Prophylaxis After Condom Breakage: A Comprehensive Approach
For patients experiencing condom breakage during sexual activity, both HIV post-exposure prophylaxis (PEP) and doxycycline post-exposure prophylaxis (doxy-PEP) should be considered within 72 hours of exposure, with the specific regimen determined by HIV risk assessment and bacterial STI risk factors. 1, 2
HIV Post-Exposure Prophylaxis (PEP)
Initial Assessment
- Evaluate timing of exposure - PEP is only effective if initiated within 72 hours of potential HIV exposure 1, 2
- Perform baseline HIV testing on the exposed person, ideally with a rapid test kit 1
- Assess HIV status of the source partner when possible 1
- Evaluate the specific type of sexual exposure and associated transmission risk 1
Risk Assessment Factors
- Highest risk exposures include receptive anal intercourse, followed by insertive anal intercourse, receptive vaginal intercourse, insertive vaginal intercourse, and oral sex 1
- Source partner risk factors include belonging to high-prevalence groups (e.g., injection drug users, commercial sex workers) 1, 2
PEP Recommendations
- For known HIV-positive source: A 28-day course of highly active antiretroviral therapy (HAART) is recommended if within 72 hours of exposure 1, 2
- For unknown HIV status source: Evaluate on a case-by-case basis, considering risks and benefits; may be recommended if source is from a high-prevalence group and exposure represents substantial risk 1, 2
- If PEP is indicated, medications should be started as soon as possible after exposure 1, 2
- After completing PEP, patients with ongoing risk should transition to pre-exposure prophylaxis (PrEP) without interruption 2
Doxycycline Post-Exposure Prophylaxis (Doxy-PEP)
Indications
- Recommended for men who have sex with men (MSM) and transgender women who have had a bacterial STI (gonorrhea, chlamydia, or syphilis) diagnosis within the past 12 months 2
- Can be discussed with MSM and transgender women who have not had a bacterial STI in the previous year but will be participating in sexual activities with increased likelihood of STI exposure 2
- Currently insufficient evidence to recommend doxy-PEP for cisgender women, cisgender heterosexual men, transgender men, and other queer and nonbinary persons 2
Dosing and Administration
- 200 mg of doxycycline (any formulation) taken as soon as possible within 72 hours after condomless sex 2
- Maximum dose of 200 mg every 24 hours 2
- Dosing may be as frequent as daily based on sexual activity 2
- Prescription should provide enough doses based on anticipated sexual activity until next follow-up visit 2
Effectiveness
- Reduces incidence of chlamydia by 65-88% 2, 3
- Reduces incidence of early syphilis by 73-87% 2, 3
- Effects on gonorrhea are less consistent, likely due to tetracycline resistance 2, 3
Patient Education and Follow-up
For HIV PEP
- Risk-reduction counseling to prevent future exposures 1
- Follow-up HIV testing at appropriate intervals 2
- Monitor for medication side effects 2
For Doxy-PEP
- Take doxycycline on a full stomach with a full glass of liquid 2
- Avoid lying down for 1 hour after taking doxycycline to prevent esophagitis 2
- Separate doxycycline dose by at least 2 hours from dairy products, antacids, and supplements containing calcium, iron, magnesium, or sodium bicarbonate 2
- Quarterly screening for gonorrhea and chlamydia at anatomic sites of exposure and blood testing for syphilis 2
Common Pitfalls to Avoid
- Delayed initiation of PEP significantly decreases effectiveness 1
- PEP should not be used for recurrent high-risk behaviors; PrEP is more appropriate in these cases 1
- Breakthrough syphilis infections with doxy-PEP may have aberrant or attenuated rapid plasma reagin characteristics 2
- Failure to provide comprehensive STI prevention counseling alongside prophylaxis 2