New Canadian Guidelines Aim to Curb Rising HIV Infections with Expanded Access to Preventative Medications
Canada is facing a concerning rise in HIV diagnoses, prompting a coalition of doctors to release updated clinical guidelines for prescribing medications that can prevent infection. Published Monday in the Canadian Medical Association Journal, the new recommendations emphasize increased promotion and awareness of pre-exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) – antiretroviral medications used to prevent HIV transmission.
The guidelines, developed over three years by a team of 19 physicians, provide 31 recommendations and 10 good practices for healthcare providers. They reflect the significant expansion of PrEP and PEP options since the last guidance was issued in 2017. The ultimate goal is to get Canada back on track to eliminate HIV as a public health threat by 2030, a target officials currently admit is unlikely to be met.
“We’re not at all on track to reach that ambitious target,” stated Dr. Darrell Tan, a physician-scientist at St. Michael’s Hospital and lead author of the guidelines.
Recent data from the Public Health Agency of Canada reveals a troubling trend. HIV diagnosis rates have steadily increased from 2021 to 2023, with a significant 35% jump in new cases between 2022 and 2023, totaling 2,434 diagnoses. This follows 1,800 first-time diagnoses in 2022 and over 1,450 in 2021. The Canadian Institutes of Health Research is set to release updated 2024 data on Monday.
Experts attribute this increase to “deep historical and structural inequities” that create barriers to accessing PrEP and PEP for specific populations. Currently, over one-third of new infections occur in women, 38% are among gay, bisexual, and other men who have sex with men, and 25% are in people who inject drugs. Indigenous communities in Saskatchewan and Manitoba are disproportionately affected, experiencing higher rates of infection than the national average.
A key tenet of the new guidelines is to remove barriers to access. Healthcare providers are now advised to prescribe PrEP to anyone who requests it, even without a detailed disclosure of HIV risk factors. The guidelines acknowledge that individuals may be hesitant to discuss sensitive behaviors due to shame, mistrust of the medical system, or experiences of discrimination related to homophobia, transphobia, racism, and colonial practices.
“There are many reasons people may not disclose HIV risk behaviours to health care providers,” the guideline states, emphasizing the need to avoid “gatekeeping” access to preventative medications.
Dr. Ameeta Singh, a member of the guideline committee, explained that the aim is to “lower the barrier to accessing PrEP.” She added that doctors across various specialties – including primary care and reproductive health – should proactively offer PrEP to patients who exhibit risk factors such as condomless sex, a history of sexually transmitted infections, multiple partners, or injection drug use.
The updated guidance also addresses the expanding range of PrEP options. In addition to daily and “on demand” pills, Health Canada approved a long-acting injectable medication in 2024, administered every two months. This new option is particularly beneficial for individuals who inject drugs and experience housing instability, for whom consistent daily pill adherence can be challenging. “This is where injectable agents have huge potential,” said Dr. Singh, a clinical professor in the division of infectious diseases at the University of Alberta.
However, some experts believe the guidelines could go further. Dr. Sean Rourke, a scientist with the MAP Center for Urban Health Solutions at St. Michael’s Hospital, expressed concern that the document lacks specific strategies for reaching communities with the highest HIV rates, particularly Indigenous people in the Prairie provinces.
According to data from Communities, Alliances and Networks, Indigenous Peoples accounted for 19.6% of new HIV diagnoses in 2023, despite representing only 5% of the Canadian population. Dr. Rourke highlighted the success of an HIV testing program launched in March by his team and Indigenous leaders, which has already tested over 15,000 people in underserved and remote Prairie communities.
“Those that are the most vulnerable. It’s impacting them, three or four times more than it would have otherwise because other things have happened and the safety net is not there,” he said. “It doesn’t happen on its own. And that’s the problem.”
The Public Health Agency of Canada maintains it provides national leadership in HIV prevention and control through its guidance for health professionals, referencing PrEP guidelines developed by the Canadian HIV Trials Network. However, a recurring theme among experts is the need for more robust public health messaging to combat the stigma surrounding PrEP and PEP.
“Almost everyone in Canada knows unequivocally that public health authorities think that influenza vaccination is something that they would support,” one physician observed, lamenting the lack of similar proactive promotion for HIV prevention. “It’s a failure of public health and authorities to push the message out in a positive way.”
The success of these new guidelines will ultimately depend on the commitment of policymakers to prioritize their implementation and address the underlying inequities that continue to fuel the rise of HIV infections in Canada.
