Reeves, I.; Waters, L. Homophobia in the provision of sexual health care in the UK. Lancet HIV 2024, 11, e125–e130. [Google Scholar] [CrossRef] [Scilit]
  42. Venkateswaran, N.; Swetschinski, L.R.; Fastl, C.; Bari, C.D.; Criscuolo, N.G.; Mulchandani, R.; Zhao, C.; Meštrović, T.; Ikuta, K.S.; Martins, S.B.; et al. Using priorities between human and livestock bacterial antimicrobial resistance (AMR) to identify data gaps in livestock AMR surveillance. BMC Infect. Dis. 2024, 24, 1027. [Google Scholar] [CrossRef] [Scilit]
  43. Stewart, J.; Oware, K.; Donnell, D.; Violette, L.R.; Odoyo, J.; Soge, O.O.; Scoville, C.W.; Omollo, V.; Mogaka, F.O.; Sesay, F.A.; et al. Doxycycline Prophylaxis to Prevent Sexually Transmitted Infections in Women. N. Engl. J. Med. 2023, 389, 2331–2340. [Google Scholar] [CrossRef] [Scilit]
  44. Heskin, J.; Dickinson, M.; Brown, N.; Girometti, N.; Feeney, M.; Hardie, J.; Evans, C.; McOwan, A.; Higgs, C.; Basnayake, S.; et al. Rapid reconfiguration of sexual health services in response to UK autochthonous transmission of mpox (monkeypox). Sex. Transm. Infect. 2023, 99, 81–84. [Google Scholar] [CrossRef] [Scilit]
  45. Frem, J.A.; Russell, A.; Nichols, K.; Buonsenno, L.; Tweed, M.; Fitzpatrick, C.; Darking, M.; Whetham, J.; Richardson, D. PrEP2U: A novel community partnership HIV pre-exposure prophylaxis clinic. Sex. Transm. Infect. 2023, 99, 574. [Google Scholar] [CrossRef] [Scilit]
  46. Coukan, F.; Thamm, W.; Afolabi, F.; Murray, K.K.; Rathbone, A.P.; Saunders, J.; Atchison, C.; Ward, H. Co-designing interventions with multiple stakeholders to address barriers and promote equitable access to HIV Pre-Exposure Prophylaxis (PrEP) in Black women in England. BMC Public Health 2025, 25, 1831. [Google Scholar] [CrossRef] [Scilit]
Venereology 05 00009 g001
Figure 1. PRISMA diagram showing the selection of manuscripts.
Figure 1. PRISMA diagram showing the selection of manuscripts.
Venereology 05 00009 g001
Table 1. Manuscripts reporting on healthcare providers’ beliefs and concerns towards patients using doxyPEP.
Table 1. Manuscripts reporting on healthcare providers’ beliefs and concerns towards patients using doxyPEP.
ManuscriptStudy Method Study Characteristics Healthcare Professionals’ Attitudes Risk of BiasComments
Park JJ, et al.
California,
USA (2021) [19]		Cross-sectional study of healthcare professionals using purposive sampling through established provider networks and local community-based clinicsn = 76 responses from healthcare providers with prescribing authority in Southern California.
HCP specific data: Doctor of Medicine (67%) or Doctor of Osteopathic Medicine (5%). Nurse practitioners (17%) and physician assistants (8%). 58% had more than 10 years of clinical practice. 		43% of healthcare professionals would agree or strongly agree to prescribe doxyPEP/PrEP to MSM: and if recommended by the CDC, 90% would prescribe doxyPEP
80% of healthcare professionals expressed concerned about drug resistance regarding use of prophylactic antibiotics		HighRecruitment through convenance sampling my indicate recruitment bias. Closed question survey limited data. More information on GBMSM than HCP attitudes, although able to focus on HCP data. Appropriate statistical analysis.
Pearson WS, et al.
USA (2024) [20]		Cross-sectional survey of healthcare providers. n = 1504 healthcare professionals, including family physicians (457, 30%), internists (545, 36%), obstetrician/gynecologists (251, 17%), and nurse practitioners/physician assistants (251, 17%). 761 (51%) were STI care providers.47% of STI care providers agreed that the benefits of DoxyPEP outweigh the risk of increased antimicrobial resistance (compared to 36.6% of non-STI care providers) (p < 0.01).
64% of STI providers and 62% of non-STI providers agreed or strongly agreed that “prophylactic use of doxycycline contributes to antibiotic resistance” (p = 0.57)		Medium Study settings and subjects where not discussed in detail. Closed question survey limited data. Cleary defined inclusion criteria. Appropriate statistical analysis.
Mogaka FO.
Kenya (2025) [21]		Qualitative interviews with Kenyan
HIV and STI policy makers, healthcare providers, and HIV-PrEP users		40 interviews with Kenyan
HIV and STI policy makers
(n = 7), HCPs involved in HIV-PrEP provision (n = 17), and HIV-PrEP users (n = 16) working within or using services within Kisumu County.		(1) Acceptability: Aware of high burden of STIs amongst HIV-PrEP users. Concerned over pill burden, antimicrobial misuse and antimicrobial resistance. Expressed the need for internationally recognised clinical guidelines. Expressed the need for user/community opinions.
(2) Feasibility: Integration into HIV-PrEP services as a low-cost strategy. Concerned about waiting times, workload and prescribing logistics.
(3) Sustainability: Concerns regarding ownership, implementation and cost. Awareness and demand creation is crucial, including community involvement (peer educators and advocacy groups).		HighEthical approval was sought and approved. Small qualitative study of healthcare professionals in Kenya
Cornelisse VJ et al., Australia (2024) [22]Mixed method study from a national committee of stakeholdersn = 49. 9 steering committee members (two co-chairs) and 40 participants from across Australasia.
Community representatives, clinicians, researchers and experts in infectious diseases, public health, epidemiology, microbiology, and antimicrobial stewardship,		Consensus agreement that: doxyPEP should be considered primarily for the prevention of syphilis in GBMSM who are at risk of syphilis, although for some individuals the reduction in chlamydia and the lesser reduction of N. gonorrhoeae might be important.
Concern expressed regarding driving further N. gonorrhoeae antimicrobial resistance 		Medium One participant withdrew due to concerns about antimicrobial resistance therefore wasn’t represented in the research. Consulted a diverse range of clinical experts in gathering opinions on doxyPEP. Open ended format permitted wide range of exploration of themes.
Phillips C et al., UK 2025 [23]Cross sectional survey of sexually transmitted infection clinic cliniciansn = 52 doctors (n = 20), nurses (n = 28), sexual health advisors (n = 4)85% were aware of doxyPEP, median Likert score rating knowledge was 3/5 (where 5 was good, 1 was poor). Clinicians scored median 4/5 on Likert scale that they would be happy to provide doxyPEP (where 5 was happy, 1 not happy). Reduction in STIs, reduced clinical attendances, improved patient self-advocacy as advantages of doxyPEP. Concerns were antibiotic resistance, drug interactions, the impact (increase or decrease) in service demand, and access for women and trans-masculine people.MediumSmall anonymous quantitative study of sexual health clinicians working in the south of England.
Allan-Blitz LT et al., 2025, USA [24]Cross sectional study of community centre health workers14 or 45 health providers completed survey (all prescribers)Median score of comfort having conversations about doxyPEP increased from 78 (interquartile range, 52–100) out of 100 after the second training to 100 (interquartile range, 88–100) after the third training. Barriers were sufficient time, lack of electronic record resources, lack of guidelines, concerns re antimicrobial resistancemediumSmall mixed method (patients and healthcare workers) cross-sectional analysis
Imerlishvili E et al., 2025, USA [25]Cross sectional online survey of clinical providers91 out of 575 clinical providers responded.Reported willingness to recommend doxyPEP (98%, 77%, and 67% for chlamydia, syphilis, and gonorrhea, respectively); preferred doxyPEP administration for MSM and transgender populations; believed recurring bacterial STIs (88%) and reported condomless sex (85%) were the most important characteristics to consider for recommending doxyPEP; and were concerned about antibiotic resistance (90%) (primarily for Neisseria gonorrhoeae). Insurance costs were the most perceived community-associated barriers (35%).LowLarge (90) cross-sectional online survey
Perkins RC. Washington, USA 2025 [26]Qualitative interviews of healthcare professionals known to be advocates of sexual healthn = 30 HCPs completed interviews. 43% of HCPs reported working with GBMSM. 47% were 31–40 years old, 53% identified as male, and 47% reported their sexual orientation as gay or queer. (1) doxyPEP provides another tool to prevent STIs
(2) Concerns about prescribing doxy-PEP as a strategy for STI prevention, including antibiotic resistance
(3) Need for more data to understand the long-term safety of doxyPEP
(4) Development of doxyPEP guidelines to facilitate and motivate prescriptive practices and inform implementation.		Medium Limited opinions from Black and Hispanic HCP. No evidence of potential influence of researcher bias. HCP’s asked had previous experience of prescribing HIV-PrEP so may have bias towards prescribing doxyPEP. Good congruity between research methodology and research objectives.
Table 2. Healthcare providers’ beliefs and concerns re doxyPEP.
Table 2. Healthcare providers’ beliefs and concerns re doxyPEP.
Providing doxyPEP to MSMRecognition of the high burden of bacterial STIs in MSM
DoxyPEP should be available to MSM to reduce syphilis (and to a lesser extent C. trachomatis and N. gonorrhoeae)
Willingness to provide doxyPEP with the support of national guidelines
Implementation of doxyPEP into existing HIV-PrEP services should be feasible
Awareness and knowledge of doxyPEP needs to improve amongst STI clinicians
Concerns about doxyPEPConcerns regarding antimicrobial resistance and drug interactions
Concerns regarding pill burden, cost, implementation logistics, clinic service demand
Research and access for other groups (trans people and cis-gendered women)
Need for patient involvement in doxyPEP implementation
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MDPI and ACS Style

