PEP in Your Step

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.

The reticence to sanction—or even explore—a proven tool for sexual risk reduction is familiar to queer communities who are expected to benefit most from DoxyPEP, including GBMSM, who shoulder the highest burden of many bacterial STIs. In previous decades, conflicts over prevention tools and techniques centered on apparent public health concerns about speculative threats like HIV-superinfection or uncontrolled upticks in STI rates. Now, DoxyPEP hesitancy seems to hinge on the possibility that its reckless uptake might accelerate antimicrobial resistance.

DoxyPEP’s origins are unwritten and often unacknowledged, but signs indicate that it likely emerged through the sexual experimentation of queer communities. The authors of the first clinical trial of DoxyPEP—France’s 2015-2016 trial known as ANRS IPERGAY—cite a number of studies that, since the 1940s, have examined the possibility of using antibiotics as a form of STI prophylaxis or “periodic presumptive treatment,” especially among sex workers. But other than citing doxycycline’s ongoing use as prophylaxis for people who might have been exposed to Lyme disease or Weil’s disease, IPERGAY’s researchers fell short of explicitly naming the confluence of contemporary, real-world factors that might have inspired their investigation into DoxyPEP as a means of STI prevention.

In parallel, since 2019, a number of surveys have consistently shown that nearly 10 percent of GBMSM who are using PrEP are already using antibiotics, acquired through means other than a prescription, as an STI prevention tool. In fact, the IPERGAY study detected that between 3 and 13 percent of participants in the placebo group had doxycycline in their blood when it was tested, suggesting that some of these individuals were themselves using some version of DoxyPEP. Thus, it seems likely that queer men—and their sexual networks, including transgender women—may already have been experimenting with doxycycline as a prevention tool at the point of its emergence to contemporary clinical inquiry and, therefore, could be said to have invented DoxyPEP, or at least given renewed life to the curio of antibiotics as STI prophylaxis.

Experimentation with forms of risk reduction is, by now, de rigueur for queer communities who have, at least since the onset of the AIDS crisis, innovated new tools, techniques, and arrangements that allow sex to flourish in the face of possible infection. Perhaps most famously, in 1983, just two years into the AIDS crisis in North America and prior even to the consensus that it was a virus that caused the illness, activists Michael Callen and Richard Berkowitz published a forty-page pamphlet entitled How to Have Sex in an Epidemic: One Approach. Initially distributed throughout New York City’s queer communities, the pamphlet offered non-judgmental advice, drawing on the input of the clinician Joseph Sonnabend, about how its intended audience might have sex as safely as possible in the midst of a deadly disease. Based on the knowledge of the time and existing STI prevention advice, the booklet articulated the relative risks of different sex acts and described new forms of sex—including “closed circles of fuck buddies” and “jerk-off clubs”—that might minimize the likelihood of acquiring AIDS. It is perhaps best known, however, as one of the first texts to advocate for condom use as a form of safer sex.

In refusing to wholly accept abstinence or monogamy as viable approaches, people like Callen and Berkowitz were able to advocate for new, innovative, and life-saving modes of prevention. Accordingly, as the activist and critic Douglas Crimp noted in 1987, while gay men were so frequently shamed, sometimes by their own community, for their apparently “compulsive” or “promiscuous” relationship to sex, “in fact it is our promiscuity that will save us.” That experimental spirit of promiscuity is alive and well in contemporary approaches to prevention, most recently during outbreaks of Covid-19 and MPOX, where complete abstention—and even quarantine—were floated as easy or default advice.

Yet, partly because of the heterodox, unwaveringly pro-sex ethics that undergird them, queer innovations in safer sex have typically been met with backlash from anxious and, more often than not, viciously homophobic adherents of the status quo. Throughout the 1980s, while grassroots campaigners and activists raised awareness about safer sex, the federal government resisted. In 1987, following a crusade waged by the conservative senator Jesse Helms, Congress passed legislation that explicitly prohibited using federal funds for any AIDS education campaigns that promoted, “directly or indirectly, homosexual activity.” Safer sex was opposed not because its logics were unsafe or unsound but because it was imagined, in the eyes of its hidebound opponents, to enable endless homosexual orgies, and to interrupt an epidemic that was otherwise perfectly pitched, in the words of the writer and activist Simon Watney, as “the viral projection of an unconscious desire to kill gay men.”

