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Engagement and retention in HIV care for uninsured or precariously insured newcomers living with HIV

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Rapid Response #193 as a PDF

Question

  • What are the best practices for providing support for engagement and retention in the HIV care cascade among uninsured or precariously insured newcomers* living with HIV?

* The term “newcomer” is used as an umbrella term for anyone who has moved to the country within the last five years (1). Newcomers constitute a diverse migrant population with varying immigration statuses, e.g., immigrants, refugees, asylum seekers, and temporary residents, such as those with work or study permits.

 Key take-home messages

  • Best organizational-level practices for supporting engagement and retention in HIV care among newcomers living with HIV include: establishing multidisciplinary teams for HIV care in clinical settings (2); adapting clinical environments to address “competing priorities” and lack of insurance (2); providing access to interpreters, language support, and bilingual staff (3–5); implementing programs and interventions grounded in an anti-racism framework (6); providing health care navigation and health education (7); linking patients to legal services; and training clinic staff in migrant-sensitive, culturally competent care (8) while educating both staff and patients on immigrant rights (2).
  • There is a gap in intervention research for newcomers living with HIV (9): designing and implementing interventions should include co-developing tailored, sustainable approaches (8) and prioritizing culturally responsive, peer-led strategies to support engagement and retention (10, 11).
  • Missed opportunities to enhance engagement in HIV care persist for uninsured or precariously insured newcomers living with HIV (12, 13), highlighting the need for approaches such as integrated “circle of care” models that link primary care, specialists, and community support to improve timely access to and retention in HIV care (14).
  • In Ontario, health care workers and service providers often play a critical role through employing workaround strategies to ensure patients can access HIV care and treatment via provincial programs (12), but these approaches are often complex and may be unsustainable (13, 14).
  • Community Health Centres (CHCs) serve as essential access points for uninsured newcomers, and strengthening their capacity, reducing administrative barriers, improving privacy, and expanding the scope of services are necessary to support continuity of care (13, 15). However, the waitlist to become a patient of a CHC can be long, and not all CHCs offer HIV care (13).
  • Pharmacy services should consider adopting culturally responsive, patient-centered approaches that extend beyond traditional adherence support to include system navigation, relationship building, medication reviews, patient education, and cultural competency, in order to enhance engagement and long-term retention for uninsured or precariously insured newcomers living with HIV (16, 17).
  • Low-barrier, partnership-driven models in Toronto play a crucial role in improving linkage and continuity of HIV care for uninsured or precariously insured newcomers (18–20). These models align with broader evidence emphasizing culturally competent and peer-supported practices (21–25); however, sustainability and resource limitations remain key challenges to long-term impact (19). Examples of such models include:
    • The Toronto People with AIDS (PWA) Foundation, in partnership with Freddie, hosting low-barrier clinics for uninsured and precariously insured individuals (18);
    • The Blue Door Clinic hosted at Casey House, providing HIV primary care to uninsured and precariously insured newcomers (19); and
    • HQ Toronto, providing HIV care for uninsured and precariously insured cis guys into guys, and two-spirit, transgender, and non-binary individuals (20).

The issue and why it’s important

Although Canada has a publicly funded universal health care system, access to health care is often restricted for individuals with temporary or no immigration status (26). While the federal government is responsible for establishing the minimum national standards for the health care system, the responsibility for organizing and delivering health services lies with each provincial and territorial government (26). As a result, every province and territory operates its own health insurance plan, which determines who can access its publicly funded health care services and what health care services are covered under these insurance plans (26).

