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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Celiac disease affects between one and two percent of Canadians, yet many patients wait years before receiving a clear diagnosis. On this episode of the CMAJ Podcast, the hosts speak with two contributors to the CMAJ review article Diagnosis and management of celiac disease about the condition’s diverse clinical presentations, appropriate testing strategies, and the practical realities of long-term dietary management.

Jedid-Jah Blom, a registered dietitian at the McMaster Celiac Disease Clinic and researcher at the Farncombe Family Digestive Health Research Unit at McMaster University, shares her own experience being diagnosed and living with celiac. She explains how patients must identify hidden gluten sources in ingredients like dextrin and malt, and why cornmeal or corn flour products may be contaminated. Blom outlines the risks of cross-contamination and dining out challenges, emphasizing whole gluten-free grains over processed products that lack fortification.

Dr. Maria Ines Pinto-Sánchez, a gastroenterologist at Hamilton Health Sciences and director of the Celiac Clinic at McMaster University, explains why celiac is called a chameleon disease. She notes that about 30 percent of patients present with gastrointestinal symptoms, while others may have brain fog, fatigue, or anemia. She describes how TTG antibodies plus total IgA are used for screening, with positive results requiring endoscopy and biopsies for confirmation. Dr. Pinto-Sánchez emphasizes that patients should not start a gluten-free diet before testing. She discusses ongoing monitoring including TTG levels, bone density, and nutrient deficiencies.

For physicians, the discussion highlights the need for a low threshold when testing TTG antibodies in patients with unexplained fatigue, brain fog, or gastrointestinal symptoms. Both guests stress the importance of completing diagnostic testing before patients begin a gluten-free diet and arranging early dietitian referral.

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This episode of the CMAJ Podcast explores how physician identity can influence patient expectations, and how those expectations may contribute to gender, race, and immigration status pay gaps. The discussion builds on the CMAJ article “Family physician pay inequality: a qualitative study exploring how physician responses to perceived patient expectations may explain gender, race, and immigration status pay differences”.

Dr. Monika Dutt, a family physician, public health and preventive medicine specialist, and PhD candidate in health policy at McMaster University, explains how the study’s interviews with 55 family physicians across Ontario revealed patterns linking patient expectations to physician identity. She describes how gender and cultural background influence the types of visits physicians are asked to provide, and how these interactions may affect their earnings under fee-for-service models.

Dr. Meredith Vanstone, professor in the Department of Family Medicine at McMaster University, outlines how physicians adapt to explicit and inferred patient expectations and the income implications that follow. She discusses how these expectations are shaped by identity and why the resulting adjustments in care can lead to financial penalties for some physicians while improving patient relationships and trust.

The guests highlight how remuneration structures can either amplify or mitigate these inequities. They suggest that moving toward salary or time-based models could help reduce the impact of physician identity on income while supporting equitable, patient-centred care.

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A recent article in CMAJ, Mental health service use among Black adolescents in Ontario by sex and stress level: a cross-sectional study, reveals how patterns of mental health service use among Black youth shift with the level of psychological distress. Lead author Mercedes Sobers, a PhD candidate in epidemiology at the Dalla Lana School of Public Health and research coordinator at the Centre for Addiction and Mental Health, joins the podcast to unpack the findings and their implications.

The study found that Black male youth had higher odds of accessing services than white male youth when at low levels of distress but lower odds of accessing services at high levels. Black female youth had lower odds of service use than white female youth at both low and high distress levels. Mercedes explains how these patterns may reflect how behaviour is interpreted: Black boys may be referred to services more often at lower distress levels but steered toward more punitive responses when distress rises. For Black girls, she points to adultification and cultural mismatches in care.

Dr. Amy Gajaria, a psychiatrist at the Centre for Addiction and Mental Health and associate scientist in the Margaret and Wallace McCain Centre for Child, Youth and Family Mental Health, describes how programs like AMANI aim to provide culturally adapted care and build trust with Black youth. She shares how early encounters with the system can shape future engagement with care.

For physicians, the discussion underscores the importance of culturally sensitive care that embraces and reflects the experiences of Black youth, creating more meaningful and effective pathways to support.

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Rates of depression in Canada are rising, but a new CMAJ guideline advises against universal screening in primary care. The Canadian Task Force on Preventive Health Care found no evidence that routinely administering depression questionnaires to all adults improves outcomes and raised concerns about false positives, overdiagnosis, and strain on limited mental health resources.

