Some gay and bi men are using the internet to self-prescribe themselves antibiotics. This goes against advice from health professionals and regulatory bodies.
So why are they doing it? And if it brings down rates of sexually transmitted infections (STIs), should we automatically condemn it?
In England, the NHS is running a trial of PrEP. However, places on the trial have almost run out. Because of this, some men are instead turning to the internet to buy the drugs from abroad.
Dynamix International is the leading online site for gay men to buy PrEP in the UK. Some herald its services as life saving. There’s no disputing it plugs a healthcare gap when it comes to sexual health. Terrence Higgins Trust and IWantPrEPNow, among others, recommend its services.
Dynamix sells generic equivalents of Truvada, the drug used for PrEP. It sells it cheaply: usually around £20 ($25/€22) for a month’s supply. In the UK, buying medicine from abroad is not illegal if for personal use only.
However, Dynamix, which is not a registered online pharmacy, also sells antibiotics: namely doxycycline.
It’s not known how many people are taking advantage of sites such as Dynamix to buy antibiotics. Dynamix International declined to comment for this article ahead of publication.
What is doxycycline?
Doxycycline is an antibiotic used to treat wide range of bacterial infections. These include bacterial pneumonia, acne, chlamydia and syphilis. It was previously also used to treat gonorrhea, but that infection is now largely resistant towards it.
Some people use it to self-medicate. They might want treat what they believe is a sexually-transmitted infection without the hassle of going to a clinic. Or they use it as a form of pre or post-exposure prophylaxis – to prevent acquiring an infection.
Maybe they’re expecting a particularly wild weekend of partying. Or a former lover tells them they have an infection and they can’t get to a clinic. Or they’re just embarrassed to speak to someone about their sexual health.
What’s the problem with people prescribing themselves doxycycline?
The main concerns around people prescribing themselves antibiotics focus on the development of drug-resistant infections. We’re already seeing this with gonorrhea. Each time medical science hits it with a new antibiotic, it tends to evolve.
Strains have emerged (dubbed ‘Super Gonorrhea’), resistant to all commonly used antibiotics.
Leading health organizations are deeply concerned about the overuse of antibiotics.
In the US, the Center for Disease Control said last month, ‘Antibiotic resistance is one of the most urgent threats to the public’s health. Antibiotic resistance occurs when bacteria develop the ability to defeat the drugs designed to kill them. Each year in the United States, at least 2 million people get infected with antibiotic-resistant bacteria, and at least 23,000 people die as a result.’
Because of this, health organizations and governments are urging healthcare providers not to prescribe antibiotics unnecessarily.
Rising rates of STIs
At the same time, both the UK and UK have seen rising rates of STIs. Syphilis and chlamydia are a particular concern. Both infections require antibiotic treatment. Without treatment, syphilis can kill while chlamydia can lead to infertility and other health problems.
There have been two studies in recent years exploring whether a daily dose of doxycycline would cut the rates of STIs in gay men.
A 2015 small study of HIV+ gay men found that a daily dose of doxycycline reduced the rates of gonorrhoea, chlamydia and syphilis.
It cut the rate of syphilis by 73% and gonorrhea and chlamydia by 53% over a nine-month period. Although welcome, by comparison, this is considerably far below the efficiency of PrEP in preventing the transmission of HIV. Some men, even taking antibiotics, still acquired infections.
A more recent study, in France, gave men on PrEP a single dose of doxycycline after they had sex (and a placebo to a similar number of other men). It found the antibiotic halved the rates of syphilis and chlamydia, but had little effect on gonorrhea rates.
Although the ability of gonorrhea to develop antibiotic resistance is a major concern, when it comes to chlamydia and syphilis, health experts are more equivocal. To date, there have been no reports of drug-resistant chlamydia infections in humans. Of course, that’s not to say it won’t happen at some stage in the future.
Similarly, syphilis has been treated with penicillin for the past 60 years. The bacteria hasn’t developed resistance to it. People allergic to penicillin are often prescribed doxycycline instead. Unlike gonorrhea, syphilis hasn’t show itself to be quick to evolve.
But antibiotic resistance is not the only concern. Doctors generally advise against taking antibiotics too often or on an longterm daily basis. Any antibiotics can upset the levels of ‘healthy’ bacteria in your gut. These levels are increasingly seen as important for a well-balanced health.
