Learning what women prefer in STI preventive care

The tendencies and preferences of sexually transmitted infection (STI) preventive care among women in Kenya became a focal point of research from the dPEP Kenya Study Team recently, after analysis into the utility of doxycycline hycate 200 mg (doxycycline PEP) showed promising treatment was underutilized by sexually active cisgender women at greater risk of STIs.¹

In the second segment of an interview with Contemporary OB/GYN, dPEP Kenya investigator Jenell Stewart, DO, MPH, assistant professor of infectious diseases at Hennepin Healthcare, discussed her perspective on her team’s findings regarding lesser doxycycline PEP adherence among cisgender women in Kenya, and the follow-up research efforts to better quantify what women may want in an STI preventive therapy.

As Stewart noted in the discussion, it may be unfair to suggest that women altogether were non-adherent to the investigative treatment—the available data from approximately 50 participants showed that about 60% of them had used doxycycline PEP at some point during the course of the study.

“So, I think it's hard to say that it never worked, it never fit into their lives,” Stewart said. “I think overall, it was clearly something that was hard to be consistent with.”

She and her colleagues are now conducting qualitative analyses to interpret the “stories, narratives and barriers” that contextualized the participants utility of doxycycline PEP—or lack thereof. One observable demographic disparity between those who did and did not adhere to the therapy after sexual encounters, Stewart noted, was age.

“In just looking at the participants who tended to not have the doxycycline detectable, there wasn't a clear trend. It didn't really correspond with their concern for STIs, their number of partners, their marital status education,” she noted. “Those who are under 24 were much less likely to have doxycycline detected in their hair. And that's fairly consistent with what we've seen in a lot of other preventive studies where at a younger age, for whatever reason—and I could hypothesize a few—you're less likely to see consistent use of the doxycycline.”

Stewart additionally discussed her team’s work on a follow-up study in Kenya assessing a weekly supported dose of doxycycline PEP to gauge the efficacy and patient preference for a fixed regimen of the therapy to prevent STIs, as well as a US-based, multi-site trial enrolling people assigned female sex at birth who have had an STI in the prior year.

Regarding the practical utility of their research, Stewart noted that while guidelines do not generally endorse the use of doxycycline PEP in people assigned female sex at birth due to lacking evidence,² many public health departments advocate for shared decision making between caregivers and patients for the prevention of STIs.

“If you're faced with a reinfection with syphilis during pregnancy or taking doxycycline, that's worth having that conversation with that person in front of you to decide if doxycycline PEP is right for them,” Stewart said. “And while you might not see comprehensive, overarching recommendations from the CDC or other governing bodies to roll this out at a broad scale, I do think it's worth having those one-on-one conversations with folks saying, 'We don't know, we think this might work if people really need other options.' Because I really don't want women to be left behind.”

Lastly, Stewart stressed the importance of continuing to evaluate the systemic drivers of STI prevalence and severity in adversely-affected populations including people assigned female sex at birth—and “recognizing the ways in which our systems are failing folks to get them access to screening and the treatment that they need.”

“I think we need to really think seriously about our systems and what is preventing people from coming in to get the testing and treatment that they need, and really putting our money where our mouth is in our health departments and in our healthcare systems to ensure that we're doing better,” Stewart said.

References

1. ^{Kunzmann K. Doxycycline Less Effective, Adhered to for STI Prevention in Women. Contemporary OB/GYN. Published February 27, 2024. https://www.contemporaryobgyn.net/view/doxycycline-less-effective-sti-prevention-women}
2. ^{Kunzmann K. Why doxycycline PEP lacks clinical data for STI prevention in women. Contemporary OB/GYN. Published April 10, 2024. https://www.contemporaryobgyn.net/view/why-doxycycline-pep-lacks-clinical-data-for-sti-prevention-women}