People living with HIV disease, particularly those in small towns and rural areas, face many barriers that prevent them from receiving important life-care services. We developed the Barriers to Care Scale (BACS) to delineate the problem severity of factors that impede care and service provision among a sample of 226 men and women living with HIV disease in a single midwestern state. Both urban and rural respondents indicated that major barriers to life-care services included the lack of knowledge about HIV among citizens in the community, insufficient personal financial resources, the lack of employment opportunities for people living with HIV, and the lack of supportive and understanding work environments. Rural persons living with HIV disease, compared to their urban counterparts, assigned significantly higher problem severity ratings to the following barriers: the need to travel long distances to medical facilities and personnel; a shortage of adequately trained medical and mental health professionals; a lack of personal or public transportation; and community residents' stigma toward people living with HIV. The large number of barriers to care identified in the present study indicates that innovative programmes designed to remove these barriers and improve the life quality of rural persons living with HIV are urgently needed.

Psychiatric co-management is often required in HIV primary care. While rates and clinical impact of linkage and retention in HIV are well explored, fewer investigations focus specifically on linkage to psychiatry. In this investigation, we evaluate factors associated with linkage to psychiatric services using a retrospective cohort study of HIV-infected patients during a two-year observation period. Descriptive statistics depict patient characteristics, and logistic regression models were fit to evaluate factors associated with failure to establish care at the co-located psychiatry clinic following referral from HIV provider. Of 370 referred, 23 % did not attend a scheduled psychiatry appointment within 6 months of initial referral. In multivariable analysis, Non-white race, younger age, non-suppressed viral load, and increased wait time to appointment (in days) were associated with failure to attend. Further exploration of barriers that contribute to disparate linkage to psychiatric care may inform future interventions to improve HIV outcomes in this population.