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Updated HIV prophylaxis guidelines: what clinicians need to know

• Canadian Medical Association Journal

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Despite a range of effective prevention tools, HIV incidence continues to rise in Canada, with stark disparities across ethnicity, gender, Indigeneity and geography. Updated Canadian guidelines on HIV pre- and post-exposure prophylaxis reflect scientific advances since 2017 and address both new formulations and persistent barriers to equitable access.

Dr. Darrell Tan, lead author and clinician scientist at St. Michael’s Hospital, outlines several prophylaxis options now available. Daily oral tenofovir disoproxil fumarate with emtricitabine is close to 100 per cent effective with perfect adherence and remains forgiving of occasional missed doses. Long-acting injectable cabotegravir, administered every two months, shows even greater effectiveness in trials largely because it reduces the adherence challenges associated with daily pills, though cost and availability continue to limit uptake.

Natasha Lawrence, a community health worker at Women’s Health in Women’s Hands Community Health Centre in Toronto, reports that most women she serves have never heard of pre-exposure prophylaxis. Many people perceive their HIV risk as low until discussions explore relationship dynamics, including uncertainty about partner fidelity or difficulty negotiating condom use. She highlights how power imbalances and gender-based violence shape women’s risk and may limit the practicality of daily pills. Long-acting injectables can offer greater privacy and autonomy for some women, reducing the risk of partner detection. Public health messaging, she stresses, must be co-designed with communities to ensure cultural relevance and avoid stigma.

Clinicians should initiate sexual health conversations routinely, not only when patients raise concerns. Pre-exposure prophylaxis can be discussed during visits for contraception, mental health or other routine care. When patients express interest, access should not be limited by rigid criteria. Long-acting options may be especially helpful for women who face safety or privacy concerns in their relationships.

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Dr. Blair Bigham:

I'm Blair Bigham.

Dr. Mojola Omole:

I’m Mojola Omole. This is a CMAJ podcast. So today, Blair, we both are really excited about this topic for different reasons. What are we talking about?

Dr. Blair Bigham:

We are talking about the newest guidelines just released in CMAJ on HIV pre- and post-exposure prophylaxis. So I think we're both excited about this for maybe the same reasons. I think there's lots of reasons to be excited about this. Certainly, I think this touches on a small part of the practice of most people who work in frontline medicine. Maybe it's not something we see every day, but every once in a while, I think it always comes to mind. Is this person at risk for HIV, either because of an acute exposure or because of background risk? And what can we do to prevent it?

Dr. Mojola Omole:

This was triggered by the five-year update from 2017, and it really addresses that some of the newer medications that's on the horizon. And then the part that is very important to me also talked about the equity piece in terms of PrEP and PEP usage and guidelines. So this is going to be a great conversation.

Dr. Blair Bigham:

Yeah, I think I'm really interested to see, you know, from my lens, I know that PrEP is very, very a hot topic in the LGBT community, particularly for men who have sex with men. And I'm really excited to go beyond that.

Dr. Mojola Omole:

Sorry, why is that your lens?

Dr. Blair Bigham:

Why is that my lens? Gee, I wonder. But I feel like it maybe is it gets too much attention or sort of too many resources compared to other populations who are at risk. So not only are we going to hear from one of the authors of the guideline, but we're also going to talk about somebody who sees this risk in the real world every day when they go to work and works really hard at addressing some of the stigma and inequities around PrEP access. Dr. Darrell Tan is the lead author of the update of the “Canadian guideline on HIV pre and post exposure prophylaxis.” He's a clinician scientist in the Division of Infectious Diseases at St. Michael's Hospital and associate professor in the Department of Medicine at U of T. All right, Darrell , welcome back to the podcast. Tell us, why was it important to update the guidelines now?

Dr. Darrell Tan:

For sure. Thanks so much for having me on, first of all, to talk about it. There's a number of reasons why I think it was really important for us to update the guideline. Perhaps some of the most important ones are that it was simply overdue. There's been a lot of science that has come out in the years since we initially published our inaugural PEP and PrEP guideline for Canada in 2017. Brand new formulations of PrEP have become available. New and more tolerable regimens have been studied in a number of different settings for use as post exposure prophylaxis, as PEP. And importantly, despite all of these scientific advances, we really haven't seen enough of moving of the needle in terms of improving HIV incidence in Canada. We still see really stark inequities across the country by ethnicity, by gender, by indigeneity, by geography. And there's a lot of need still out there. And we thought it was really important for us to get scientific best practice evidence out there to the broader community to try to really advance the use of these safe and effective tools.