However, ever since condom use was enshrined in sexual health initiatives as the paragon of responsible safer sex, any departure from the practice tends to draw scorn and scrutiny. Notably, the advent of PrEP and its users were met with opprobrium not just from the expected cabal of anti-gay right-wingers but also from members of queer community itself. Vocal critics of PrEP in its early years included Michael Weinstein, the president of the AIDS Healthcare Foundation in Los Angeles, who, in 2014, wrote off PrEP as a “party drug”; and Larry Kramer, the veteran AIDS activist and longstanding critic of gay promiscuity, who, also in 2014, claimed that PrEP users had “rocks in their head” and that there was “something to me cowardly about taking [PrEP] instead of using a condom.” Other forms of early resistance to PrEP were subtler, including concerns held by prescribing clinicians about increases in so-called “sexual risk compensation” in PrEP users that might increase transmissions of treatable STIs or even infection by “resistant strains” of HIV. The Overton window of acceptable concern may have shifted since the days of Helms and co., but there remains a dim and pathologizing regard for the choices made by queer communities: their apparent recklessness, hedonism, and lack of concern for anything except fucking.

A similar dynamic has emerged in the reception to DoxyPEP, still itself a nascent technology. Last November, after the San Francisco Department of Public Health recommended DoxyPEP for use in certain demographics at elevated risk of STI infection (GBMSM and transgender women), Nature published an article entitled “Push to use antibiotics to prevent sexually transmitted infections raises concerns.” While extolling the benefits of DoxyPEP, the authors cited fears expressed by some researchers that the repeated use of doxycycline could accelerate the development of antimicrobial resistance in bacteria that doxycycline is required to treat, like those that cause bacterial pneumonia. The framing of this reportage—echoed in the pages of the New York Times and Washington Post—is one that occludes the plausible benefits of DoxyPEP by giving primacy only to the risks of the intervention.

Antimicrobial resistance, considered a “global health and development threat” by the World Health Organization, is certainly of immense concern, and it will require sustained observation in tandem with DoxyPEP’s widening implementation. But such a framing risks overstating the scale of the problem, which is already being carefully monitored and has only been very moderately indicated by existing clinical trials. And it singles out DoxyPEP—and, more subtly, its queer users—as exceptional threats for antimicrobial resistance. Note, for instance, that microbiologist Chris Kenyon expressed concern in the Nature piece over the apparently “astronomical” number of doses (twenty) of doxycycline taken by some trial participants in a single month. Such alarmism feels misplaced when considering that extended and daily dosing of doxycycline is already routinely prescribed for the treatment of mild cases of acne and that an estimated 66 percent of all antibiotics used worldwide is given to livestock—by far, the greatest contributor to antimicrobial resistance. Perhaps for researchers like Kenyon it is not the “astronomical” quantity of DoxyPEP use that is egregious but the quality; deployed recklessly toward the shallow ends of an “astronomical” quantity of bareback sex.

The question for advocates is how to achieve and expand access to sexual health interventions like PrEP and DoxyPEP. One widespread and even obligatory tactic has been to work directly to allay institutional concerns. For a swathe of PrEP advocates, both inside and outside medical institutions and including pro-PrEP clinicians, meeting concerns about the apparent recklessness of would-be PrEP users meant working to rehabilitate the image of the PrEP user as a highly responsible proponent of sexual health. Some early interventionists even sought to playfully embrace—and, therefore, neuter—the pathology that PrEP users were accused of, proudly labeling themselves “Truvada Whores.”