Spence, M.; Fowler, C.; Absalom, S.; Roper, T.; Williams, D.; Richardson, D. Healthcare Professionals’ Beliefs and Concerns About the Use of Doxycycline Post-Exposure Prophylaxis (doxyPEP): A Systematic Review. Venereology 2026, 5, 9. https://doi.org/10.3390/venereology5010009

AMA Style

Spence M, Fowler C, Absalom S, Roper T, Williams D, Richardson D. Healthcare Professionals’ Beliefs and Concerns About the Use of Doxycycline Post-Exposure Prophylaxis (doxyPEP): A Systematic Review. Venereology. 2026; 5(1):9. https://doi.org/10.3390/venereology5010009

Chicago/Turabian Style

Spence, Molly, Clare Fowler, Saxon Absalom, Tom Roper, Deborah Williams, and Daniel Richardson. 2026. "Healthcare Professionals’ Beliefs and Concerns About the Use of Doxycycline Post-Exposure Prophylaxis (doxyPEP): A Systematic Review" Venereology 5, no. 1: 9. https://doi.org/10.3390/venereology5010009

APA Style

Spence, M., Fowler, C., Absalom, S., Roper, T., Williams, D., & Richardson, D. (2026). Healthcare Professionals’ Beliefs and Concerns About the Use of Doxycycline Post-Exposure Prophylaxis (doxyPEP): A Systematic Review. Venereology, 5(1), 9. https://doi.org/10.3390/venereology5010009

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