Dr. Blair Bigham:

So we're going to try to break all of this down, and we're definitely going to talk about why that needle might not be moving as much as we hope. But first, tell us about the new tools that have emerged over the last eight years. What's out there for people to prescribe for.. and how about we break it down by PrEP and PrEP? So starting with PrEP, what new tools are out there for physicians to prescribe?

Dr. Darrell Tan:

Absolutely. Well, there's a number of different options that can now be used for pre-exposure prophylaxis against HIV. For a long time, we've had a daily pill, and that daily pill has been tenofovir dizoproxyl fumarate with m-tricitabine. That's a lot of letters. T-D-F-F-T-C is how we abbreviate that. The trade name that many people might recognize is Truvada, although it's now available as a generic. And that's been around for many years. It can be used daily by virtually anybody who thinks there could be a chance that they could come into contact with HIV, and that still exists. But some of the important advances are that we now know, based on excellent science, that same medication can be used in what we call an on-demand fashion, specifically among gay, bisexual, other men who have sex with men, as well as transgender women. So just taking a few doses around the time of sex or around the time of an exposure. And that's an important innovation that's really favored by a lot of people. You don't want to take a pill every day.

Dr. Blair Bigham:

So for those two options, the daily pill and the on-demand regimen, how effective is that?

Dr. Darrell Tan:

It's a great question, and the answer in a nutshell is extraordinarily effective. So by that, we mean if someone is able to succeed at taking it exactly as prescribed, we think that the efficacy is close to 100 percent. And there's very few things out there in clinical medicine that are that extraordinarily effective. This truly can be that effective. In addition, we know that it's quite forgiving, as we say, of imperfect adherence. So even someone who might be striving to take their pills every single day, but, you know, life gets in the way, they might miss a pill here and there. We know that it's still associated with really, really excellent effectiveness, still rivaling 100 percent decrease in HIV acquisition risk, although there's a slightly wider confidence interval around that. And this is one of the reasons that we really want to advance the use of these tools. They're really extraordinarily safe and effective.

Dr. Blair Bigham:

And then there's other options on the market now. Tell us about those.

Dr. Darrell Tan:

That's right. So one of the small downsides of the daily pill, especially in someone who might be using it for many, many years in a row, is that it can be associated with a little bit of bone and kidney issues. This is not something we want to overstate because I think it's also easy to overstate these risks. They're actually quite modest. They are reversible when someone comes off the medications and they're largely things that we can monitor for. Nevertheless, because of those aspects, there is another pill. It's another version of tenofovir, something called tenofovir alafenamide, again, together with that other medication, m-tricitamine. So we abbreviate that TAF or T-A-F slash F-T-C. The trade name that that is also known as is Descovy. And that is an option that has also been demonstrated to be extremely effective, specifically in sexual minority men and transgender women. But again, by extension, we think that it's very reasonable. We would offer a weak recommendation for its use in other populations as well who might find themselves at risk of acquiring HIV.

Dr. Blair Bigham:

And then, Darrell , the last time you were on the podcast, we were talking about an exciting injectable option.

Dr. Darrell Tan:

That's right. So perhaps one of the most exciting advances in the field is that we now have long acting injectable medications that can be used as PrEP. And there is an option called long acting injectable cabotegravir that can be administered through an injection in the butt muscle every two months and is, if you can believe it, even more effective than taking that daily oral pill. Now, there's a bit of a built in paradox to some people's ear maybe when they hear that, because we've just said that the daily pill is virtually 100 percent effective on its own. If someone takes it successfully or is able to adhere with it regularly, and that's, in fact, the crux of the matter. We know that that's actually quite challenging for people for all kinds of reasons that are very understandable to do. And the injection, kind of, is able to overcome that because it really only requires someone to take action about six times a year, every two months to go in and get that injection administered. And, you know, they can more or less forget about that the rest of the time. So that's become available and it's now publicly, publicly reimbursed in a number of jurisdictions in the country.

Dr. Blair Bigham:

How do you actually get it injected if you're able to afford it or if it is covered in your province? Is it something that you inject yourself or do you need to go to a clinic?

