2024 年 11 月 8 日線上發表 / https://doi.org/10.1016/ S1473-3099(24)00690-X / www.thelancet.com/infection Vol 24，2024 年 12 月
多西環素暴露後預防 (DoxyPEP)，通常稱為事後預防藥 (morning-after pill)，可以幫助預防細菌性傳傳播感染 (STIs)。在無套性行為後72 小時內服用200 毫克多西環素 (doxycycline) 已被證明可以使男同性戀、雙性戀男性和跨性別女性的梅毒和衣原體感染減少70% 以上，淋球菌感染減少約50%。 DoxyPEP 已成為一個有爭議的話題，尤其是無論是在沒有處方的情況下分發，還是由具有執照的醫療保健提供者 (HCP) 以外的人去分發。
在美國洛杉磯，加州大學洛杉磯分校 LGBTQ+ 倡導、研究與健康中心有人私下報告稱，過去一個月，私人性派對結束時，參加性派對的人會服用 DoxyPEP。由於對這一事件感到好奇，我們聯繫了一位派對主持人，他願意與我們交談，但要求匿名。
主持人解釋說：「我確保每個人離開時都會得到一些特別的東西——DoxyPEP，為我們所享受的樂趣提供一點保障。我的醫生認為我只是一個注重健康、希望保持積極主動的人，但他對我舉辦的派對一無所知。我只是告訴他我想在生活中遇到的任何事情時做好準備。他幾乎不知道，[……]這是我確保我的顧客安全並不斷回來的方式。儘管他的行為源於保護社區的願望，但藥物共享引起了潛在的重要擔憂。
最重要的是，隨意分享處方藥破壞了負責任的醫療保健提供的原則。 DoxyPEP 需要由持照的醫療保健提供者 (HCP) 根據個人健康評估開立處方，並考慮個人的病史和過敏情況以及潛在的藥物交互作用和不良事件。當公眾在沒有醫療監督的情況下分發 DoxyPEP 時，他們可能會危及他人的健康，後果可能是災難性的。
許多藥物可以與 DoxyPEP 相互作用。例如，與異維A酸（isotretinoin，通常用於治療痤瘡，例如藥名為Accutane）一起使用是禁忌的。全身性維生素A衍生物（例如retinoids，類視黃醇，類維生素A）與四環素類藥物同時使用可能會增加假性腦瘤（稱為顱內高壓）的風險，可導致永久性視力喪失。另一種用於治療牛皮癬的類維生素A阿曲汀 (Aacitretin) 也是禁忌的。此外，一些常見的非處方藥和補充劑可能與 DoxyPEP 相互作用，包括抗酸劑、鐵補充劑和鉍（例如： 次水楊酸鉍Pepto bismol）。
最初向中心通報這一事件的派對常客，當被問及服用 DoxyPEP 後的反應時，他說：「我的醫生不知道我是同性戀，所以我以前從未聽說過[DoxyPEP] 這件事。我真的很感激，這讓我安心了，因為事後我通常會因為感染性傳染病而感到非常焦慮。」，此人的醫療保健提供者不知道他的性取向，可能顯示了更深層的社會擔憂：性取向和性健康的恥辱，特別是在性少數和性別少數群體中。
2022 年，同性戀和雙性戀男性占美國愛滋病毒感染病例的 70%， 進一步向醫護人員灌輸應了解病患性傾向的重要性。由於擔心受到評判或無法充分獲得文化上合格的照護，許多人感到需被迫轉向正規醫療保健系統之外的替代方案。這項擔憂凸顯了醫療保健專業人士和初級保健機構需要創造更安全、更具包容性的環境，讓性少數群體能夠放心地尋求性健康指導，並了解可以預防愛滋病毒和其他性傳播感染的藥物。
儘管降低性傳播感染風險的意圖值得讚揚，但謹慎實施這些策略並確保安全至關重要。在性派對上分發 DoxyPEP 等藥物，可能顯示更廣泛的文化上的轉變正在朝向減少傷害策略發生。然而，減少傷害的核心原則是，作為減少其行為危害的主要推動者，面臨風險的人應該擁有能力減少自己的風險，並支持其他人也這樣做。在透過抗病毒藥物暴露前預防來預防愛滋病毒和DoxyPEP 的時代，關於負責任用藥的社區教育和有關性健康的定期對話，是培育安全文化的重要組成部分，這種文化不依賴於藥物共享的危險做法。此外，公共衛生訊息傳遞應適應這些不斷變化的動態，包括有關藥物共享和禁忌症相關風險的準確訊息，以及諮詢醫療保健提供者的重要性和常規的性傳播感染 (STI) 之檢測。儘管在性聚會上分享 DoxyPEP 等藥物的願望可能源於社區照護場所，但它會帶來不容忽視的潛在重要健康風險。
我們聲明不存在競爭利益
*Matthew J Mimiaga, Nina T Harawa mmimiaga@ph.ucla.edu
加州大學洛杉磯分校菲爾丁公共衛生學院流行病學系，洛杉磯，CA 90095，美國（MJM，NTH）；加州大學洛杉磯分校格芬醫學院精神病學和生物行為科學系 (MJM) 和醫學系 (NTH)，美國加州洛杉磯；加州大學洛杉磯分校 LGBTQ+ 倡議、研究與健康中心，美國加州洛杉磯 (MJM)；芬威研究所、芬威健康中心，美國麻薩諸塞州波士頓 (MJM)；查爾斯·R·德魯醫學與科學大學精神病學系，美國加利福尼亞州洛杉磯 (NTH)
The dangers of medication sharing at private sex parties
Published Online November 8, 2024 https://doi.org/10.1016/ S1473-3099(24)00690-X / www.thelancet.com/infection Vol 24 December 2024
Doxycycline post-exposure prophylaxis (DoxyPEP), often known as a morning after pill, can help prevent bacterial sexually transmitted infections (STIs). Taking 200 mg of doxycycline within 72 h after condomless sex has been shown to reduce syphilis and chlamydia infections by more than 70% and gonococcal infections by about 50% among gay and bisexual men and transgender women. DoxyPEP has become a controversial topic, especially in the context both of its distribution without a prescription and by someone other than a licensed health-care provider (HCP).