Another issue is people prescribing themselves the wrong antibiotics. There are good reasons to undergo proper laboratory tests, under medical supervision, to find out exactly what’s going on with your health. Some experts think if people start self-prescribing, they may stop going for regular STI check-ups, mistakenly believing they’re protected.
Although everyone in the sexual health field wants to see the transmission rates of syphilis and chlamydia reduced, no country in the world currently prescribes prophylactic doses of doxycycline as a public health strategy.
In fact, last year, Public Health England issued a blunt statement.
‘Doxycycline Post Exposure Prophylaxis for sexually transmitted infections (STIs) is not endorsed by BASHH or Public Health England … We recommend the use of antibiotics as prescribed by a healthcare professional and as indicated by the results of a suitable diagnostic test.’
Earlier this year, Keith Henry, MD, from Hennepin County Medical Center told BetaBlog: ‘I don’t think prophylactic doxycycline is ready for prime time.
‘Regularly testing for all STDs every three months and treatment for STDs diagnosed is my recommendation for sexually active men.’
The UK’s largest sexual health charity comments on doxycycline use
The Terrence Higgins Trust (THT) recently announced it was launching a poverty fund for PrEP in the UK. If people are at risk of contracting HIV, want PrEP, but can’t access the current NHS trial and genuinely can’t afford to buy it, they may be eligible for funding from its PrEP Access Fund.
This gives them money to spend at Dynamix on generic Truvada. THT told Gay Star News the funding is for PrEP only. ‘[It] cannot be redeemed for anything else on the Dynamix website.’
Asked about gay men buying antibiotics online, THT’s Medical director Dr Michael Brady told Gay Star News, ‘Someone should only take antibiotics when they really need them.
‘We recommend only using antibiotics as prescribed by health professionals or guided by the results of suitable lab tests and advise that people should only purchase antibiotics if they know they have an infection and are sure they are using the right antibiotic.
‘Antibiotic resistance is a growing problem and, at Terrence Higgins Trust, we would always advocate sensible antibiotic use.’
Asked specifically about Dynamix selling doxycycline, Brady said,
‘We currently don’t support doxycycline being used as a pre- or post-exposure prophylaxis as any potential benefits are likely to be offset by the risk of contributing to the development of drug resistant infections from incorrectly or partially treated infections.’
However, he didn’t fully close the door on the idea.
‘Using doxycycline as post-exposure prophylaxis is an interesting concept but there needs to be further research to better understand the potential risks as well as the benefits.
He too cited, ‘a small study which showed doxycycline led to significant reductions in both chlamydia and syphilis diagnoses among gay and bisexual men, but it had no impact on gonorrhoea rates.
‘We need to understand more about the longer term implications of this approach and, in particular, it’s implications for the development of drug resistance.’
The need for more research
Dr Will Nutland is a sexual health expert who helped launched the website PrEPster. Nutland’s a strong advocate for allowing gay men access to PrEP. He told Gay Star News he shares Public Health England’s concern about the increasing availability of doxycycline. However, he also keeps an open mind.
‘We need more research. There have been some arguments that we don’t know the implications of long-term use of doxycycline – and also counter arguments that doxycycline is already used on a medium term to long-term basis for conditions such as acne. I used it for several years during my early 20s for this.’
‘There are the beginnings of new research starting to develop: I’m most interested in seeing if there’s a potential for doxycycline PEP and PrEP to be targeted at the highly sexually active as a way of reducing STIs on a population level.
‘Doxycycline sold with almost no community-based information to support its use’
‘Am I concerned about doxycycline being easily available online?’ continues Nutland. ‘Partly: but I’m also concerned about the over-use and misuse of antibiotics globally … Online doxycycline purchasing is just one part of that concern.
‘For me, what contrasts most with online availability of HIV PrEP vs doxycycline, is that doxycycline is being sold with almost no community-based information to support its use.
‘We started to generate evidence and information about buying and using HIV PrEP when it was not available via the NHS, including information on the pros and cons of using PrEP, evidence-based dosing regimes, information about side-effects and how to manage them, etc.
‘That same information does not exist for people considering using doxycycline to the same extent, and so many people won’t have access to the same levels of information (and access to research about doxy PEP or PrEP) as we’ve had with HIV PrEP.’
In short, rather than just offering doxycycline for sale online, LGBTI communities need to start having proper conversations about it. This includes sharing information and calling for more research.