Dr. Darrell Tan:

These are great questions, and unfortunately, it is not yet a product that, or we don't yet have a product that a person could self administer by injection that would last for a long time like this. So this product does need to be administered by a health care provider of some sort. And there's a number of different innovative implementation strategies that are in place that are being looked at, that are being expanded in different parts of the country. But yes, it does require someone to seek out that form of health care every two months.

Dr. Blair Bigham:

Anything else in the pipeline when it comes to PrEP choice?

Dr. Darrell Tan:

Yeah, really excitingly, we have not only a two-monthly injectable option, but we now have really groundbreaking science demonstrating that a six-monthly injectable product is safe and effective. Once again, extraordinarily good HIV prevention rates that we're seeing in these pivotal studies. That drug is called lenacapavir. It is not yet available and approved for use as PrEP in Canada. We anticipate regulatory approval in the future, and then reimbursement will be looking at that question after that. But certainly the science behind that product is extremely strong, and we're all very much looking forward to that because just two visits to a health care facility to get an injection a year would really be groundbreaking.

Dr. Blair Bigham:

Tell us what's happening with HIV incidents in Canada. Cabotegrevir may be new, but PrEP isn't. Are we seeing a decline in HIV across the country?

Dr. Darrell Tan:

So sadly, the high-level answer to that question is no. In fact, 2023 numbers recently came out for HIV in Canada from the Public Health Agency and don't really show improvement, if anything, a little bit of a worsening in our incidence rate. We're sitting steady at an incidence of something like six point something per hundred thousand. And that is really in many ways shameful. It's really a representation of our failure to implement the safe and effective tools that we have both for treatment and for prevention and for testing and all the services that need to surround that.

Dr. Blair Bigham:

So where aren't we seeing uptake? What populations deserve sort of that equity focus at this point in time?

Dr. Darrell Tan:

So there's many. I mean, in the HIV epidemic, we know that we always want to be thinking about some of the key populations that have borne a disproportionate burden. And largely in Canada, since the beginning of the epidemic, roughly half of the epidemic has occurred among gay, bisexual, other men who have sex with men. However, within that group, there are actually many folks who are doing as a population or as a group actually fairly well in terms of PrEP uptake. And we see disproportionately low uptake among sexual minority men who may face intersecting identities that have been historically underrepresented. So, for example, racialized GBM, gay, bisexual, other men who have sex with men, Black, Indigenous, Two-Spirit individuals are overrepresented. And then when we think about other populations aside from sexual minority men, as we mentioned a moment ago, Indigenous populations in some parts of the country. Again, it's quite varied, right? There's many, many Indigenous identities and communities across this huge land, of course, but certainly in some settings, notably in the Prairie Provinces of Saskatchewan and Manitoba, it is really quite dire. The numbers that we're seeing. And there's simply a need for much, much more resourcing there. Finally, I think I would just point out that there's an enormous gender gap with PrEP uptake. We know that relative to HIV diagnoses, which is not quite the same thing as new HIV infections necessarily. So it's an important nuance there, but at least relative to HIV diagnoses, we know that there is far less PrEP uptake in women overall, both cisgender and transgender than in, for example, men, notably GBM. And then finally, there's been very low uptake among people whose risk for HIV acquisition might be related to the use of injection drugs. So really many disparate groups overlapping in some ways and a lot of complexity underlying who we need to be doing a better job of bringing PrEP to.

Dr. Blair Bigham:

In your article, you mention that in the 2017 guidelines, they may have had an unintended consequence of creating barriers to access that may affect some of the populations you just mentioned. What's changed in your most recent guideline to prevent those types of barriers?

Dr. Darrell Tan:

Yeah, thanks for raising that, Blair. It's a really important point. I think in 2017, just to set the stage a tiny bit, this was an era in which PrEP had just become approved by Health Canada. There was actually really a lot of reticence, reluctance, apprehension, even among scientific authorities at that time about the potential role of PrEP. There was a lot of fear and apprehension. And it was in that context that we put the guideline out and we gave some very specific suggestions on things that a clinician might take into consideration in deciding to say that PrEP was a good idea for somebody. And I think unintentionally, this did create a barrier, as you're pointing out, because it was perceived, interpreted, perhaps misinterpreted in some cases as criteria, as though the guideline was saying, do not use PrEP unless you can jump through these hoops. And that was certainly not the intent, but I can completely appreciate why it was interpreted and seen through that lens in many senses. We clearly recognized shortly after that, that that kind of gatekeeping was not at all what PrEP should be about, not at all what we intended. And we took a very deliberate approach in the 2025 update as a result to do away with that thinking. So we now say that in order to access PrEP, there's two broad categories of ways that someone could be connected to PrEP. One way is that the person themself might put up their hand, step forward and say, you know what, I want PrEP and say that to a provider of some sort. And we have a good practice statement in the guideline that very clearly says, now, if that happens, it is completely appropriate to prescribe PrEP to that individual. We want to do away with the kind of test, as it were, or idea that there's criteria that you must meet in order to deserve PrEP. Instead, we recognize there's a lot of reasons that someone may not be empowered, may not be able, may not be comfortable to talk to a health care provider about the specific circumstances of their life that might increase their chances of coming into contact with HIV. And we say, regardless, if someone's putting up their hand, we should be prescribing it to them.

Dr. Blair Bigham:

It makes sense to me to just give it out when people ask for it, for sure. But then I imagine, especially when we talk about the equity issues, there are many groups who, if they even know about it, they're unsure about it. How can a physician walk through the risk assessment with a patient to determine if a strong recommendation should be made from our side of the table as opposed to someone coming to us sort of self-identifying the risk?

Dr. Darrell Tan:

Absolutely, yeah. I think there's unfortunately no simple answer to that question, but there are a lot of tools out there that we undertook an exercise in putting together the guideline to review. So we did a systematic review to synthesize literature about these, what we call HIV risk tools. That's what they're commonly called in the literature. These are scoring systems or lists of criteria that a clinician could use to try to identify someone as having a higher than average risk of acquiring HIV, and in other words, really helping to identify folks who could benefit from PrEP. Now, what we learned from that exercise is that although there are a lot of good tools out there, particularly for sexual minority men, unfortunately, that's really not the case for most other populations and there's a huge need there. But nevertheless, by looking at that literature, we were able to find a number of common elements that we put forward as things that clinicians should be thinking about. And we point them to the various tools that do exist to encourage clinicians to think about. And we make that point that the other way that someone could come to PrEP is that a clinician actively considers whether the person in front of them could benefit. And we encourage clinicians to actively recommend PrEP to folks who could benefit, but maybe aren't aware of it, as you said, aren't coming in the door asking for it, maybe are coming in for a very different reason. But we want to encourage this to be worked into visits for contraception, visits for other aspects of sexual health, visits for mental health related concerns, a whole host of kind of routine preventive care settings as well, so that a diverse range of clinicians could be actively recommending it to many people who could benefit.

Dr. Blair Bigham:

My knowledge is old. Maybe a decade ago, I remember with PrEP, you were supposed to have blood work done pretty frequently, I think every three months or something like that, or get blood work done before starting PrEP. Has that all been brushed to the side now?

Dr. Darrell Tan:

Great question. The short answer is no. There are certain fundamentals of PrEP prescribing that we do still recommend be routine. And HIV testing is absolutely a fundamental aspect of PrEP delivery that we really can't get away from. And that's really important because the goal is to prevent HIV. If someone inadvertently does acquire HIV, we really need to know about it as soon as possible to link them to the services that could benefit them, and to make sure that the intervention, the drug that we would otherwise be prescribing as PrEP, isn't unintentionally causing harm by driving resistance. That risk isn't a huge risk, but it's a risk that does exist and we can't ignore it. In fact, one important caveat around the frequency of testing is that with the long-acting injectable formulation that cabotegravir we spoke about, the requirement actually, according to the regulatory label, is to do an HIV test around the time of each injection. So technically, that's even a little bit more frequently, in other words, two monthly. That being said, if I'll just briefly add, there are some other ways in which we really have thought about how we could simplify PrEP delivery. One example of that is that we used to be recommending routine testing of creatinine for renal function at every three-month interval because of the small risk of kidney issues with the original formulation of TDF-FTC. We now scaled that back a little bit to say, maybe this isn't something that every single person needs, and it should really be tailored to the underlying renal risk of the person in front of us. And certainly with the other regimens where there's no particular risk of end-organ dysfunction or toxicity, it's not recommended at all.

Dr. Blair Bigham:

Darrell, before we let you go, tell us about any advances that we have for post-exposure prophylaxis.

