Unmasking legislative constraints: An institutional ethnography of linkage and engagement in HIV healthcare for African, Caribbean, and Black people in Ontario, Canada.

The Human Immunodeficiency Virus (HIV) epidemic significantly impacts African, Caribbean, and Black (ACB) immigrants in Canada. Health scholarship has revealed striking injustices within Canada's public healthcare system that restrict access to healthcare and violate the human rights of ACB immigrants living with HIV who are marginalized. We conducted an institutional ethnography to comprehensively understand how HIV healthcare in Ontario is organized and experienced by ACB immigrants, focusing on unjust and discriminatory legislative frameworks and institutional practices regulating access to publicly funded healthcare resources and services. We interviewed 20 ACB immigrants and 15 healthcare workers, including specialists, primary care providers, immigration physicians, and social workers. We found a disjuncture between the organization of HIV healthcare in Ontario and how ACB immigrants experienced access to care. We uncovered how immigration, public health and healthcare laws and related institutional practices intersect to produce structural violence which create barriers and missed opportunities to timely linkage and engagement in HIV healthcare. Black immigrants' accounts revealed that they underwent mandatory HIV under the Immigration Medical Examination policy (IME) without providing informed consent and receiving pre and post-test counselling. Furthermore, Black immigrants did not receive referrals and were not adequately linked to care following HIV diagnosis. Troubling encounters with immigration and public health state agents and healthcare legislative barriers including difficulty finding a physician, the 3-month waiting period under the Ontario Health Insurance Plan (OHIP), long wait times, lack of drug coverage, and stigma, discrimination, and anti-Black racism shaped and affected Black people's linkage and engagement in HIV care. We elucidate how the legislative and structural organization of healthcare regulated and constrained health service access for ACB immigrants living with HIV, including their ability to "achieve" HIV undetectability.