Linkage to Care

The Linkage to Care Program provides intensive case management for people living with HIV, prioritizing community members who identify as Indigenous, Black and Persons of Colour (IBPOC). The program recognizes that people face many challenges in trying to navigate the complex systems of immigration, criminal justice, poverty, addictions and mental health, gendered violence, generational trauma, and forced displacement on their own.

The Linkage to Care Program Team is committed to providing support, connections, and care through referrals to necessary services, accompaniments, and advocacy. The Team has several case managers which include people with lived experience. The program offers a mix of outreach, team-based case management, and individual case management to support community members in navigating these systems.

The Linkage to Care program began in 2018 as a pilot project between the Ontario HIV Treatment Network, Toronto Public Health, and the Hassle Free Clinic. The goal was to support newcomers who tested positive with HIV through the Immigration Medical Exam as well as individuals diagnosed in settings with no direct link to ongoing care. The project focused on rebuilding relationships with AIDS Service Organizations (ASOs), the HIV community, and medical and immigration systems in order to bridge the divide in service access.

The Linkage to Care program also participated with several community advocates and ASOs in the development of the Blue Door Clinic which provides accessible and affordable HIV care and treatment to individuals with limited to no health coverage. 

As of 2021, the Linkage to Care program has moved to Fife House and has assumed many of the functions and services of Fife House’s former Homeless Outreach Program.

Photo of a cluster of personal belongings of a houseless person on a side street

Linkage to Care Program Initiatives & Partnerships

This program aims to provide short to medium-length case management for individuals living with HIV who are experiencing houselessness. The program prioritizes individuals who identify as IBPOC and delivers culturally-responsive case management services.

Eligibility Criteria:

  1. Must be living with HIV
  2. Must be experiencing houselessness, or significant physical health, substance use, and/or mental health issues

How to Refer:

Complete the online referral form below, or by downloading the form here and emailing to

This initiative is funded by the City of Toronto to provide support to individuals who are exiting homelessness and moving into permanent housing. Fife House prioritizes people who identify as 1) Indigenous, Black, and/or as a Person of Colour, and/or 2) Living with HIV. The program provides intensive supports to meet the unique strengths and needs of each household while assisting their transition from shelter or outdoors into permanent housing. Follow-up supports help people connect to their community and provide linkages to ongoing services, supports and resources that help ensure successful housing outcomes.

 Eligibility Criteria:

  1. Identify as Indigenous, Black, and/or as a Person of Colour. Priority is given to individuals living with HIV.
  2. Must be exiting houselessness and have secured a permanent housing unit
  3. Require additional support in the community to maintain housing

How to Refer

This program is delivered in partnership with immigration panel physicians, Toronto Public Health, and Hassle Free Clinic. It focuses on linking individuals to HIV care and resources in the community. The program also advocates for affordable and accessible HIV care, including medical care and medications, and supports individuals in accessing the care that they need. This program also has access to interpretation services.

Eligibility Criteria:

  1. Must be referred by an immigration panel physician, Toronto Public Health, or the Blue Door Clinic, and living with HIV.
  2. Identify as a newcomer in Toronto (i.e. arrived within the last 6 months) and have precarious immigration status
  3. Require additional support to connect with HIV care and services

How to Refer:

Contact your panel physician and request that they fax a referral to 416-548-7232.

The Blue Door Clinic provides short-term HIV primary care to individuals living with HIV with limited or no health coverage. The team consists of doctors, nurses, case managers, peer navigators, pharmacists, and community workers all there to help access affordable care. The clinic has access to interpretation services. The Fife House Linkage to Care team provides in-kind staffing to the clinic, assisting with intakes, follow-up supports, and discharge planning.

Eligibility Criteria:

  1. HIV positive
  2. Limited or no health and/or drug coverage (i.e. no OHIP or IFH coverage)
  3. Precarious immigration status (i.e. visitors, temporary workers, international students, etc.)

How to Refer:

Please submit this Blue Door Clinic Referral Form (click to download) to the Nurse Coordinator via email at or fax to 416-364-0822, include the words “Attention: Blue Door”.

The Linkage to Care team coordinates a weekly drop-in program to support residents on George Street, facilitating social activities and engagement for individuals living with the Toronto Community Housing building. The drop-in is focused on providing harm reduction supports and linkage to care. The program also provides individualized supports to 12 Fife House clients that reside within the building on an ongoing basis.

The Linkage to Care team provides bi-weekly support to tenants in scattered site programs, which includes building life skills, navigation support, referrals to services, and housing maintenance support. The team supports 15 tenants in three permanent housing sites in partnership with St. Clare’s Multifaith Housing Society.

Linkage to Care Program – Partner Organizations


Linkage to Care – Referral Form

  • Client Information

  • Alternative Contact

  • Eligibility Information

  • Summary of Support Needs (Rate each item as: 1 – Low, 2 – Moderate, 3 – High, N/A – Not applicable)

  • Residence and Accommodation History

  • Description of presenting situation and concerns:

  • Referral Source