Dr. Eddy Lang, lead author of the guideline and professor of emergency medicine at the Cumming School of Medicine, University of Calgary, explains the rationale behind the Task Force’s recommendation. He describes how the review found no benefit from universal screening in improving depressive symptoms or quality of life and that commonly used questionnaires frequently misidentify patients, generating false positives and false negatives. Lang emphasizes that while physicians should remain attentive to patients’ mental health, questionnaires are not the answer to identifying depression in the general population.

Dr. Jennifer Young, a family physician in Collingwood, Ontario, and past president of the Ontario College of Family Physicians, reflects on what this recommendation means for everyday practice. She agrees that routine screening would add little value, pointing out that vigilance and continuity of care already allow family doctors to identify depression through clinical judgment and patient relationships. She underscores that time spent on universal questionnaires could displace care for patients with other pressing needs.

For physicians, the key takeaway is clear: be alert to signs of depression, especially in vulnerable patients, but don’t rely on blanket screening tools. Thoughtful conversation, familiarity with patients, and clinical intuition remain the best ways to identify those who need help.

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Evidence is mounting that cannabis use can trigger first episode psychosis, particularly among young people. On this episode of the CMAJ Podcast, hosts Dr. Mojola Omole and Dr. Blair Bigham speak with researchers and a patient with lived experience about what the data show, who is most at risk, and how clinicians should respond.

Bailey Peterson, a 26-year-old student from Mississauga, Ontario, describes how her cannabis consumption progressed from casual use to daily, all-day use of high-potency products. She recounts her experience with psychosis, the challenges of her hospitalization, and what she wishes she and her clinicians had known earlier.

Sophie Li, a fourth-year medical student at the University of Ottawa and an author of the CMAJ article Cannabis and psychosis, explains how rates of schizophrenia associated with cannabis use disorder have risen sharply in recent years and notes that young men in their late teens and early 20s are most at risk. For women, the highest risk tends to occur later, in their late 20s and 30s. Dr. Marco Solmi, psychiatrist and medical director of On Track: The Champlain First Episode Psychosis Program, reviews the evidence supporting a causal link between cannabis and psychosis and discusses how clinicians can distinguish cannabis-induced psychosis from schizophrenia, as well as approaches to treatment and patient education.

For physicians, the takeaway is clear: cannabis use—particularly before age 25—carries worrisome psychiatric risks, and psychosis can occur even without very high levels of consumption. Detailed cannabis histories, psychoeducation, and early counseling should be part of routine care for patients at risk of psychosis.

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Spinal and bulbar muscular atrophy (SBMA), also known as Kennedy’s disease, is a rare, progressive neuromuscular disorder that is often misdiagnosed and diagnosed late. A new CMAJ guideline offers Canadian-specific recommendations for its recognition and management.

On this episode we hear from Richard Paul, a former bus driver from Saskatoon, who recalls how his symptoms began suddenly with an inability to bite into a sandwich and, over the years, progressed so gradually he barely noticed the loss of strength. His experience captures both the slow, inexorable progression of SBMA and the uncertainty of living without a diagnosis for decades.

Mr. Paul was finally diagnosed by Dr. Kerri Schellenberg, a neuromuscular neurologist at the University of Saskatchewan and lead author of the guideline. She explains the clinical hallmarks of SBMA, its overlap with conditions such as ALS, and the non-motor manifestations that require attention. She also discusses the higher prevalence among Indigenous populations in Canada and how her team worked with a community Guiding Circle to ensure the recommendations reflect culturally appropriate care.

For physicians, the guideline provides practical direction to support earlier recognition, timely referral, and multidisciplinary management. While there is no cure, coordinated care can significantly improve quality of life for people living with SBMA.

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Homelessness among pregnant and parenting people in Canada is rising, with grave consequences for both parents and children. On this episode of the CMAJ Podcast, Dr. Mojola Omole and Dr. Blair Bigham explore the scope of the problem and the supports that can improve outcomes for parents and children.

Dr. Stéphanie Manoni-Millar, co-author of the CMAJ commentary Tackling the crisis of homelessness amongst pregnant and parenting people in Canada, explains who is most affected and what risks they face. She describes a predominantly young population, many of whom are homeless or experiencing precarious housing. She highlights the health consequences for children, including developmental delays, infections, and increased rates of anxiety and depression, and stresses the importance of affordable housing and integrated services to support families.

