It is estimated that between 252,000 and 312,000 people in the United States are unaware that they are infected with HIV/AIDS and are unaware of their risk for HIV/AIDS transmission to other people (Morbidity and Mortality Weekly, 2003). Placed near the bottom in incidence for HIV/AIDS prevalence rates in the United States, North Dakota has 227 HIV/AIDS (North Dakota Department of Health, 2011). With low prevalence rates, a lack of cohesive healthcare provider groups is a challenge due to low demands for care. The purpose of this project was to identify the needs of persons newly diagnosed with HIV/AIDS and services available to address their needs in the Fargo, ND region. Bridging the gaps between where patients go from the point of diagnosis to the next step in care is where there are fragmented services that could be addressed by an established coordination of HIV/AIDS-related services in the state of North Dakota. Six individuals living with HIV/AIDS within the Fargo community were interviewed for stage one of this project. For stage two of this project, three key informants who specialize in the care of HIV/AIDS patients were identified within the Fargo community and interviewed. Data results from the HIV/AIDS-positive patients as well as the key informants supported the literature that there are gaps within the healthcare system, such as a lack of HIV/AIDS case managers to help patients coordinate and facilitate their care. An HIV/AIDS care quick reference guide was developed to identify the services available and those recommended to bridge the care gap in Fargo, ND. This practice improvement project has the potential to improve healthcare practice by providing practitioners with a resource guide on managing care for individuals living with HIV/AIDS.