Depending on their immigration status upon arrival in Canada, newcomers who are at risk of or living with HIV may face challenges getting health care coverage (27). The Interim Federal Health Program (IFHP) offers limited, temporary coverage of health care benefits to protected persons, resettled refugees, refugee claimants, and other eligible groups until they qualify for provincial programs such as the Ontario Health Insurance Plan (OHIP) or the Ontario Drug Benefit Program (27, 28). Conversely, newcomers to Ontario on student, work, or visitor visas must purchase private health insurance, which often does not fully cover their health care needs (27). As a result, they may have limited coverage, and therefore may not have access to services such as HIV testing, HIV pre-exposure prophylaxis (PrEP), or HIV treatment (27). This can be problematic, for example, for international students requiring HIV treatment, as their migrant status often leads to severe health coverage limitations where “not all insurance providers cover HIV care and treatment and getting access to public health insurance can be a major challenge, or not possible, when [navigating] or transitioning between immigration statuses in Canada” (29).  Individuals with work permits valid for at least six months can eventually qualify for OHIP; however, there are  requirements, including working full-time for at least 90 days (27).

Across high-income countries, insurance gaps stemming from immigration status and health insurance eligibility have been shown to limit newcomers’ access to antiretroviral therapy (ART) and other essential HIV services (2, 30). In these contexts, precarious or absent insurance coverage has been shown to hinder newcomers’ access to sexual and reproductive health services (30), including accessing HIV care and treatment (2). In Ontario specifically, differences in eligibility across programs (e.g., IFHP, OHIP, private insurance) can create gaps in access to health care, laboratory testing, and medications (31, 32). These policy-level barriers can delay ART initiation and discourage newcomers living with HIV from continuing to engage with care (2).

Research indicates that compared to the rest of the population, newcomers are more likely to delay entry into the health care system to access HIV care and are less likely to be retained at successive stages of the HIV care cascade (3, 33). Newcomers living with HIV in high-income countries appear to have lower treatment adherence, poorer retention in care, and poorer virological response compared to the non-migrant population (3). In Ontario, HIV epidemiological data show that a growing proportion of HIV diagnoses have occurred through immigration medical examinations (IME): nearly half (47.7%) of first-time HIV diagnoses in 2023 were identified by immigration physicians/clinics, continuing an upward trend observed since 2021 (34). However, a diagnosis by IME alone does not ensure timely linkage to care; a Montreal-based study found that only 45% of newly diagnosed asylum seekers were linked to care within a 30-day timeframe (35), highlighting a major bottleneck along the HIV care cascade (36).

Gaps in insurance coverage are compounded by structural barriers across the HIV care cascade, including stigma, fear related to deportation, the consequences of disclosing HIV status, side effects of initiating ART, limited host-language proficiency (e.g., English or French), and challenges navigating health care systems (2, 37). For instance, newcomers expressed that the fear of deportation acts as a barrier to HIV testing and linking to initial medical appointments (38). Moreover, among some newcomers these fears resulted in a delay in HIV care until expression of symptomatic disease and/or utilization of emergency services (39). Experiences of stigma and social burden among newcomers living with HIV may further hinder engagement with health and social care services (37). Social determinants of health and epidemiological patterns also place some newcomers at a greater risk of acquiring HIV before and/or after they arrive in Canada (40).

As a result of insurance coverage gaps, inequities in HIV treatment access and retention persist in Ontario (27). Considering the goals and vision of the Ontario Advisory Committee on HIV/AIDS (OACHA) Action Plan to 2030, which aim to improve HIV-related health outcomes and achieve high quality care for all people living with HIV (27, 41), there is a need to identify strategies and best practices to support engagement and retention in care among uninsured or precariously insured newcomers living with HIV (41). This review aims to synthesize literature on the best practices and strategies of providing support for engagement and retention in the HIV care cascade for uninsured or precariously insured newcomers living with HIV.

What we found

Review articles on strategies and best practices for supporting engagement and retention in HIV care among newcomers living with HIV

Identified literature review articles suggest that facilitators and strategies for improving engagement, retention and participation across the HIV care cascade among newcomers living with HIV in high-income countries operate at multiple levels. These levels are individual, interpersonal, organization, community, and health systems (2–5, 8, 9). A summary of strategies/best practices for providing support for newcomers living with HIV is presented in Table 1.