Nerina Chiodo, a social worker in Toronto with MotherCraft Breaking the Cycle, shares insights from more than two decades of supporting pregnant people who are homeless. She describes what stability can look like when housing, addiction treatment, mental health services, and social supports are coordinated, an approach often described as wraparound care. Chiodo also reflects on the stigma many of her clients face in medical settings and underscores the importance of small acts of validation and compassion from clinicians.

Both guests emphasized that people experiencing homelessness during pregnancy often want to parent and demonstrate resilience despite immense challenges. They urged clinicians to approach this population without stigma, to recognize the risks faced by children, and to understand how even brief, supportive interactions can influence whether patients return for care.

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Smoking remains the leading cause of preventable disease and death in Canada. A new clinical practice guideline published in CMAJ on tobacco smoking cessation outlines evidence-based behavioural and pharmacological interventions to help patients quit. On this episode of the CMAJ Podcast, Dr. Mojola Omole and Dr. Blair Bigham speak with Dr. Eddy Lang, co-author of the guideline, and Dr. Andrew Pipe, a pioneer in smoking cessation research and practice, about how clinicians can better support patients ready to stop smoking.

Dr. Eddy Lang, an emergency physician and professor at the Cumming School of Medicine, describes how the Canadian Task Force on Preventive Health  assessed a wide range of interventions to make sense of a complex evidence base. He outlines the strong recommendations in favour of pharmacological therapies such as nicotine replacement therapy, bupropion, varenicline, and cytosine, as well as behavioural interventions including counselling, group therapy, and quit lines. He also explains the conditional recommendation against e-cigarettes, citing limited long-term safety data and concerns about normalizing their use among youth.

Dr. Andrew Pipe, professor of medicine at the Ottawa Heart Institute and co-creator of the Ottawa Model of Smoking Cessation, offers practical guidance for everyday practice. He highlights how a state-of-the-art smoking cessation intervention can be delivered in as little as 26 seconds. This brief approach is non-judgemental, empathetic, and emphasizes that help is available whenever the patient is ready.

He also stresses that clinicians should treat cessation pharmacotherapy like any other chronic disease medication—titrated to patient response and continued as long as needed. Pipe emphasizes that nicotine replacement therapy is often underdosed, which undermines its effectiveness. He encourages physicians to combine long-acting patches with rapid-acting forms such as gum or lozenges, and to adjust dosing based on patient comfort, allowing individuals to guide their own titration.

This episode underscores that even brief encounters can open the door to meaningful change for patients ready to stop smoking. Asking about smoking status, offering practical, evidence-based assistance, and prescribing cessation therapies in sufficient doses can effectively help patients quit.

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—This is an encore presentation of an episode previously published June 30—

On this episode of the CMAJ Podcast, hosts Dr. Mojola Omole and Dr. Blair Bigham speak with two authors of the latest “Hypertension Canada guideline for the diagnosis and treatment of hypertension in adults in primary care”

The discussion reflects a shared urgency: despite past successes, Canada’s hypertension control rates are declining. The new guidelines aim to reverse this trend by simplifying diagnosis and treatment for frontline clinicians.

Dr. Rémi Goupil, a nephrologist and clinician researcher at Sacré-Cœur Hospital in Montreal, and Dr. Greg Hundemer, a nephrologist and clinician scientist at The Ottawa Hospital, explain that the updated guideline is deliberately designed for primary care providers. They highlight key shifts: lowering the diagnostic threshold for hypertension to  ≥ 130/80 mm Hg, simplifying blood pressure targets, and emphasizing accurate, standardized measurement techniques both in clinic and at home. The guidelines were created with input from a majority-primary care committee—including family physicians, nurses, pharmacists, and patient partners—to ensure clinical applicability.

Together, the panel outlines a streamlined nine-step treatment algorithm, emphasizing combination therapy as first-line pharmacologic management. They explain the evidence supporting ARB–thiazide combinations, discuss cost considerations for drug selection, and address adherence challenges. They also explore red flags for secondary hypertension and how the algorithm supports—but does not replace—clinical judgment.

For physicians, this guideline offers a clear and practical roadmap: measure blood pressure correctly, aim for systolic pressure below 130 mm Hg, and use the simplified treatment sequence to improve adherence and outcomes. Designed to be easy to implement, the new approach aims to empower primary care providers to act with confidence.

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