Dr. Darrell Tan:

Yeah, in the space of PEP, there perhaps hasn't been as much groundbreaking science that's totally changed the paradigm. But importantly, there have been a number of different regimens that have been now studied as PEP and demonstrated to be associated with good outcomes. When we talk about PEP, the main outcomes we're interested in are tolerability of the regimens, such that people can finish taking the whole 28 days of pills. And we now have a number of regimens that are based on integrase inhibitors, notably those that include bictegravir and those that include dolutegravir, together with two other agents, that are very safe, very well tolerated, and associated with excellent outcomes. So those are now our recommended options, but there's a host of others that we also think are reasonable alternatives. That means that virtually anyone we think who finds themselves needing PEP after an exposure should be able to find an option that will work well for them.

Dr. Blair Bigham:

And first-line therapy is one pill a day, 28 days, and then you're done.

Dr. Darrell Tan:

So the standard is a dose per day for 28 days, and then you're done. One of the regimens that we recommend is indeed one pill a day. The other one that we recommend is actually two pills a day. But there are many others that are one pill, more than one pill, that, again, can suit different circumstances that someone might find themselves in.

Dr. Blair Bigham:

Gotcha. And is there a reason a clinician might recommend a two-pill-a-day regimen instead of a one-pill-a-day?

Dr. Darrell Tan:

It might be related to very pragmatic issues around cost, for example, that there's a modest cost-benefit. And if the number of pills that they're taking at a time isn't hugely important to them, then that might be outweighed by the cost-benefit, for example. There's also simply just a lot of data supporting that as an excellent option that has comparable outcomes. And as a result, we think that either of these are very reasonable and recommended first-line PEP options.

Dr. Blair Bigham:

Darrell , thank you so much for joining us.

Dr. Mojola Omole:

Thank you.

Dr. Darrell Tan:

Thank you so much for having me.

Dr. Blair Bigham:

Dr. Darrell Tan is the lead author of the new guidelines on HIV pre- and post-exposure prophylaxis. He's a clinician scientist in the Division of Infectious Disease at St. Michael's Hospital and associate professor in the Department of Medicine at the University of Toronto.

Dr. Mojola Omole:

We're going to speak now with someone working on the ground in one of these communities where PrEP awareness is lower. Natasha Lawrence is a community health worker at the Women's Health and Women's Hands Community Health Centre in Toronto. She leads a project to increase PrEP awareness and access for Black women. Natasha, thank you so much for joining us tonight.

Natasha Lawrence:

Hi, thank you so much for having me.

Dr. Mojola Omole:

So when we spoke to Dr. Tan, he acknowledged in our conversation that PrEP isn't reaching certain communities, women, racialized communities, Black women, Indigenous communities, the way they've been reaching gay men, men who have sex with men, bi and trans. How familiar with PrEP are the women you're working with?

Natasha Lawrence:

Yeah, so in my experience in the many consultations, the community discussions, the conversations that I've had in community, oftentimes it is their first time hearing about PrEP. So they didn't even know that it was something that existed. And if they did hear about it, they heard about it in the context of the gay bi men who have sex with men who utilize PrEP. So they didn't even think that PrEP was something that was geared towards them or something that they could use.

Dr. Mojola Omole:

What is their response when you share with them the risks that women, Black women face in terms of HIV rates?

Natasha Lawrence:

Oftentimes there's a low risk perception that folks may have when it comes to their actual HIV risk. So they may, if you ask them, you know, what do you think your risks are? They may say, oh, yeah, I think I'm pretty low risk. But then when you start to ask around about specific behaviors or activities, then you start to be able to have that discussion around how perceived risk may be low. But when actually looking at the actual behaviors and activities, that it actually potentially is a bit higher than what you expected. Being able to have those discussions and also, I think, being able to have those discussions intersectionally has been really helpful for our clients to really see the different ways in which risk can manifest. So, for example, including the intersection of gender-based violence, if there are unequal power dynamics within a relationship and how that can impact one's ability to choose prevention methods that are a little bit more obvious. For example, condoms, right? Where one partner may not want to use condoms, another partner might want to use condoms, but there's a power imbalance. So it's difficult to navigate that.

Dr. Mojola Omole:

How do you tell them that PrEP can change those power dynamics or can help mitigate maybe some perceived risk because of the power dynamics?