Although multiple review articles identify lack of health insurance/coverage as a barrier to HIV care, we found less evidence pertaining to strategies aimed at overcoming these barriers faced by uninsured or precariously insured newcomers living with HIV (2, 3, 8, 9). Nonetheless, the evidence presented in these reviews is relevant for identifying missed opportunities to provide better support in engagement and retention among newcomers living with HIV, including those who are uninsured or precariously insured.

Table 1. Best practices/strategies for providing support for engagement and retention in HIV care for newcomers living with HIV, grouped within five-level Socio-Ecological Model categories (level categories adapted from Arora et al., 2021) (2).

Level

Best practices/strategies identified for providing support for engagement and retention in the HIV care cascade among newcomers living with HIV
Individual • Address “competing priorities” which may impact engagement (e.g. housing, food security, financial stability, work commitments, mental health) (2)
• Psychological support for people with depressive disorders (3)
Interpersonal• Peer education, group and/or self-directed learning in sexual health programs (4)
• Building trust with clients by assuring immigration status is not collected (2)
Organizational • Establishing multidisciplinary teams for HIV care in clinical settings (2)
• Adapting clinical environments to address competing needs and lack of insurance (2)
• Flexible consultation hours and options for home visits (3)
• Availability of interpreters, language support, and bilingual staff members (3–5)
• Programs/interventions to help with health care navigation and health education (7)
• Hiring multilingual staff familiar with the immigration process, as well as people with lived immigration experience, and linking clients to legal services to assist with immigration status (2)
• Educate staff and clients around immigrant rights (42), provide training of health professionals in migrant-sensitive and culturally competent care (8)
• Integrate community health workers into the care team (3)
• Utilization of mobile health (mHealth) and mobile units to bring HIV care to newcomers (8)
• Implementing an equity, inclusion, diversity and anti-racism framework (6)
Community • Partner with newcomer communities to co-design, implement, and evaluate tailored HIV engagement and retention programs that directly respond to their lived realities, intersectional vulnerabilities, and stigma (8)
Policy • Free treatment/free access to care (3)
• Provision of HIV care regardless of (im)migration status (8)
• Financial support within programs (4)
• Proposals focused on humanising and optimising HIV care (9)
• Development of tailored interventions for newcomers living with HIV (8)

Facilitators and best practices/strategies for promoting engagement across the HIV care cascade for newcomers living with HIV

A 2024 review by Goupil de Bouillé et al. identified 69 studies to determine the specific features of adherence to the HIV care process among newcomers living with HIV in high-income countries (3). Most of the included studies focused on barriers to adherence to the HIV care process rather than the facilitators (3). The authors identified several facilitating factors for adherence to the HIV care process in newcomers: inclusion of community health workers in staff composition, providing home visits, involvement of interpreters, psychological support for depressive disorder, flexible consultation hours, free treatment for persons with financial difficulties, and having a residence permit (3). Considering these facilitators, the authors highlight how health care organizations and health policies can tackle the barriers faced by newcomers living with HIV and empower them to become actors in their own care trajectory (3).

A 2021 systematic review by Arora et al. aimed to generate a multilevel understanding of the barriers and facilitators influencing the HIV care cascade steps for newcomers living with HIV in countries that are members of the Organization for Economic Co-operation and Development (OECD), including Canada (2). The review included 59 studies from 17 OECD member countries and found that newcomers living with HIV faced similar barriers and facilitators regardless of their host country, ethnic or geographic origins, or legal status (2). In the context of strategies for supporting engagement among uninsured or precariously insured newcomers living with HIV, the review identified that having an adaptive clinical environment was the most prevalent facilitator affecting HIV care engagement for newcomers (2). The authors noted that “[t]he clinical environment played one of the most important roles in linking newcomers living with HIV to and retaining them in HIV care and treatment” (2). A good clinical environment foundation seemed to be built upon a strong patient-physician relationship, approachability of the entire clinical team, and a multidisciplinary team (including nurses, community health workers, case managers, social workers) to better address newcomers’ competing needs and address retention issues (2).

