United States Government Accountability Office

GAO Testimony 

Before the Subcommittee on Federal Financial Management, 

Government Information, and International Security, 

Committee on Homeland Security and Governmental Affairs, 

U.S. Senate

RYAN WHITE CARE ACT

Factors that Impact HIV and 

AIDS Funding and Client 

Coverage 

Statement of Marcia Crosse 

Director, Health Care

For Release on Delivery 

Expected at 2:30 p.m. EDT 

Thursday, June 23, 2005 

 

GAO-05-841T
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

June 23, 2005

RYAN WHITE CARE ACT 

Factors that Impact HIV and AIDS 

Highlights of GAO-05-841T, a testimony Funding and Client Coverage 

before the Subcommittee on Federal 

Financial Management, Government

Information, and International Security,

Committee on Homeland Security and 

Governmental Affairs, U.S. Senate

The Ryan White Comprehensive 

AIDS Resources Emergency Act 

(CARE Act) was enacted in 1990 to

respond to the needs of individuals 

and families living with the Human 

Immunodeficiency Virus (HIV) or

Acquired Immunodeficiency 

Syndrome (AIDS). In fiscal year

2004, over $2 billion in funding was 

provided through the CARE Act,

the majority of which was 

distributed through Title I grants to

eligible metropolitan areas (EMA) 

and Title II grants to states, the 

District of Columbia, and 

territories. Titles I and II use 

formulas to distribute grants 

according to a jurisdiction’s

reported count of AIDS cases. Title

II includes grants for stateadministered AIDS Drug Assistance 

Programs (ADAP), which provide

medications to HIV-infected

individuals. 

GAO was asked to discuss the

distribution of funding under the

CARE Act. This testimony presents

preliminary findings on (1) the

impact of CARE Act provisions that

distribute funds based upon the

number of AIDS cases in 

metropolitan areas, (2) the impact

of CARE Act provisions that limit

annual funding decreases, (3) the

potential shifts in funding among

grantees if HIV case counts were

incorporated with the AIDS cases 

that are currently used in funding

formulas, and (4) the variation in

eligibility criteria and funding

sources among state ADAPs. 

Under the CARE Act, GAO’s preliminary findings show that the amount of 

funding per AIDS case varied among states and metropolitan areas in fiscal

year 2004. Some CARE Act provisions that distribute funds based on the 

AIDS case count within metropolitan areas result in differing amounts of 

funding per case. In particular, when a state or territory has an EMA within

its borders, the cases within that EMA are counted twice during the 

distribution of CARE Act funds—once to determine the EMA’s funding 

under Title I, and once again to determine a state’s Title II grant. 

The hold-harmless provisions under Titles I and II guarantee a certain

percentage of a previous year’s funding amount, thus sustaining the funding 

levels of CARE Act grantees based upon previous years’ measurements of 

AIDS cases. Title I’s hold-harmless provision for EMAs has primarily 

benefited the San Francisco EMA, which received over 90 percent of the 

fiscal year 2004 Title I hold-harmless funding. San Francisco alone continues 

to have deceased cases factored in to its allocation, because it is the only

EMA with hold-harmless funding that dates back to the mid-1990s when

formula funding was based on the cumulative count of diagnosed AIDS 

cases. 

If HIV case counts had been incorporated with AIDS cases in allocating Title 

II funding to the states in fiscal year 2004, about half of the states would 

have received an increase in funding and half of the states would have 

received less funding. Many of those states receiving increased funding 

would have been in the South, a region that includes 7 of the 10 states with 

the highest estimated rates of individuals living with HIV. However, wide 

variation in the maturity of states’ HIV reporting systems could limit the 

adequacy of their HIV case counts for the distribution of CARE Act funding. 

Among state ADAPs, there is wide variation in the criteria used to determine

who is eligible for ADAP medications and services, and in the additional

funding received beyond the Title II grant for each state ADAP. States have

flexibility to determine what drugs they will cover for their ADAP clients and

what income level will entitle a person to eligibility, among other criteria, 

and the resulting variation can contribute to client coverage differences 

among state ADAPs. There is similar variation in additional funding sources 

and eligibility criteria among states that have established waiting lists for 

eligible clients. The Centers for Disease Control and Prevention and the

Health Resources and Services Administration provided comments on the 

facts contained in this testimony and GAO made changes as appropriate. 

www.gao.gov/cgi-bin/getrpt?GAO-05-841T.

