Locked out of the ward: Workflow-based care refusal for people living with HIV in China's general hospitals.

BACKGROUND

With the scale-up of antiretroviral therapy (ART), people living with HIV (PLWH) increasingly require non-HIV inpatient and procedural care in general hospitals, yet access remains precarious.

AIMS: To examine how refusals of non-HIV care for PLWH unfold within routine general-hospital workflows.

METHODS

We conducted an interpretive qualitative study in three provincial capitals in China (Changsha, Guangzhou, and Nanning) between May 2024 and October 2025. We interviewed 58 PLWH about one index non-HIV care-seeking episode each (80 interviews, including 22 follow-ups) and 16 key informants spanning perioperative, ward/bed, infection-control, and HIV follow-up roles. Episodes were reconstructed as node-by-node event chains and analysed using framework analysis and mechanism-oriented thematic analysis.

RESULTS

Participants seldom described refusal as a single explicit denial. Instead, they described a recurrent care-refusal cascade across routine nodes including admission, consultation, perioperative assessment, ward acceptance, and transfer. Five linked mechanism modules connected HIV visibility to responsibility shifting, procedural deferral or delay, pathway resetting, navigation burden, and anticipatory avoidance. Costs are reported only as banded spillover indicators. The cascade appeared less likely to escalate when decision ownership was explicit, HIV was managed under standard precautions, and navigation support was available.

CONCLUSION

Unequal access can be interpreted as processual discrimination embedded in routine workflow governance rather than as isolated acts of refusal. By specifying a process model of "denial without denial", the study identifies organisational breakpoints for accountable, traceable, and repairable hospital pathway governance.