Stigma, racism, and discrimination experienced in clinical environments can threaten newcomers’ willingness to engage with care (2), highlighting the importance of implementing equity, inclusion, diversity, and anti-racism frameworks in addressing systemic inequities within the health system (6).

Notably, the review identified multiple cases where health care team members in some jurisdictions found ways to obtain care for newcomers living with HIV without health insurance (2). In addition, team members were also found to resolve critical needs and “competing priorities” such as assistance with securing housing, food, acquiring health insurance, and arranging support with clinical or legal appointments (2). When HIV clinics establish medical-legal partnerships, they can enable a direct response to immigration needs (2, 42). A U.S. study from California revealed best practices for HIV clinics in reaching and retaining their newcomer community patients during a period of reductions in accessible public resources and immigration rights (42). These best practices included recruiting bilingual and bicultural staff, linking patients to immigration-related legal services, providing training for both clinic staff and patients around immigrant rights and responses to Immigration and Customs Enforcement (ICE) raids, and fostering trust by assuring patients’ immigration status would neither be collected nor disclosed (42).

The authors emphasized a key finding of the review: unmet basic needs pose a significant barrier for newcomers living with HIV (2). Even when individuals are successfully linked to care and treatment, failure to address these “competing priorities” can lead to disengagement from care (2). Thus, there is great potential for multidisciplinary teams to resolve competing issues faced by newcomers living with HIV, especially uninsured or precariously insured individuals, to provide support with “competing priorities” and improve long term engagement in HIV care and treatment (2). Furthermore, primary HIV care clinics should consider adopting multidisciplinary models with sufficient funding for a social worker or clinical staff member with similar training and expertise (2).

A 2020 scoping review by Djiadeu et al. found that the language barrier remains an important gap in HIV care delivery to Francophone newcomers living with HIV in Ontario and Manitoba (5). A key recommendation in the review findings was an opportunity for increased training and recruitment of bilingual health care practitioners, especially specialists and AIDS Service Organization (ASO) staff, aligning with a culturally sensitive approach to improve HIV care for Francophone newcomers to Canada who live outside Quebec (5).

Facilitating access to health care systems for newcomers living with HIV

We identified two review articles, both published as part of the “HIV in Migrant Populations Series” (2024) in The Lancet HIV, focused on accessing HIV care and navigating health care systems for newcomers living with HIV (8, 9). A narrative review of 16 articles by Cortes et al. reviewed evidence focused primarily on access and barriers to HIV diagnoses, prevention, and treatment for displaced people and refugees (9). The authors found that addressing challenges faced by newcomers living with HIV requires a focus on equitable health care access, with both actionable local interventions and broader policy changes and an emphasis on long-term sustainability (9). This is a key item as it pertains to uninsured or precariously insured newcomers, who are faced with navigating complex insurance systems in host countries where free health care is not guaranteed (9). Although this review focused largely on a health systems/policy level for humanising and optimising HIV health care for newcomers, a critical research gap on intervention research was found (9). Namely, it was found that investigation into HIV care cascade implementation among newcomers is insufficient (9). The second review in the above-mentioned series presents an evidence synthesis by Kamenshchikova et al. of interventions and recommendations that aim to strengthen community and health systems to ensure the continuity of HIV care for newcomers from low-, middle-, and high-income countries (8). In conducting this narrative review, the authors recognized that a linear depiction of HIV care does not capture the complex cycle of entry and re-entry into care (8). Of the 134 included articles in this review, most focused on HIV testing and linkage, with scarce evidence on the needs and challenges of newcomers who need to re-enter care (8). Despite this research gap, the review identified different potential interventions including provision of HIV care regardless of migration status; utilisation of mobile health (mHealth), mobile units, and community-led initiatives to bring HIV care to migrants; and utilisation of participatory and co-creation methods to develop tailored and sustainable HIV-related interventions with migrant communities (8). Health care interventions aiming to strengthen community and health systems must consider intersectional vulnerabilities (e.g., HIV-stigma, racism, sexism, homophobia, and transphobia) that determine an individual’s access to HIV care (8). 