To view the full product, including the scope 

and methodology, click on the link above.

For more information, contact Marcia Crosse

at (202) 512-7118.
Mr. Chairman and Members of the Subcommittee:

I am pleased to be here today to discuss the Ryan White Comprehensive 

AIDS Resources Emergency Act of 1990 (CARE Act).

1

 I will specifically

address factors that impact CARE Act funding of services for those with

the Human Immunodeficiency Virus (HIV) or Acquired Immunodeficiency 

Syndrome (AIDS) and program coverage for CARE Act clients. As of

December 2003, over 1 million individuals within the United States are 

estimated to be infected with HIV, including about 406,000 individuals with

AIDS. Administered by the Health Resources and Services Administration 

(HRSA), the CARE Act makes funds available to states and localities to

provide health care, medications, and support services to individuals and 

families affected by HIV and AIDS. 

In fiscal year 2004, more than $2 billion was provided through the CARE 

Act for these health care and support services. The majority of these funds 

were distributed under Title I and Title II within the CARE Act through 

formula-derived base grants, which distribute funding to all eligible 

jurisdictions, and through supplemental grants, which distribute funding 

to a subset of all eligible jurisdictions. Title I provides funding to all 

eligible metropolitan areas (EMA) according to an EMA’s number of AIDS

cases.2

 Title II provides funding to all states, territories, and the District of

Columbia. Within both of these titles are formula grants intended to

distribute funds proportionally to grantees based upon a measure of each

grantee’s share of AIDS cases. Grantees’ reports of AIDS cases are used in 

funding formulas because when the CARE Act was enacted in 1990, most

jurisdictions tracked and reported AIDS cases instead of HIV cases. 

The CARE Act’s reauthorizations in 1996 and 2000 modified the original 

funding formulas. Prior to the 1996 reauthorization, the CARE Act

measured a jurisdiction’s caseload by its cumulative count of AIDS cases, 

which is the number of AIDS cases recorded since reporting began in 1981. 

The 1996 reauthorization changed the measurement of a jurisdiction’s 

 1

Pub. L. No. 101-381, 104 Stat. 576 (codified as amended at 42 U.S.C. §§ 300ff—300ff–101

(2000). The CARE Act added a new title XXVII to the Public Health Service Act. In general,

because Title I of the CARE Act authorized grants to metropolitan areas and Title II 

authorized grants to states, these programs are referred to as Title I and Title II programs, 

respectively. 

2

Under Title I, a metropolitan area with a population of at least 500,000 and 2,000 reported 

AIDS cases in the last 5 calendar years becomes eligible to receive a portion of Title I

funding. 

Page 1 GAO-05-841T
caseload to an estimation of the number of living AIDS cases.

3

 This switch 

would have resulted in large shifts of funding away from jurisdictions with 

a longer history of the disease and a higher proportion of deceased cases 

than other jurisdictions. The CARE Act includes hold-harmless provisions

under Title I and Title II that protect grantees from decreases in funding 

from one year to the next. Title I of the CARE Act also includes a 

grandfather clause for EMAs. A type of hold-harmless itself, this

grandfather clause guarantees that once a metropolitan area has become

an EMA, it will continue to receive funding under Title I, even if its 

caseload drops below the threshold for eligibility. The most recent

reauthorization of the CARE Act in 2000 maintained these modifications, 

and it further specified that HIV cases should be used in funding formulas

no later than fiscal year 2007. As of June 2005, HIV case counts have not 

been used to distribute funding under the CARE Act.

A portion of Title II funding is for state AIDS Drug Assistance Programs

(ADAP), which provide medications to infected individuals. In fiscal year 

2004, Title II base ADAP grants—the ADAP grant given to all states—

totaled $728 million, accounting for 36 percent of all CARE Act funding. 

The programs are administered at the state level and each state is allowed 

flexibility in determining its program eligibility criteria and the drugs it 

provides. Some ADAPs establish waiting lists for eligible individuals for a 

period of time when the ADAP cannot provide covered drugs. 