Natasha Lawrence:

It's basically framing it in the sense of you have this extra layer of protection that is something that you could utilize. And because this is your own private health information, it's not something that you have to make folks aware of that you are accessing PrEP or that you are using PrEP. So if there is an issue around gender-based violence and around unequal power dynamics within a relationship, then using something like PrEP puts more power into the person's hands who has the lack of power within that relationship. And especially with the advancements of the long-acting injectable, where it doesn't require a person to carry medication in the event that maybe potentially a partner could find medication and say, hey, what is this? If it was something that someone was trying to keep private. And it really just goes back to there needing to be choice and options for folks. And the fact that there needs to be a better job being done at ensuring that communities that need it are also aware that this is something for them, that this is something that they can use.

Dr. Blair Bigham:

Natasha, this sounds like really pragmatic advice that you're giving people here. Can you go a little bit further for me? For people who don't have the supports and the experience that Women's Health and Women's Hands has, what other language or phrases can a frontline clinician, say a family doctor, use when they're only having this conversation maybe a couple times a month instead of every day?

Natasha Lawrence:

I think that what frontline clinicians, whether those are family doctors or other health care professionals, what I think the number one thing that they can do is initiate the conversation, number one, because that is one of the largest barriers that gets oftentimes reported, not just by the clients, but also by the providers themselves that are saying that sometimes they're not sure on how to initiate the discussion. So we try to frame it in the same way that, like, if someone has a family history, for example, of diabetes, right, or any other type of chronic illness, for example, you may ask them follow-up questions upon their visits, right? Ask them if anything's changed in their life, in their situation, in their diet, in their, whatever the potential factors are that can increase their risk of either developing this chronic illness. So why not do the same thing when it comes to sexual health? For example, there's a question that we ask when we do testing. We ask folks, you know, do you have one regular partner, casual partners, both, and we'll get that they have one regular partner. But then we also ask the question, does your partner have sex with other people, right? And oftentimes the response that we'll get is, well, I hope not, right? Or I don't think they are, or I'm not 100% sure. Or sometimes we will get the response where they say, actually, yeah, sometimes they do, right? Whether that's an agreed-upon choice or not, right? So that's the opportunity there for, that's where we take the opportunity to say, it sounds like you have one regular partner and you all have discussed, or it's just been, you know, somewhat agreed upon between you two that you won't use condoms because it's just you. But it sounds like you still, you have some uneasiness or unsureness around your partner's fidelity or your partner having other sexual partners. So if that is ever a concern for you, there's this thing called PrEP that you could take and that's how, and then we go into the conversation, right?

Dr. Mojola Omole:

What can public health do to increase their awareness and just more uptake of PrEP in vulnerable populations? You know, women, Black women, Indigenous communities, IV drug users. What can public health do to just increase that awareness and acceptance of PrEP?

Natasha Lawrence:

Yeah, public health, I think, can do a lot when it comes to the way in which they promote, the way in which they spread awareness. And it's also important that public health does this with the consultation of the communities that they're going to be promoting and spreading this awareness to. Because representation is important, but not if it increases stigma for that community. So it's really important how it needs to be done very intentionally and that cultural relevance, that cultural safety, that those pieces need to be included in the messaging. I think public health working in connection with frontline organizations who are doing the work and who are work and including community members' voices in those discussions is something that could really help to build a strong awareness campaign where women, and particularly Black women, Indigenous women and women who have other factors that increase risk can actually see themselves in PrEP as an option, can actually see that as an option for themselves. Because until we at least increase awareness of it, like that's the first tip of the iceberg. There's a few other things we have to do as well too, but you can't make a choice about something if you don't know about it.

Dr. Blair Bigham:

Awesome, thank you so much.

Thank you so much, Natasha. Natasha Lawrence:

is a community health worker at Women's Health and Women's Hands Community Health Center, and she joins us from Toronto. So Blair, can I jump in and say my first thought?

Dr. Blair Bigham:

Yeah, go for it.

Dr. Mojola Omole:

Okay, so my family doctor always asks me when I visit, even if we're like doing like a quick check for my son, it's like, you know, how it's going on? Are you dating anyone? I thought she was just like being nosy, but maybe this is what she was doing. Shout out to Joanna Sachs.

Dr. Blair Bigham:

She's just assessing risk.