Program intervention characteristics

The literature emphasizes the importance of greater engagement of newcomers in sexual and reproductive health care services (30). A 2024 review by Inthavong et al. described the characteristics of programs for improving sexual health among newcomers in high-income countries (4). While most (18 of 20) of the included studies were conducted on STI and/or HIV prevention and control, the authors identified the following items to be key characteristics of sexual health programs: consumer consultation and engagement, cultural appropriateness, language support, peer education, self-directed learning, group learning, financial support, and outreach services (4). A 2025 health equity-oriented scoping review by Liu et al. did not identify any HIV-focused interventions that facilitate effective transitions in care for newcomers (7). However, in evaluating the impact of 38 unique interventions, the authors did find that the most promising programs for health outcomes involved health navigation or providing public health education for newcomer populations (7). The most common equity-relevant characteristics addressed by the studied interventions were language, cultural background, and education level (7).

Strategies for supporting engagement and retention in care among newcomers in Canada

Ontario, like other Canadian provinces, offers a number of publicly funded assistance programs that can be used by people living with HIV to cover their financial, medical, and other support needs. But these programs are often fragmented and governed by restrictive criteria. For example:

  • Trillium Drug Program (TDP) (43): Provides coverage based on household income but applicants cannot complete application forms unless they have filed taxes in Canada for the preceding tax year (14). As a result, newly arrived immigrants who are unemployed or lack a Canadian tax filing history may be ineligible (14).
  • Ontario Drug Benefit (ODB) program (44): Restricts prescription drug coverage to individuals with a valid OHIP card who meet specific criteria (e.g., adults aged 65 or older, young adults/youths under 24 with no private insurance, those receiving social assistance, or registered for TDP). These criteria often make HIV-positive immigrants aged 25 to 65 and without drug coverage ineligible for ODB (14).
  • Ontario Disability Support Program (ODSP): Provides financial assistance, health benefits, and employment support for eligible adults with disabilities and in financial need (45). In general, people living with HIV are medically eligible to receive ODSP benefits (46). Frontline workers frequently advise uninsured newcomers to apply for ODSP to secure HIV medications and extended benefits (e.g., housing, transportation, special diet, dental and eye care), with health care providers often filling out required forms for them (11, 13). 
  • Compassionate Drug Programs: May be facilitated by ASOs and CHCs through pharmaceutical companies to secure temporary supply of medications, though health care workers express concerns that these programs typically only last 6 to 12 months and are unsustainable for long-term care (13, 14).

To better support engagement and retention for newcomers living with HIV in Canada, including those who are uninsured or precariously insured, there is a need for culturally sensitive trauma-informed care models (10). For example, a 2024 Vancouver cohort study found that collaboration with the Black community was imperative to developing culturally sensitive, trauma-informed HIV services rooted in peer-based approaches (10). Peer-led strategies that engage Black communities in non-intrusive and informal settings with culturally and linguistically safe tools have been largely successful (11, 47). A 2021 Manitoba cohort study reported that once newcomers are engaged in care, they have similar clinical outcomes to Canadian-born persons (11).

