在使用暴露前預防性投藥的男男性行為者中Doxycycline的使用

資料來源：剌胳針愛滋病毒醫學期刊；www.thelancet.com/hiv Vol 5 September 2018；

財團法人台灣紅絲帶基金會編譯

在HIV暴露前預防投藥（PrEP）之IPERGAY試驗的一項亞組研究顯示，以Doxycycline在男男性行為者中作為暴露後預防投藥可減少半數細菌性之性感染症（STIs）。Doxycycline在性健康診所用作對已證實的性傳播感染包括披衣菌和梅毒上的治療，以及更廣泛用於痤瘡治療和瘧疾的預防；在英國它也可以在線上購買。英國國家用藥指引反對建議使用Doxycycline作為性感染症預防以減少抗生素抗藥性的發展。

在2018年7月2日至7月25日期間，我們調查了在英國倫敦迪恩街56號的性健康診所所監控之參加暴露前預防投藥( PrEP )的男男性行為者，以一份匿名的紙質問卷詢問其年齡、PrEP持續時間、來源，和治療方案，以及過去6個月內性感染症的病史。我們特意問參與者自從接受PrEP以來，他們是否曾服用過抗生素來預防性感染症？如果他們說有，則我們會問這些參與者他們正在服用哪些抗生素？有多頻繁？和他們從哪裡得到它們？這項調查被視為是一項服務評估故由我們醫院的研究和發展部門來進行評估，因為我們係在收集常規的臨床數據，因此不需要倫理委員會批准。

在592名參加PrEP接受追蹤的男男性行為者中，有107人提供了問卷（參與者之選擇依臨床人員所允許的便利性去進行）; 所有問卷都已完成。中位年齡為36歲（四分位距IQR為31-42）; 有92人（86％）受過大學教育，每日服用PrEP者為84％，按事件服用PrEP者為16％。 PrEP的中位時間是8個月。46人（43％）在過去6個月內曾患有性病。 106人中有8人（8％）曾服用抗生素預防性感染症。二人沒有說明哪種抗生素，五人使用Doxycycline，以及有一個人使用Doxycycline和amoxicillin二種藥。四人是每日服用抗生素，兩人則是在發生性行為當時服用，兩個人則是在每天和性行為之後服用。五人從性健康診所獲得了抗生素，兩個人來自他們的全科醫生，一個則在線上取得，且沒有進一步的細節描述是如何獲得抗生素。

英國性健康和愛滋病毒協會建議服用Doxycycline來預防性感染症的任何潛在好處將會被選擇性的抗藥性之風險所抵消，因此需要更廣泛地進一步研究來衡量這種介入的影響。然而，在我們的調查的男男性行為者當中已有8％是在服用預防性抗生素。

我們相信這數字可能是低估了，因為人們可能不太會去承認服用預防性抗生素，如果他們認為他可能會遭遇到醫療照護者的反對，對這種做法的影響去作進一步之評估將是至關重要的。

（註：Doxycycline是一種四環素類抗生素，用於治療由細菌和某些寄生蟲引起的感染。可用於治療細菌性肺炎、痤瘡、披衣菌感染、早期萊姆病、霍亂和梅毒；它還用於預防瘧疾以及與奎寧結合治療瘧疾。可以透過口腔或注射到靜脈中使用。）

Doxycycline use in MSM taking PrEP

A substudy of the IPERGAY trial of HIV pre-exposure prophylaxis (PrEP) showed that doxycycline postexposure prophylaxis halved rates of bacterial sexually transmitted infections (STIs) in men who have sex with men.1 Doxycycline is used as a treatment for proven STIs including chlamydia and syphilis in sexual health clinics and more widely as a treatment for acne and malaria prophylaxis; in the UK it is also available to purchase online. UK national guidance advises against use of doxycycline as STI prophylaxis to minimize the development of antimicrobial resistance.

Between July 2 and July 25 2018, we surveyed MSM attending for PrEP monitoring at 56 Dean Street, a sexual health clinic in London, UK, using an anonymous paper questionnaire asking age, PrEP duration, source, and regimen, and history of STI in the past 6 months. We specifically asked participants if, since taking PrEP, they had taken antibiotics to prevent an STI. If they said they had, we asked participants which antibiotics they were taking, how frequently, and where they got them from. The survey was assessed by our hospital Research and Development department as a service evaluation, and because we were collecting routine clinical data ethical approval was not required.

Of 592 MSM attending for PrEP follow-up, 107 were offered a questionnaire (participants selected by convenience as clinic staffing allowed); all questionnaires were completed. Median age was 36 years (IQR 31–42); 92 (86%) were university educated, 84% on daily PrEP, 16% event-driven PrEP. Median time on PrEP was 8 months. 46 (43%) had an STI in the past 6 months. Eight (8%) of 106 had taken antibiotics to prevent STIs. Two did not state which antibiotic, five used doxycycline, and one doxycycline and amoxicillin. Four were taking antibiotics daily, two at the time of sex, and two both daily and after sex. Five obtained the antibiotics from a sexual health clinic, two from their general practitioners, and one online; no further details were given about how antibiotics were obtained.

The British Association for Sexual Health and HIV advises that any potential benefits of taking doxycycline as prophylaxis against STIs will be outweighed by the risk of selecting resistance and that further studies are required to measure the wider impact of this intervention.  However, 8% of MSM in our survey are already taking prophylactic antibiotics. We believe that this is likely to be an underestimate because people might be less likely to admit to taking prophylactic antibiotics if they think that his may be met with disapproval from health-care practitioners. It is crucial that the impact of this practice is further assessed.

www.thelancet.com/hiv Vol 5 September 2018