But over the years, as PrEP has become incorporated into mainstream HIV prevention strategizing, most messaging invokes PrEP as the patent choice of the upstanding neoliberal sexual actor. The rational gay man chooses PrEP; it would be reckless not to. This image of individual responsibility—which has, like a rhetorical contagion, been neatly displaced from the condom onto PrEP pills—manifests not only in the cultural imagination. It is mandated by and built into the infrastructures of PrEP provision and monitoring. By attending quarterly clinical appointments for STI and HIV testing to receive PrEP and agreeing to adhere closely to prescribed PrEP protocols, GBMSM have participated in clinical and research architecture that circuitously proves their motives and capacity to take PrEP “responsibly.”

Perhaps there is hope for the future of DoxyPEP in HIV PrEP’s tidy success story, moving from a source of prevention anxiety to a mainstay of sexual health initiatives. Perhaps if DoxyPEP advocates could simply prove that they—and the plausible user-base—take antimicrobial resistance seriously, they might meet gatekeepers on common ground. And, perhaps, this might be achieved by rallying DoxyPEP users en masse to the cause of antimicrobial resistance monitoring by erecting new infrastructures of clinical surveillance as a prerequisite to accessing DoxyPEP.

PrEP’s success story, however, contains hidden failures, which should be instructive for coming waves of DoxyPEP advocacy. In working to secure access to PrEP by constructing an idealized vision of the “responsible” user, PrEP advocacy has just as readily limited access to those groups or individuals that cannot—or will not—submit to this logic of responsibility. While white, middle class, gay men have been easily and readily configured as responsible sexual health subjects by virtue of their longstanding and often frictionless engagement with clinics and clinicians, other groups that stand to benefit from PrEP have significantly more fraught relationships with the medical establishment.

Black queer men in particular face a number of barriers to accessing PrEP, including economic hurdles and the lack of culturally specific messaging, as well as personal and collective experiences of institutional and clinical racism that produce real distrust of services and alleged infrastructures of care. Similarly, groups who are at higher risk of acquiring HIV because of unfairly criminalized behavior—like people who inject drugs or sex workers—experience stigma and fears of retribution that make it more difficult to engage with sexual health services that expect, as proof of “responsibility,” acquiescence to surveillance. The idealization of “responsibility” by PrEP advocates, therefore, is itself a barrier to access—one that is exacerbating long-standing inequalities in the burden of HIV infections such that, in the United States, if current rates remain the same, around one in two Black men who have sex with men will be diagnosed with HIV in their lifetimes.

DoxyPEP advocates, like the San Francisco AIDS Foundation, therefore, must remain mindful of how they approach the inevitable concerns over the intervention. No doubt, an important facet of the response will be to take seriously the matter of antimicrobial resistance; to ignore these concerns is to deny to the realities of the risks and benefits of DoxyPEP. But those working to empower communities to access to DoxyPEP, my employer—the London-based community health promoter, The Love Tank—and myself among them, must not simply offer up the existing circuitry of personal or community “responsibility” as a solution. In part, this is because to do so would mean ceding entirely to the latent anxieties and moral judgements that position DoxyPEP as little more than a ticking time bomb of antimicrobial resistance.

Better, instead, to respond by unpacking the component parts, moral and biological, of these concerns and instigating a reasonable conversation that takes seriously the benefits of DoxyPEP’s facilitation of the pleasure of condomless sex. But, in part, eschewing “responsibility” as a framework is a refusal to accept the default position that infrastructures of surveillance are the only option, which will only benefit those communities and the slices of those communities that least fear the strong arm of the state, who only see its gentle hand. Others, like the Black communities that already shoulder a disproportionate burden of STI infections precisely because they are failed by existing sexual health architecture, stand to lose out from these long-established arrangements. DoxyPEP, like interventions past that have arrived on the wings of queer community experiments, should incite us to think more promiscuously—about forms of provision that might lie outside of the status quo, about monitoring bacteria without monitoring people, about freedoms even from the objects and tools that once served us: clinics, condoms, and other saints.