Updated Canadian HIV prevention guidelines released
DECEMBER 18, 2025
CATIE
- Researchers have updated guidelines on HIV pre- and post-exposure prophylaxis (PrEP and PEP)
- The guidelines support prescribing PrEP to individuals who request it based on self-assessed risk
- The strength of evidence and accessibility of newer and injectable PrEP options are also outlined
New HIV infections continue to occur in Canada. Biomedical prevention—which consists of pills or injections containing anti-HIV medicines—is an important part of several strategies to prevent the transmission of HIV. A team of leading Canadian HIV experts reviewed evidence for the use of these medicines and updated the Canadian guidelines for reducing the risk of HIV infections.
This CATIE News story summarizes key developments in the updated guidelines.
According to the research team that wrote the guidelines, the document is meant “to support clinical decision-making in primary care, infectious diseases, emergency medicine, sexual health, nursing, pharmacy and related disciplines, and to support community workers who play an important role in promoting [HIV prevention].”
The guidelines focus on two key biomedical modalities:
- PrEP – HIV pre-exposure prophylaxis (taking anti-HIV medicines before potential exposure to the virus)
- PEP – HIV post-exposure prophylaxis (taking anti-HIV medicines after potential exposure to the virus)
The researchers emphasize the role of clinicians in “providing evidence-based information to people who could benefit [from PrEP and PEP]” and encourage them “to use information in this guideline to counsel potential users on their safety and efficacy.”
The guidelines state that “all sexually active adolescents and adults, and those who inject drugs, should be counselled regarding PrEP and PEP as part of a comprehensive approach to preventing HIV and other sexually transmitted and blood borne infections (STBBIs).” The guidelines note that these populations “should be made aware of the excellent safety and efficacy profile of PrEP and PEP, and how they can be accessed.” Furthermore, they state that “this information should be framed in a positive light to counteract the stigma and apprehension that sometimes surrounds PrEP and PEP.”
PrEP – HIV pre-exposure prophylaxis
The guidelines state that “it is appropriate to prescribe PrEP to adults and adolescents who request it. If individuals actively seek out PrEP based on self-assessed HIV risk, it is appropriate to prescribe PrEP. There are many reasons people may not disclose HIV risk behaviours to health care providers, including shame, medical mistrust, and structural barriers linked to homophobia, transphobia, racism, colonial practices, HIV stigma, and other forms of discrimination. Providing PrEP to those who request it decreases such barriers. Providers should make this safe and effective intervention available to the widest possible array of users, rather than ‘gatekeeping’ access.”
The guidance encourages clinicians to “actively offer PrEP to individuals in their care when risk for HIV is identified.” Furthermore, the guidelines state that “many individuals underestimate their HIV risk and may not be aware of PrEP.”
Opportunities for assessing HIV risk and prescribing PrEP when necessary
The guidelines note that “many types of health care encounters provide opportunities to offer PrEP,” including the following:
- testing for sexually transmitted infections (STIs)
- reproductive health (contraception, pregnancy-related care, cervical cancer screening)
- harm reduction service provision
- mental health and addiction services
- primary care
Although the researchers did not recommend a specific HIV risk assessment tool, they noted that the following are factors found in many assessment tools that “may prove useful in identifying HIV risk,” including:
- condomless intercourse (particularly if outside a closed relationship)
- previous bacterial STIs (chlamydia, gonorrhea, syphilis)
- greater number of partners
- use of methamphetamines or inhaled nitrates in association with sex
- sharing equipment for drug use
The research team notes that although “most HIV infections in Canada are related to sex between cisgender men, heterosexual activity, and injection drug use […], people of all sexes and genders may benefit from PrEP and should be actively included in programs and policies. Clinicians should elicit information about patients’ anatomy and sexual partners (for instance, partners’ anatomy, partners’ gender identities, relationship type, frequency of encounters) in a culturally sensitive and affirming manner to determine which recommendations apply.”
PrEP options in Canada
The researchers note that “multiple safe and effective PrEP regimens—including daily pills, event-based or ‘on-demand’ pills, and a long-acting injectable medication—are now available in Canada. The diversity of choices renders it increasingly possible to find suitable options for all who could benefit.”
The guidelines outline specific anti-HIV drugs or combinations of such drugs for PrEP, such as the following:
- oral TDF (tenofovir DF) + FTC (emtricitabine) – sold in a pill called Truvada and available in generic formulations; it contains 300 mg of TDF and 200 mg of FTC
- oral TAF (tenofovir alafenamide) + FTC – sold in a pill called Descovy; it contains 25 mg of TAF and 200 mg of FTC
- long-acting injectable cabotegravir (LA-CAB) – sold as Apretude; it contains 600 mg of cabotegravir
The guidelines grade their recommendations as either “strong” or “weak” for different forms of PrEP for different populations. Please read the guidelines for complete details.