Studies by Odhiambo et al. have revealed missed opportunities for HIV cascade engagement strategies for uninsured or precariously insured newcomers living with HIV in Ontario (12–14). In general, data in these studies were generated by interviewing Black newcomers living with HIV, as well as health care workers in Ontario (12–14). Missed opportunities for timely linkage and engagement in HIV health care included the implementation of a “circle of care” model which could enable easy and quick access to panel physicians, family doctors, specialists and social workers from community organizations (14). One HIV specialist who was interviewed expressed that “it is ideal to be connected to a family doctor, an ASOs or CBO [Community-Based Organization], and HIV specialist…Kind of a like a triangle…We are all working together to service that individual in a shared decision-making model” (14). Nested within this “circle of care” model, CBOs, social workers, ASOs, and health care workers act as primary conduits in supporting Black newcomers to navigate structural barriers (i.e., insurance) to access health resources including HIV health care and treatment (14). For example, Toronto-based TAIBU Community Health Centre’s AYA Circle of Care actively implements this holistic approach by pairing intensive HIV case management with patient navigation, connecting individuals to clinical care, education, wrap-around support services, and peer-led groups (48).  

Odhiambo et al. further demonstrate that engagement and retention in HIV care are heavily shaped by intersecting structural and social inequities, including precarious immigration status, racial discrimination, anti-Black racism, stigma, housing and financial instability, and health system barriers (12). These findings highlight the importance of incorporating an anti-racism and intersectionality lens into strategies to support engagement and retention among uninsured or precariously insured newcomers living with HIV.

Health care workers may rely on workaround strategies to support uninsured newcomers to access HIV medication, including assessing eligibility and assisting with applications to programs such as the ODSP and the TDP (14). However, restrictive eligibility criteria (e.g., prior tax filing for TDP) limit access for many newcomers (14). These challenges are further compounded by the structure of existing public drug coverage programs (14). The publicly funded ODB program only provides prescription drug coverage for people with a valid OHIP card who are either aged 65 or older, children and youth 24 years of age or younger who are not covered by a private insurance plan, those on social assistance or registered for the TDP with high prescription drug costs relative to their household income, or those meeting some other specific criteria (14, 44). Health care providers noted that newcomers do not register for TDP because they are precariously employed, or ineligible, or unable to pay the deductible, which is equally expensive (13).

Given these structural barriers, health care providers often “scramble” to secure access to HIV medication for patients (14). As one physician emphasized, “people who fall through the crack [HIV health care and treatment cascade] are those between 25 years and 65 years, majority of whom are HIV-positive immigrants without drug coverage” (14). Health care workers explained in their interviews that they advise people living with HIV who are uninsured and unable to afford treatment out of pocket to apply for the ODSP (14). The interviewed Black newcomers relied on ODSP to access HIV medication and extended health care benefits, including housing, transportation, special diet, dental, and eye care (12). Health care workers also play a critical role in the ODSP application process (14),  which takes little time and does not require a detailed knowledge of a person’s medical background (46). Health care providers do not need to fill out the full ODSP application forms–they only need to provide a signature, attach a positive HIV laboratory test result, and note in writing that the attached result confirms the diagnosis (46).

Black newcomers and health care providers reported that HIV medication access may be obtained through compassionate drug programs provided by pharmaceutical companies and facilitated by ASOs and CHCs (13); however, health care workers pointed out that these programs are often temporary and not sustainable (14). Even when referred to a CHC, patients often cannot access care immediately: CHCs prioritize clients based on “catchment areas” (i.e. geographic zones that determine which region a CHC serves) and place those outside their catchment on waiting lists, and intake is a structured process governed by these waiting lists, requiring extensive paperwork before someone is accepted as a client (13). Frontline workers describe sometimes having to plead a patient’s case directly to a CHC manager before the person could be made a client and scheduled for care (13).

Newcomers described CHCs as having rigid eligibility criteria, tedious paperwork, long waiting lists, prolonged on-site waiting times, understaffed facilities, and a lack of secure, private waiting areas for HIV-positive people (13).  

Strengthening CHCs and similar team-based primary care settings with integrated providers (e.g., family physicians, nurses, and social supports) could improve linkage to HIV care while also facilitating continuity of primary care and long-term engagement in treatment among different population groups, such as Black newcomers (13) and women (15).