To assist the subcommittee in its consideration of the CARE Act, my

testimony provides our preliminary findings on some of the issues we are

reviewing for the Chairman and other requesters. My remarks today will 

focus on selected provisions of the CARE Act and ADAP. Specifically, I

will discuss 

1. the impact of CARE Act provisions on the distribution of funds that is

based upon the number of AIDS cases in metropolitan areas, 

2. the impact of the CARE Act’s hold-harmless provisions and a 

grandfather clause on the distribution of funds, 

 3

HRSA calculates a jurisdiction’s estimated living AIDS cases by using data from the

Centers for Disease Control and Prevention on the reported AIDS case counts for the last

10 years and weighting those numbers to account for the likelihood of deaths. We used this

estimate in our analyses of CARE Act funding formula allocations, and we refer to this 

measure as the number of AIDS cases in our discussion of these analyses. 

Page 2 GAO-05-841T
3. the potential shifts in funding among grantees if HIV case counts had 

been incorporated in fiscal year 2004 funding formulas, and 

4. the variation in eligibility criteria and funding sources among the state 

ADAPs.

To address these issues and those within our broader review of the CARE 

Act, we interviewed officials from HRSA and the Centers for Disease 

Control and Prevention (CDC). CDC collects HIV and AIDS case counts

from states and territories. We also interviewed officials from the National

Alliance of State and Territorial AIDS Directors. We obtained and analyzed

data from HRSA regarding the distribution of CARE Act funding and from

CDC regarding AIDS and HIV case counts.4

 We obtained and analyzed HIV 

case counts from those states from which CDC does not accept these data

because they do not use names to identify the cases. CDC and the states 

provided us with case counts that were available as of June 30, 2003, the 

cutoff date for data used to determine fiscal year 2004 funding. HRSA 

provided us with CARE Act funding distributions for fiscal year 2004.5

Based on the information HRSA, CDC, and the states provided regarding 

its verification of the reliability of these data, we determined these data to 

be sufficiently reliable for the purposes of our analyses. We performed our 

work from July 2004 through June 2005 according to generally accepted 

government auditing standards. CDC and HRSA provided comments on 

the facts contained in this statement, and we made changes as

appropriate. 

In brief, our analysis shows that certain CARE Act Title I and Title II

provisions related to the distribution of funds to metropolitan areas result

in variability between the amounts of funding per case among grantees. 

States and territories that have EMAs within their borders receive more 

funding per estimated living AIDS case than those without EMAs because 

cases within EMAs are counted twice—once to determine Title I funding 

to EMAs, and once again to determine a state’s Title II grant. Metropolitan 

areas that have been affected by the epidemic but do not have the 

necessary number of AIDS cases to become EMAs and receive Title I 

funding may qualify for funding as Emerging Communities under Title II.

 4

The HIV case counts were calculated by subtracting the number of reported deaths among 

HIV cases from the number of reported HIV cases. 

5

Our analyses include CARE Act funding and programs in the 50 states, the District of 

Columbia, and Puerto Rico. 

Page 3 GAO-05-841T
However, the allocation of these grants is made by separating eligible 

jurisdictions into two tiers based on their reported number of AIDS cases. 

Because one half of the total Emerging Communities grant award is

allocated to each tier regardless of how many cases are in each tier, in 

fiscal year 2004 jurisdictions in one tier received $1,052 per case while 

jurisdictions in the other tier received $313 per case. 

The hold-harmless provisions under Titles I and II and the grandfather

clause for EMAs under Title I sustain the funding and eligibility of CARE 

Act grantees on the basis of a previous year’s measurements of the number

of AIDS cases in these jurisdictions. By guaranteeing either a certain 

percentage of previous years’ funding amounts or an EMA’s eligibility to 

receive funding, these provisions make it more difficult for CARE Act

funding to track the most current distribution of the epidemic. The San 

Francisco EMA has primarily benefited from Title I’s hold-harmless 

provision, receiving over 90 percent ($7,358,239) of the fiscal year 2004 

Title I hold-harmless funding. San Francisco’s current hold-harmless 

funding can be traced to its 1995 base grant, which was determined using 

the cumulative number of AIDS cases, living and dead, reported since 

1981. In essence, deceased cases are still being used to determine funding

for San Francisco. Hold-harmless provisions under Title II also sustain a

state’s level of funding based on case counts from previous years. Because 

funding for one of these Title II hold-harmless provisions is drawn from a 

set-aside for states with a severe need for drug assistance, this holdharmless provision could affect the amount of funding received by these 

severe-need states in the future. The grandfather clause in Title I 

maintained the funding for 29 of the 51 EMAs that became eligible for Title 

I base grants in the past. These EMAs, however, would not have qualified

for Title I base grants in fiscal year 2004 based upon their case counts, 

which were below the eligibility threshold of 2,000 reported AIDS cases in

the last 5 calendar years.