TDF + FTC
The research team states that “daily oral tenofovir DF + FTC is the most widely evaluated PrEP regimen, with high-quality studies documenting excellent safety, efficacy, and acceptability in multiple populations, and nearly 100% efficacy at decreasing HIV acquisition risk if used consistently.” What’s more, the researchers note that “oral tenofovir DF + FTC is the only approved PrEP product currently available in generic formulations in Canada, rendering it the most affordable.” They state that an analysis of 10 placebo-controlled trials showed that the frequency of adverse events is similar to that with placebo. In rare cases, extended use of tenofovir DF + FTC can affect kidney and bone health.
The guidelines make recommendations about the frequency of taking TDF + FTC for PrEP (daily or “on-demand” usage) and for different populations. In general, the guidelines make a “strong” recommendation for the use of daily TDF + FTC.
TAF + FTC
The guidelines also mention the use of TAF + FTC, which is a highly effective PrEP combination. They note that in a large randomized clinical trial, the combination of TAF + FTC “was associated with fewer adverse effects on bone mineral density and [kidney health], but greater weight gain.” Therefore, the guidelines state that “[TAF + FTC] may thus be preferred in people with kidney problems or osteoporosis. However, lack of a generic version means it is more costly and not currently publicly reimbursed in most jurisdictions.”
The guidelines grade their recommendation for the use of TAF + FTC as “weak.”
Long-acting injectable cabotegravir
The guidelines make a “strong” recommendation for the use of long-acting injectable cabotegravir in “HIV-negative cisgender men and transgender women in whom risk of HIV acquisition is related to sex with cisgender men.” They also make a “strong” recommendation for LA-CAB as an option for “HIV-negative cisgender women in whom risk of HIV acquisition is related to heterosexual activity.”
The guidelines’ recommendations about LA-CAB for other populations, such as people who use drugs and heterosexual men, are graded as “weak.”
After cessation of LA-CAB, low levels of cabotegravir can persist in the body for up to one year after the last injection. The guidelines note that there is a need for patients to “use another HIV prevention modality (for example, oral PrEP) for one year after discontinuation, starting two months after the last injection, if at continued HIV risk.”
PEP – HIV post-exposure prophylaxis
The guidelines explain the use of PEP and in what circumstances it can be used. They note that PEP should be initiated as soon as possible after [potential exposure to HIV], up to a maximum of 72 hours afterward.
The research team strongly recommends one of the following two regimens for PEP:
- a pill containing bictegravir + TAF + FTC – sold as Biktarvy; taken once daily for 28 consecutive days
- a pill containing dolutegravir (Tivicay) + a pill containing TDF + FTC – both pills taken once daily for 28 consecutive days
The researchers reviewed evidence about these drugs when used as PEP and found that they were effective and generally well tolerated.
The guidelines note that prescribers may consider factors such as “drug availability, cost, pill burden, and pharmacologic [issues]” when choosing which regimen to use for PEP. However, the guidelines also state that “many other PEP regimens may be considered, providing flexibility (allowing regimen switches as needed) when clinicians are limited by drug availability, costs, drug interactions, drug intolerances, or other factors.”
A comprehensive package
The guidelines state that “both PrEP and PEP should be part of a combination prevention strategy that includes behavioural interventions (e.g., condoms, sterile injecting equipment, risk reduction counselling), biomedical interventions (e.g., treatment of people living with HIV, testing, treatment and prevention of STIs) and attention to syndemic conditions that contribute to HIV risk (e.g., depression, substance use, housing instability) as appropriate.”
Showing the way
What’s more, the guidelines add that “because lack of PrEP and PEP awareness among key populations and clinicians is a common barrier to implementation, public health officials, professional societies, and other trusted authorities should play leadership roles in promoting these strategies in collaboration with community organizations and tracking uptake in conjunction with HIV surveillance data.”
Additionally, the guidelines state that “health systems should strive to engage a broad number and range of clinical providers in PrEP and PEP delivery, including family physicians and other specialists, nurses, nurse practitioners, and pharmacists, where provincial scope of practice allows, or under appropriate delegation of responsibility. Non-prescribing health care and service providers should be encouraged to have roles in PrEP and PEP delivery, including clinical monitoring, screening and management of STIs, counselling on risk reduction, and adherence support.”
For the future
The updated guidelines were developed through the Canadian Institutes of Health Research (CIHR) the Pan-Canadian Network for HIV and STBBI Clinical Trials Research (CTN+). The document is comprehensive, up to date and chock-full of useful information. We encourage anyone interested in PrEP and PEP to read the guidelines, available from the CTN+.
The guidelines will be updated in the future as the need arises.
—Sean R. Hosein
Resources
Canadian guideline on HIV pre- and postexposure prophylaxis: 2025 update
CTN+
REFERENCE:
Tan DHS, Hull MW, Onyegbule SO, et al. Canadian guideline on HIV pre- and postexposure prophylaxis: 2025 update. CMAJ. 2025; in press.
From Canadian AIDS Treatment Information Exchange (CATIE).
This content was originally published by CATIE, Canada’s source for HIV and hepatitis C information.
Source: CATIE:
https://www.catie.ca/catie-news/updated-canadian-hiv-prevention-guidelines-released
For more information visit CATIE's Information Network at www.catie.ca
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