A 2020 study by David et al. explored the pharmaceutical services provided to newcomers in Montreal during times of disruptions in service provision (i.e. IFHP policy changes in medical coverage for newcomers), particularly regarding access to treatment (16). Clients (n=9) and clinic staff (n=9, including three pharmacists) were interviewed (16). Considering policy-level changes in coverage for newcomers, researchers discussed the following best practices related to the provision of pharmaceutical care adopted at the clinic (16): Pharmacy care teams for newcomers should consider the patient’s cultural background, by supporting patients holistically (beyond traditional adherence support), and build a culture of care within a multidisciplinary team (16). In addition, the pharmacy team should consider assisting with navigation of the health system including active assistance and patient education (e.g., increased patients’ awareness of the importance of planning ahead for drug renewals), and advocacy (16). Cultural competency training could help pharmacy staff improve their cultural awareness and practice in a culturally safe way (16).

Similarly, a 2023 scoping review by Filmer et al. found that suggested strategies for facilitating efficient care in the interactions of migrant/refugee patients with pharmacy staff included improvement of communication, medication review, community education, and relationship building (17).

Service models for uninsured or precariously insured newcomers

 Examples of service models for uninsured or precariously insured newcomers living with HIV in Toronto

In 2025, Toronto People with AIDS Foundation launched a pilot project clinic, in partnership with Freddie (a health organization that specializes in HIV prevention and care), to provide free medication and care to people living with HIV (18). The one-room clinic is staffed with two nurses, and they see patients once a week, on Wednesdays (18). Clients do not need to be covered by OHIP or insurance and vary in immigration status, from international students to visitors and citizens (18).

The Blue Door Clinic, hosted at Casey House in Toronto, provides interim health care and social support to people living with HIV in the greater Toronto area who do not have health insurance coverage or access to HIV medication (19). A service evaluation was conducted to investigate the effectiveness of the Blue Door Clinic Intervention in linking uninsured or precariously insured people living with HIV to stable, long-term primary care (19). In focus groups, both clients (n=31) and service providers (n=35) discussed strengths and challenges of the intervention (19). Key strengths of the clinic included a compassionate human-centred approach, multi-sectored partnerships pooled to link clients to care, language services (e.g. offered in English, French, and Spanish) and interpretation support offered by peers, and overall dedication to providing equitable care and treatment access (19). Challenges discussed were primarily connected to a lack of sustainable resources for the clinic, which translates into limited capacity to meet growing service needs of the community (19).

Similarly, HQ Toronto provides free HIV care and treatment for “cis guys into guys and two-spirit, transgender and non-binary people” regardless of their immigration or insurance status, including uninsured newcomers (20, 49). Additionally, HQ offers mental health, sexual health, and social services and programs to clients (20, 49).  

Other service models and interventions among newcomers living with HIV (outside Canada)

Although not specifically focused on those who are uninsured or precariously insured, we identified several studies on developing and implementing interventions to improve engagement and retention in HIV care for newcomers living with HIV in several high-income settings (21–25). Common themes identified from these service models and interventions included the implementation of culturally competent care (21–23), peer navigation (24), and peer support (25).

A U.S.-based study by Saldana et al. (2025) found that a culturally responsive social media outreach campaign combined with peer navigation successfully engaged primarily uninsured, foreign-born Latino gay and bisexual men (n=70) in Atlanta, and enabled rapid, same-day linkage to HIV prevention and care services (21). High retention and engagement were driven by the program’s ease of use, practical support, and empathetic, culturally tailored communication from peer navigators (21). Similarly, another study implemented a culturally informed approach in improving HIV care engagement (22). A pilot project conducted by Bogart et al. (2020) developed a nine-session, community-based, culturally tailored cognitive behavioral therapy group intervention to address coping with discrimination among Latino sexual minority male immigrants living with HIV in California (22). The intervention showed good acceptability and feasible engagement, with participants (n=30) attending multiple sessions (five out of nine sessions on average) despite structural barriers like work and illness (22). In addition, the program supported retention by decreasing negative emotional coping responses to discrimination and strengthening resilience, helping Latino sexual minority men living with HIV to stay engaged in care and support services (22). In addition to implementing client-focused interventions, there are also opportunities for implementing health care provider-focused interventions (23). A study by Dyrehave et al. (2022) developed a Behavior Change Wheel-informed culturally sensitive intervention for nurses to better care for people of African Background living with HIV in Denmark (23).

