Barriers abound with respect to access and treatment of both HIV and MI, given the findings that a large fraction of each population is not receiving any treatment. While many barriers are similar across diagnoses, this section focuses primarily on the barriers to care of MI—either alone or comorbid with HIV.
Two landmark reports of the United States Surgeon General have analyzed the barriers that deter more than half of those with diagnosable mental disorders from receiving care (DHHS, 1999, 2001). Three overarching barriers to care were identified: the stigma attached to mental illness, the cost of mental health services, and the fragmentation of services. The latter refers to the patchwork of programs and settings of care (e.g., a hospital, community clinic, private office, or school) and a myriad of financing streams that make it difficult for people to find care and remain in care. Members of ethnic and racial minority groups not only face these three barriers, but also a host of others, including fear and mistrust of mental health care providers, providers’ lack of awareness of cultural concerns, and language barriers for immigrants (DHHS, 2001). Rates of both access and utilization of mental health care are lower for minorities than for whites, a striking finding considering the already low rate of service utilization for whites (<50 percent receives any treatment in a given year) (DHHS, 2001). Minorities are overrepresented in the most vulnerable groups of homeless and incarcerated persons (DHHS, 2001). While the HCSUS study of people in HIV care found relatively high rates of utilization of mental health services (61.4 percent used mental health services), it also uncovered regional variation and inequities among certain demographic groups. Access was lower by minority and low education, and income populations (Burnam, 2001).
Individuals with comorbid MI-HIV appear to face additional barriers even if they manage to reach care. The barriers include lack of detection of HIV and physician withholding HIV treatment. These barriers stem partly from the complexity of coordinating care among three overlapping, yet distinct service systems—mental health, substance abuse, and general medical care. People with mental illness, regardless of severity, are seen by specialty mental health providers or by general medical providers (e.g., primary care) (DHHS, 1999). People with HIV are seen in primary medical care or by infectious disease specialists. To complicate matters, care for substance abuse has its own treatment settings and treatment philosophies, and substance abuse providers do not always diagnose mental disorders (Zweben, 2000).