New clinical guidelines released Monday aim to curb a concerning rise in HIV diagnoses across Canada, with a reported 35% increase in new cases between 2022 and 2023, bringing the total to 2,434. Developed by a team of 19 physicians over three years, the recommendations focus on expanded access to HIV prevention medications like PrEP and PEP. While the guidelines are designed to support Canada’s goal of eliminating HIV as a public health threat by 2030, experts caution notable systemic barriers remain, particularly for vulnerable populations.
New clinical guidelines released Monday offer 31 recommendations and 10 best practices for prescribing antiretroviral medications both before and after potential HIV exposure, aiming to prevent infection. The guidelines come as Canadian health officials report a concerning rise in new HIV diagnoses in recent years.
Dr. Darrell Tan, lead author of the guidelines, said that 19 physicians volunteered their time over the past three years to review the latest research and develop the updated recommendations. Options for pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) have expanded significantly since the last guidelines were published in 2017.
The recommendations are intended to help Canada reach its national goal of eliminating HIV as a public health threat by 2030. However, Dr. Tan cautioned, “We are far from reaching this ambitious goal.”
Data from the Public Health Agency of Canada show a consistent increase in HIV diagnoses from 2021 to 2023. There was a 35% increase in new HIV cases between 2022 and 2023, with 2,434 diagnoses reported. In 2022, there were 1,800 new cases, and over 1,450 in 2021. Data for 2024 are expected to be released Monday.
According to Dr. Tan, the increase in cases is linked to “deep historical and structural inequities” that disproportionately affect certain populations’ access to PrEP and PEP. These inequities create barriers to preventative care and contribute to the rising infection rates.
More than one-third of new infections are among women, 38% are among gay, bisexual, and other men who have sex with men, and 25% are among people who inject drugs. Certain Indigenous communities, particularly in Saskatchewan and Manitoba, have also experienced higher-than-average rates of infection.
The guidelines emphasize the importance of addressing stigma surrounding PrEP and PEP, and Dr. Tan expressed concern that national, provincial, regional, and territorial health authorities haven’t done enough to promote public health messaging about these medications. “Almost all Canadians are well aware that public health authorities support vaccination against the flu,” he said. “It’s a failure on the part of public health authorities not to have communicated this message positively.”
The Public Health Agency of Canada stated that it provides national leadership in the prevention and control of sexually and blood-borne infections through its guidance for healthcare professionals, which references guidelines on HIV PrEP developed by the Canadian HIV Trials Network of the Canadian Institutes of Health Research.
Easing Access to PrEP
A key recommendation in the new guidelines is that healthcare providers should prescribe PrEP to anyone who requests it, regardless of whether they disclose their HIV risk factors. This shift aims to remove barriers to access and acknowledge that individuals may have valid reasons for not sharing personal information.
“There are many reasons why people may not disclose their HIV risk behaviors to healthcare providers, including shame, distrust of the medical system, and structural barriers related to homophobia, transphobia, racism, colonial practices, HIV-related stigma, and other forms of discrimination,” the guidelines state.
Dr. Ameeta Singh, a member of the guideline development committee, explained that the goal is to make PrEP more accessible. Physicians across all specialties, including primary care and reproductive health, should also proactively offer PrEP to patients they identify as being at risk, such as those with unprotected sex, a history of bacterial sexually transmitted infections, multiple partners, or injection drug use.
The growing range of PrEP options is also addressed, with the guidelines outlining appropriate situations for their use. In addition to daily and “on-demand” pills, Health Canada approved a long-acting injectable medication in 2024.
This extended-action option, administered every two months, could be particularly beneficial for people who inject drugs and experience housing instability, as it eliminates the need for daily pill adherence. “That’s where the injectable agents have huge potential,” said Dr. Singh, a clinical professor in the division of infectious diseases at the University of Alberta.
She added that the next step is for policymakers to prioritize the implementation of these guidelines.
A Call to Action
Dr. Sean Rourke, a scientist at the MAP Centre for Urban Health Solutions at St. Michael’s Hospital, said he wished the guidelines had more thoroughly addressed how to reach communities with the highest HIV rates, particularly Indigenous people in the Prairies.
According to Communities, Alliances and Networks, an organization addressing HIV issues in Indigenous contexts, Indigenous people accounted for 19.6% of new HIV diagnoses in 2023 (when ethnicity was reported) despite representing only 5% of the population.
“The document says nothing about how to reach these people,” he stated.
Dr. Rourke and a team of advocates are collaborating with Indigenous leaders to reach populations in the most affected communities in Canada. A HIV testing program they launched in March for underserved and remote Prairie communities has screened over 15,000 people.
“It’s the most vulnerable who are affected, three or four times as much as expected, because other factors come into play and the social safety net is non-existent,” he explained.
Dr. Rourke noted that solutions like this testing program already exist to address health inequities. However, he added, “it doesn’t happen on its own. And that’s the problem.”
