What is the recommended prophylactic treatment for sexually transmitted diseases (STDs) in a sexually active male?

Prophylactic Treatment of STDs in Men

The cornerstone of STD prophylaxis in sexually active men is consistent and correct condom use with every sexual encounter, combined with appropriate vaccinations (hepatitis B for all men, hepatitis A for men who have sex with men), and consideration of doxycycline post-exposure prophylaxis (200 mg within 72 hours of condomless sex) specifically for men who have sex with men. 1, 2

Primary Prevention Strategies

Barrier Methods

• Male latex condoms, when used consistently and correctly, provide strong protection against HIV, gonorrhea, chlamydia, and other STDs transmitted between mucosal surfaces 1, 3
• Condom failure rates are approximately 2 per 100 condoms used, with failure typically resulting from inconsistent or incorrect use rather than breakage 1, 3
• Protection is more effective for infections transmitted between mucosal surfaces than those transmitted by skin-to-skin contact (such as HPV or herpes) 1

Critical Condom Use Instructions

• Use a new condom with each act of sexual intercourse 1
• Put the condom on after the penis is erect and before any genital contact with the partner 1
• Use only water-based lubricants (K-Y Jelly, Astroglide, AquaLube, glycerin) with latex condoms—oil-based lubricants weaken latex 1
• Hold the condom firmly against the base of the penis during withdrawal while the penis is still erect to prevent slippage 1

Vaccination Recommendations

• Hepatitis B vaccination is recommended for all unvaccinated men being evaluated for STD risk or treatment 1
• Hepatitis A vaccination is specifically recommended for men who have sex with men 1, 2
• Complete the full 3-dose hepatitis B series (0,1-2 months, 6 months) 2

Post-Exposure Prophylaxis (Within 72 Hours)

Doxycycline Post-Exposure Prophylaxis

• For men who have sex with men: doxycycline 200 mg orally as a single dose within 72 hours of condomless sex is recommended as part of comprehensive STI care 2
• This regimen covers chlamydia, gonorrhea (when combined with ceftriaxone), and early syphilis 2

Empiric Treatment Regimen (High-Risk Exposure)

When immediate prophylactic treatment is warranted (such as after high-risk exposure where follow-up is uncertain):

• Ceftriaxone 125 mg IM single dose (covers gonorrhea) 2
• Doxycycline 100 mg orally twice daily for 7 days (covers chlamydia and early syphilis) 2
• Metronidazole 2 g orally single dose (covers trichomonas) 2

Important caveat: This empiric approach should be reserved for situations where follow-up compliance is poor and early treatment prevents complications 2. It is not a substitute for regular screening.

Pre-Exposure Prophylaxis (PrEP) for HIV

When to Consider PrEP

• Emtricitabine-tenofovir disoproxil fumarate (Truvada) is FDA-approved for HIV PrEP in adults and adolescents weighing at least 35 kg (77 pounds) 4
• PrEP should be considered for sexually active men with multiple or anonymous partners, inconsistent condom use, or partners with HIV 2

Critical PrEP Requirements

• The patient must be confirmed HIV-negative before starting PrEP—do not initiate if HIV status is unknown or positive 4
• HIV testing must be performed at least every 3 months while on PrEP 4
• PrEP does not prevent other STDs—condoms must still be used consistently 4
• Patients must be counseled that missing doses increases HIV acquisition risk 4

PrEP Monitoring

• Test for HIV, syphilis, gonorrhea, and chlamydia every 3 months 2, 4
• Screen for hepatitis B before initiating PrEP 4
• Monitor renal function—PrEP is not recommended if creatinine clearance is below 60 mL/min 4

Screening Recommendations

Routine Screening Intervals

• Men who have sex with men and other high-risk men should undergo comprehensive STI screening every 3-6 months 2, 5
• Annual HIV testing is recommended at minimum for men who have sex with men 6
• More frequent screening (every 3 months) is indicated for men with multiple partners, anonymous partners, substance use during sex, or history of STIs 2

Site-Specific Testing Based on Exposure

This is a critical point often missed in clinical practice:

• For urethral/vaginal penetration: urine or urethral specimens for chlamydia and gonorrhea NAAT 2
• For receptive anal intercourse: rectal specimens for chlamydia and gonorrhea NAAT 2
• For receptive oral sex: pharyngeal specimens for gonorrhea NAAT (pharyngeal chlamydia testing is not generally recommended) 2
• Failing to test exposure-specific sites misses a substantial proportion of infections, particularly in men who have sex with men 2

Post-Exposure Screening Timeline

• Immediate screening for chlamydia, gonorrhea, syphilis, and HIV at presentation 2
• Repeat HIV testing at 4-6 weeks and definitively at 12 weeks post-exposure due to the window period 2
• Repeat syphilis testing at 6-12 weeks if initial test was negative 2
• If initial chlamydia or gonorrhea tests were positive and treated, retest at 3 months due to high reinfection risk 2

Common Pitfalls to Avoid

Testing Errors

• Testing too early and stopping there is the most critical error—a negative test at 1 week does not rule out infection 2
• Not testing at exposure-specific anatomic sites (pharynx, rectum) misses infections, especially in men who have sex with men 2, 5
• Accepting patient self-report of "always" using condoms as sufficient reassurance without performing screening 2

Counseling Gaps

• Assuming condoms provide 100% protection—they do not cover all exposed areas and are less effective against skin-to-skin transmitted infections 1
• Not discussing that fellatio, commonly thought to be "safe," is an independent risk factor for urethral gonorrhea and nongonococcal urethritis 7
• Failing to counsel that PrEP does not prevent bacterial STIs or other viral infections 4

Follow-Up Issues

• Not ensuring 3-month follow-up for HIV and syphilis testing after potential exposure 2
• Missing the 72-hour window for post-exposure prophylaxis (both doxycycline for bacterial STIs and antiretroviral therapy for HIV) 2
• Not retesting at 3 months after treating chlamydia or gonorrhea, when reinfection rates are high 2

Partner Management

• All sexual partners within the preceding 60 days must be evaluated and treated, even if asymptomatic 2
• Partners should receive the same empiric prophylactic regimen if treatment is indicated 2
• Both patient and partners should abstain from sexual activity until 7 days after completing treatment 2
• Expedited partner therapy may be appropriate depending on local regulations 2

Special Considerations for High-Risk Populations

Men Who Have Sex with Men

• Higher rates of bacterial STIs, with studies showing 20% positivity for chlamydia and 17% for gonorrhea with frequent screening 2
• Increased risk for rectal and pharyngeal infections that are often asymptomatic 5, 7
• Known HIV infection is an independent predictor of urethral gonorrhea (OR 2.3) 7
• Adherence to quarterly screening is essential but often declines over time, particularly in adolescents who may benefit from more frequent visits 4

Geographic Disparities

• Men in the Southeast United States are significantly less likely to receive consistent urogenital (aPR 0.86) and rectal STI screening (aPR 0.76) during PrEP care compared to other regions 5
• This is particularly concerning given the substantial STI burden in these states 5