If the HIV case counts from state reporting systems had been used with

estimated living AIDS cases in allocating fiscal year 2004 Title II base

funding, about half of the states would have received increased funding

and the other half would have received decreased funding. Using two 

different approaches, we found that at least 11 of the states with increased 

funding were located in the South, the region with the highest estimated 

number of people living with HIV or AIDS in 2003. All states have

established HIV case reporting systems, and the 2000 reauthorization of

the CARE Act required that HIV cases be used in determining formula 

funding no later than fiscal year 2007. However, wide differences between 

states’ HIV case reporting systems—in their maturity and reporting 

Page 4 GAO-05-841T
methods, for instance—could affect the use of HIV and AIDS case counts 

to distribute CARE Act funding because an immature reporting system

might not capture an accurate count of a state’s HIV cases. More mature 

systems have longer histories of collecting newly diagnosed HIV cases and 

retroactively reporting HIV cases that had been diagnosed before the 

reporting system existed. We found that funding would have shifted to 

jurisdictions with more mature HIV reporting systems, which includes 

many of the reporting systems in the South. However, changes in funding 

would be largely offset, at least initially, if the funding formulas included

hold-harmless and minimum grant provisions. 

There is wide variation among state ADAPs in the eligibility criteria they 

set for their programs and in the additional funding those programs

receive from sources other than their Title II base ADAP grant. States

determine what drugs they will cover for their ADAP clients and what

income level will make a client eligible for ADAP coverage, among other

criteria. States also vary in the amount of funding they receive from other 

sources in addition to their Title II ADAP base grant. State ADAPs can 

receive funding from a variety of sources, including transfers from other 

CARE Act grants and contributions from states, that can lead to a wide 

range of funding amounts per AIDS case. However, we did not find a 

relationship between any one factor—a particular income eligibility 

criterion, for example, or a type of additional funding beyond the base 

grant—and the existence of a waiting list of ADAP clients that could not 

be served at a particular time. 

Over the course of the last quarter century, the epidemic has spread to 

every region of the country. HIV and AIDS cases have been reported in all 

states, the District of Columbia, and U.S. territories, but the impact of the 

epidemic varies by region and within states. The South is estimated to

have the highest cumulative number of diagnosed AIDS cases, people

living with AIDS, and deaths from AIDS. In 2003, 7 of the 10 states with the 

highest estimated rates of individuals living with HIV were located in the 

South. 

Background 

The CARE Act was enacted in 1990 to respond to the needs of individuals

and families living with HIV or AIDS and to direct federal funding to areas 

disproportionately affected by the epidemic. Titles I and II of the act 

provide base funding to affected EMAs and states based on the proportion

Page 5 GAO-05-841T
of each jurisdiction’s caseload of AIDS cases. These titles also establish 

other types of grants to provide supplemental funding.6

 For example, Title 

II includes Severe Need grants for states with demonstrated need for 

supplemental funding to support their ADAPs. Title II also includes 

funding for emerging communities that are affected by AIDS but do not

have the 2,000 AIDS cases reported in the last 5 calendar years in order to 

be eligible for Title I funding as EMAs. In order to address the impact of

the disease on racial and ethnic minorities, Minority AIDS Initiative grants

are distributed through both Title I and Title II to EMAs and states. 

Metropolitan areas heavily affected by HIV or AIDS have always been 

recognized within the structure of the CARE Act. We previously found 

that, with combined funding under Title I and Title II, states with EMAs

receive more funding per AIDS case than states without EMAs.7

 To adjust

for this situation, the 1996 reauthorization instituted a two-part formula for

Title II base funding that takes into account the number of AIDS cases that

reside within a state but outside of any EMA’s jurisdiction. Under this

distribution formula, 80 percent of the Title II base grant is based upon a 

state’s proportion of all AIDS cases, and twenty percent of the allocation is

based on the number of AIDS cases within that state’s borders but outside 

of EMAs. A second provision included in 1996 protected the eligibility of

EMAs. The 1996 CARE Act amendments provided that once a jurisdiction 

is designated an EMA, that jurisdiction is “grandfathered” so it will always 

receive some amount of funding under Title I even if its reported number 

of AIDS cases drops below the threshold for eligibility. Hold-harmless 

provisions and the grandfather clause were maintained in the 2000 

reauthorization of the CARE Act. Table 1 describes selected CARE Act 

formula grants for Titles I and II. 

