Referral and Referral Facilitation Behavior of Family Planning Providers for Women with HIV Infection in the Southern United States Holly C. Felix, Ph.D., M.P.A., 1 Janet Bronstein, Ph.D., 2 Zoran Bursac, Ph.D., M.P.H., 1 M. Kathryn Stewart, M.D., M.P.H., 1 H. Russell Foushee, Ph.D., 2 and Joshua Klapow, Ph.D. 2 Abstract Background: Many women receive family planning (FP) services from federally supported FP providers. These FP services include testing for sexually transmitted infections (STD), including the human immunodeficiency virus (HIV). FP providers are expected to refer patients with non-FP conditions, including HIV, to other pro- viders for treatment. Prompt HIV treatment improves outcomes and survival, yet many women face barriers to accessing treatment. Facilitation of referrals improves referral follow-up. However, little is known about the referral practices and facilitation activities of FP providers for their clients testing positive for HIV. Methods: To fill this gap, this article reports the findings of a study that used a mail survey of FP providers (n ¼ 456) to document referral practices and facilitation activities when providers see HIV-positive patients. Results: The study found that nearly all FP providers report referring HIV-infected clients to another provider rather than providing treatment themselves. Factors associated with significantly more facilitation of referrals included perception of less competent patients, perception of more referral resources, personal relationships with referral providers, rural locality, and information support staff. Conclusions: Some factors associated with low facilitation (such as perception of few referral resources and no personal relationships with referral providers) are amenable to change. Interventions targeting these factors should be designed and tested to increase facilitation of referrals and the follow-up with referrals for HIV treatment. Introduction O ver 38,000 Americans are diagnosed with human immunodeficiency virus (HIV) infections annually, 25% of whom are women. 1 Early testing and prompt treatment of HIV are important for improved health outcomes and sur- vival. 2 Unfortunately, a substantial number of people are unaware of their HIV-positive status or initiate testing later in their disease’s progression, as indicated by a high percentage (36%) of people diagnosed with AIDS within 12 months of being diagnosed with HIV infection. 1 Research has shown that younger persons, African Americans and Hispanics, less educated people, and those exposed through high-risk het- erosexual contact are tested significantly later in the disease’s progression (compared with older people, white people, those persons with more education, and men who have sex with men [MSM], respectively). 3 Once diagnosed, infected people may delay initiation of HIV treatment, 1 with treatment delays up to 5 years reported in the literature. 4,5 Factors associated with delays in HIV treatment include lack of a usual provider, limited trust in the healthcare system, 6 injection drug use, high poverty residence, being foreign born, being tested at a site without colocated HIV treatment services, 7 and being a racial/ethnic minority group member. 6,7 Travel distances to providers, concerns about privacy and confidentiality, and economic disadvantages have also been identified as access barriers for people residing in the rural South. 8 Studies have found differences in barriers to care for HIV by gender, with women reporting significantly more barriers than men. 9 Barriers to HIV care reported by women include long waits for treatment, denial of the need for treatment, fear of losing custody of children, difficulty making or keeping appointments, and difficulty communicating with providers. 9 Even after diagnosis and entry into the healthcare system, 1 Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas. 2 School of Public Health, University of Alabama at Birmingham, Alabama. JOURNAL OF WOMEN’S HEALTH Volume 19, Number 7, 2010 ª Mary Ann Liebert, Inc. DOI: 10.1089/jwh.2009.1747 1385