In Los Angeles (USA), at the UCLA Center for LGBTQ+ Advocacy, Research & Health, there have been personal reports during the past month of DoxyPEP being given to sex partygoers at the end of private sex parties. Curious about this occurrence, we reached out to one of the party hosts, who was willing to speak with us but requested anonymity.
The host explained, “I make sure everyone leaves with something special—DoxyPEP, a little insurance for the fun we’ve had. My doctor thinks I’m just a health-conscious guy looking to stay proactive, but he has no clue about the parties I host. I just tell him that I want to be ready for anything life throws my way. Little does he know, […] it’s my way of making sure that my guests stay safe and keep coming back.” Although his actions stem from a desire to protect the community, medication sharing raises potentially important concerns.
Most importantly, the casual sharing of prescription medications undermines principles of responsible health-care delivery. DoxyPEP requires a prescription by a licensed HCP based on individual health assessments, considering a person’s medical history and allergies, as well as potential drug interactions and adverse events. When people from the general public distribute DoxyPEP without medical oversight, they potentially risk the health of others. The consequences can be calamitous.
Numerous medications can interact with DoxyPEP. For example, use with isotretinoin (commonly used to treat acne—eg, Accutane) is contraindicated. Concomitant use of systemic vitamin A derivatives (eg, retinoids) with tetracyclines could increase the risk of pseudotumour cerebri, also known as intracranial hypertension, which can lead to permanent vision loss. Another retinoid, acitretin, that is used to treat psoriasis is also contraindicated. In addition, some common non prescription medications and supplements can interact with DoxyPEP, including antacids, iron supplements, and bismuth (eg, Pepto bismol).
When the partygoer, who initially informed the centre of this occurence, was asked about his reaction when given DoxyPEP, he said, “my doctor doesn’t know I’m gay, so I had never heard about it [DoxyPEP] before. I really appreciated it. It helped to put my mind at ease, as I usually feel very anxious afterwards about getting a sexually transmitted disease.” That this person’s HCP does not know about his sexual orientation could be indicative of a deeper societal concern: the stigmatisation of sexual orientation and sexual health, particularly among sexual and gender minorities.
In 2022, gay and bisexual men accounted for 70% of incident HIV cases in the USA, further instilling the importance for HCPs to know their patients’ sexual orientation. Many individuals feel compelled to turn to alternatives outside the formal health-care system due to fears of judgement or inadequate access to culturally competent care. This concern highlights a need for HCPs and primary care settings to create safer, more inclusive environments where sexual and gender minorities can feel comfortable seeking guidance on sexual health and be informed about medications that can prevent HIV and other STIs.
Although the intention to reduce the risk of STIs is commendable, it is crucial to approach these strategies with caution and a commitment to safety. Distribution of medications like DoxyPEP at sex parties could be indicative of a broader cultural shift towards harm reduction strategies. However, a core principle of harm reduction is that, as the primary agents of reducing the harms of their behaviors, people at risk should be empowered to reduce their own risks and support others in doing the same. In the age of antiretroviral pre-exposure prophylaxis for HIV prevention and DoxyPEP, community education on responsible medication use and regular dialogue about sexual health are essential components in fostering a culture of safety—one that does not rely on the risky practice of medication sharing. Moreover, public health messaging should adapt to these changing dynamics by including accurate information about the risks associated with medication sharing and contraindications, as well as the importance of consulting a HCP, and routine HIV/STI testing. Similarly, HCPs can educate their patients about appropriate use and provide a referral mechanism to DoxyPEP for individuals within their patients’ social and sexual networks. Although the desire to share medications such as DoxyPEP at sex parties might stem from a place of care for the community, it raises potentially important health risks that cannot be overlooked.
We declare no competing interests
*Matthew J Mimiaga, Nina T Harawa mmimiaga@ph.ucla.edu
Department of Epidemiology, UCLA Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA 90095, USA (MJM, NTH); Department of Psychiatry and Biobehavioral Sciences (MJM) and Department of Medicine (NTH), UCLA Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA; UCLACenter for LGBTQ+ Advocacy, Research & Health, University of California Los Angeles, Los Angeles, CA, USA (MJM); The Fenway Institute, Fenway Health, Boston, MA, USA (MJM); Department of Psychiatry, Charles R Drew University of Medicine and Science, Los Angeles, CA, USA (NTH)