A 2025 study by Krulic et al. found that peer navigation provided newcomers living with HIV (n=15) in Australia with emotional support, by providing a source of hope, reassurance, acceptance, and belonging amid experiences of stigma and discrimination (24). It also improved engagement and retention by offering a pathway and connections to health, legal, and social services, with effectiveness strengthened by shared cultural and lived experiences of navigators (24). Other peer-based interventions have been investigated to improve psychological and HIV-related health outcomes (25). Been et al. (2020) evaluated the feasibility and efficacy of four existing interventions aimed at improving HIV treatment adherence among migrants (newcomers) living with HIV in The Netherlands: directly administered antiretroviral therapy (DAART), group medical appointments (GMA), early detection and treatment of psychological distress, and peer support by trained newcomers living with HIV (25). The researchers found that DAART and GMA were considered by study participants as intrusive and impractical, and consequently not feasible interventions (25). Peer support was considered feasible by study participants: detectable HIV RNA declined (from 10.3% to 6.8%) as did internalized HIV-related stigma (from 15 to 14 points), and the percentage of participants who were adherent increased (by 5.5%–8.3%) (25).

Factors that may impact local applicability

Local applicability of strategies, best practices or service models to provide support with engagement and retention in HIV care among newcomers may be influenced by differences in provincial/territorial funding, health insurance eligibility, and access to HIV drug coverage. The generalizability of the findings may be limited due to heterogeneity across included studies (e.g., different newcomer populations, health systems, and intervention designs), which may limit their transferability to local settings.

Another limitation is that newcomers/migrants are not always uniformly categorized based on how long they have been in the host country. The term “newcomers” for the purposes of this rapid review includes refugees, asylum seekers, immigrants, temporary residents such as those with work or study permits, and other migrants.

What we did

We searched Ovid MEDLINE® using text term HIV AND (terms [newcomer* or immigrant* or migrant* or refugee* or asylum or undocumented or immigrat*] in titles or abstracts OR MeSH term “Emigrants and Immigrants”/). Searches were conducted on February 17, 2026 and results were limited to articles published in English since 2020. The literature search was restricted to research conducted in high-income countries. Reference lists of identified articles were also searched. Google (grey literature) searches using different combinations of these terms were also conducted. The searches yielded 1,233 references of which 49 were included.

Reference list

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  2. Arora AK, Ortiz-Paredes D, Engler K, Lessard D, Mate KKV, Rodriguez-Cruz A, et al. Barriers and facilitators affecting the HIV care cascade for migrant people living with HIV in Organization for Economic Co-Operation and Development countries: A systematic mixed studies review. AIDS Patient Care & STDs. 2021;35(8):288–307.
  3. Goupil de Bouillé J, Pascal C, Voyer B, Zeggagh J, Kherabi Y, de Andrade V, et al. How do migrants living with HIV adhere to the HIV care process in high-income countries? A systematic review. BMJ Open. 2025;15(5):e093620.
  4. Inthavong AB, Pourmarzi D. Characteristics of sexual health programs for migrants, refugees, and asylum seekers: A scoping review. International Journal of Environmental Research & Public Health. 2024;21(8):23.
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Suggested citation

The Ontario HIV Treatment Network (OHTN). Rapid Response Service. Engagement and retention in HIV care for uninsured or precariously insured newcomers living with HIV. Toronto, ON. September 2026.

Prepared by

Ryan LaPenna and David Gogolishvili