GUIDELINE ALERT: Should you be prescribing more 2-1-1? HIV PrEP
- Dr. Simon Moore
- 3 days ago
- 3 min read
It's in the news. Get ready for patient requests: New options, new rules, and the "2-1-1" strategy you need to know.
Major Canadian news outlets are reporting that HIV PrEP guidelines have changed, and when they hear that, patients could soon be asking YOU for a PrEP prescription…instead of the other way around!
Things have changed a lot in PrEP: in the last guidelines 8 years ago, we were told to recommend if high risk, and if patients didn’t meet risk criteria, we wouldn’t prescribe.
That’s now out with the release of the 2025 Canadian guideline on HIV pre-exposure prophylaxis (PrEP). We now should help them choose the best option.
Before scrolling down, ask yourself: For which specific patient population is "On-Demand" (2-1-1) PrEP strictly contraindicated?
Side note: We’re always compiling the latest Canadian guidelines you need to know for your clinic & the exam.
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Tl;dr: - If they ask you for PrEP, they qualify for PrEP. Daily dosing is the option to know for all patients at risk (one pill a day Truvada, which is Emtricitabine/tenofovir).
The 2025 update expands our toolkit significantly. In addition to daily dosing, we now have "On-Demand" dosing and a new injectable option (plus another one expected in 2026) that changes the game for adherence.
The most buzz-worthy addition is Long-Acting Injectable Cabotegravir (CAB-LA) injected every 2 months. This is a game-changer for patients who struggle with daily adherence or prefer discretion. Downside: it’s expensive and not covered for most patients.
We also need to get comfortable with "On-Demand" or "2-1-1" dosing. This involves taking two pills 2-24 hours before sex, one pill 24 hours later, and a final pill 24 hours after that. This is strongly recommended for cisgender men and transgender women who have sex with cisgender men.
Crucially, this is NOT recommended for cisgender women or for preventing HIV from injection drug use, as existing data shows it’s not as effective in these populations (though studies are pending for even longer-acting subcutaneous PrEP. It is also contraindicated in patients with Hepatitis B due to the rare but real risk of viral flares upon stopping.
Practical PrEP barrier: every province and territory has different rules for access and coverage. So, while the Canadian guidelines to know for the exam have changed, you might still not be able to access or get coverage for PrEP for your patients…yet.
Come join us at Vital FM Update for in-practice docs and NPs, or The Review Course CCFP Exam Prep!
EXAM TIP: On a Short Answer Management Problem (SAMP) or Simulated Office Oral (SOO), pay close attention to the patient's anatomy and gender identity when selecting a regimen. If you prescribe "On-Demand" (2-1-1) PrEP to a cisgender female patient or a patient with chronic Hepatitis B, this would likely cost you marks. Always check Hepatitis B status before initiating on-demand protocols. More Exam Essentials
Image credit: By Tony Webster from Minneapolis, Minnesota, United States - Truvada for HIV PrEP - Gilead Blue Pills, CC BY-SA 2.0, https://commons.wikimedia.org/w/index.php?curid=84687221