Dr. Mojola Omole:

Exactly, but she said it in a way, I thought we were doing girl talk. I didn't actually clock it as that, oh, she's actually talking about my sexual health. So anyways, just that popped into my head after we were talking to Natasha.

Dr. Blair Bigham:

And I don't think my family doctor has ever asked me how my sex life is, or if I'm in a relationship or anything like that. For me, it was always like having to request PrEP and people kind of just sidestepping the conversation being like, sure, here's a prescription, but never actually getting into the conversation. And that's me as a white guy talking to another white male physician. And it was still kind of, like, a little bit taboo. Now, this is not in the last few years, this is going back a bit, but I feel like it's probably even worse for many other populations. It just seems like all of the attention has gone into the LGBT community and other communities at risk have basically been forgotten about.

Dr. Mojola Omole:

Yeah, and I do think that, you know, in terms of public health, you go for where you're going to get your bang for your buck because, you know, it's limited resources. But now that we're actually able to see there's a wider landscape of different groups who are getting HIV at higher rates than the traditional groups that we've assumed, that we need to, this is the time to shift the lens into those groups to be able to de-stigmatize HIV itself and also PrEP use and PEP.

Dr. Blair Bigham:

Yeah, I guess as the conversation gets more nuanced, you know that you're moving in the right direction because it's no longer sort of just those top ticket items. And now it does seem like we're in that more nuanced territory.

Dr. Mojola Omole:

Yeah, and I do, I think part of it is also like some of the discomfort that us physicians have talking about sex and not wanting to admit that, everybody is having sex. And like Salt-N-Pepa said, let's talk about sex. And that probably would make it better.

Dr. Blair Bigham:

It does seem like something that's hard for a lot of people to bring up, either on the physician end or on the patient end. And I also wonder if this is part of the importance of that longitudinal care that 20 percent of Canadians can't access because they don't have a family doctor. This isn't something that you're going to talk about in a one-off walk-in clinic conversation, I imagine. Or if you do, you're probably not going to have a lot of success getting through to the heart of the issue. You know, even in our conversation with Natasha, there's a lot of sort of sidestepping the actual question, right? Like it seems like it's very delicately positioned a lot of the time just to establish risk, let alone bringing up de-risking. But what I really liked about Natasha's conversation, and we could probably count in the transcript the number of times she used the word choice. Like she's really wrapping all of this up in a message of empowerment, right? Like there are options for you to de-risk. Here's what they are. I feel like that is a winning approach. You know, I'm here for you to make choices because there are choices that you can make that help de-risk you.

Dr. Mojola Omole:

And I also do think that oftentimes people do get their misinformation from social media. I'll be honest, when I first saw this article, it's because I finished watching Cardi B on Instagram Live talking about how more women have to use PrEP. And I do think those types... And she was just like, yeah, y'all be out of here having sex. If you're not using PrEP, you're going to catch... Like, it was just very interesting to see the amount of people who were interested in that live. And don't ask me why I was watching Instagram Live of Cardi B. But, you know, I do think having more of those conversations widely open in social media is really important. And that makes it easier also, as practitioners, when someone does come in, maybe they do come into a walk-in clinic and they're like, well, you know, I want to have PrEP because I don't have a family doctor. You just you dispense it and then you give them requisition for blood work in two months. And I think that knowing that, as Daryl had said, that the HIV rates are not going down, but they're actually slightly increasing, is troublesome, especially when we have so many ways to not contract HIV, that there is a sort of urgency in, from a public health perspective, to get the information out regarding PrEP and PEP for not just one community, but for all communities. And I think as physicians, I know both of us are not primary care physicians, but maybe I can start having that conversation, right? Because I do see patients for a variety of different things. And be like, hey, have you thought about PrEP? You know, here's some information. Maybe next time you see your family doctor, you should bring this up. That type of thing.

Dr. Blair Bigham:

Right. And we'll know over time if rates continue to go up or if we can get them to change direction. That's it for this episode of the CMAJ Podcast. The guideline is in our show notes. Feel free to check out the link. The podcast is produced by PodCraft Productions. Neil Morrison is our producer. Catherine Varner is deputy editor at CMAJ, as well as senior editor for the podcast. If you have a chance, please like or share our podcast wherever it is you download, or leave a comment. It helps us get the message out. I'm Blair Bigham.

Dr. Mojola Omole:

I'm Mojola Omole. Until next time, let's talk about sex.