 

i

6

There are supplemental grants under Title I that are determined by a competitive

application process. For purposes of this testimony, these Title I supplemental grants were

not included. 

7

See GAO, Ryan White CARE Act of 1990: Opportunities Are Ava lable to Improve Funding

Equity, GAO/T-HEHS-95-126 (Washington, D.C.: Apr. 5, 1995). See also related GAO

products at the end of this statement.

Page 6 GAO-05-841T
Table 1: Description of Selected CARE Act Title I and Title II Formula Grants 

Formula grant Eligible grantees Distribution Minimum grant Hold-harmless provisiona

Title I Base Grant Jurisdictions with 500,000 

or more in population and 

with 2,000 reported AIDS

cases in the most recent 5 

calendar years become, 

and remain, EMAs 

Distributed among all EMAs 

based on proportion of all AIDS

cases 

No Grant annually declines to 

98%, 95%, 92%, and 89% of 

the base year grant, 

respectively.b

 In fifth and all

subsequent years, EMA 

receives 85% of base year 

grant. 

Title II Base Grant All 50 states, the District of 

Columbia, and U.S. 

territories 

Eighty percent of base grant 

divided among states/territories

based upon their proportion of

all AIDS cases. Twenty percent

of base grant is divided among

states/territories based upon 

proportion of all AIDS cases that 

are located outside the EMAs 

within the states’/territories’

borders. 

For states with 

less than 90

AIDS cases,

$200,000;

states with 90 or 

more AIDS 

cases,

$500,000; for 

territories, 

$50,000 

Base formula grant declines

by 1% per year from the 

fiscal year 2000 award. In

fifth and subsequent years of 

provision, grant remains at 

95% of 2000 appropriation. 

Title II ADAP Base

Grant 

All 50 states, the District of 

Columbia, and U.S. 

territories 

Distributed among all 

states/territories according to 

their proportion of all AIDS

cases 

No Grant declines by 1% per 

year from the fiscal year 

2000 grant. In fifth and

subsequent years of

provision, funding remains at 

95% of 2000 grant. 

Title II ADAP Severe 

Need Grantc

States and territories 

demonstrating a severe 

need that prevents them

from providing medications 

to clients in a manner 

consistent with Public 

Health Service guidelines 

Distributed among all qualifying

states/territories based upon 

their proportion of AIDS cases in 

all qualifying states/territories; 

eligible states/territories must 

also agree to match 25% of their 

Severe Need grant 

No No

Title II Emerging 

Communities Grant 

Jurisdictions with more than

50,000 in population, not 

eligible for Title I, and with 

500-1,999 reported AIDS

cases in the most recent 5 

calendar years 

Funds are divided into two tiers: 

50% distributed among 

communities with 1,000-1,999 

AIDS cases, and 50%

distributed among communities

with 500-999 AIDS cases, based 

on their proportion of AIDS

cases in Emerging Communities 

within the tier 

Minimum of $5 

million for each 

tier 

No

Source: HRSA.

a

If the distribution formula would otherwise result in decreased funding, a hold-harmless provision

may be triggered to mitigate the decrease in funding.

b

The base year is the fiscal year prior to that in which the provision is triggered.

c

Funding for Severe Need grants may be reduced to maintain funding for some states under a Title II

hold-harmless provision.

Page 7 GAO-05-841T
The 2000 reauthorization specified that CARE Act Title I and Title II

funding formulas should use HIV case counts as early as fiscal year 2005 if

such data were available and deemed “sufficiently accurate and reliable” 

by the Secretary of Health and Human Services (HHS).8 The 2000 

reauthorization also required that HIV data be used no later than the

beginning of fiscal year 2007. In June 2004 the Secretary of HHS 

determined that HIV data were not yet ready to be used for the purposes of

allocating formula funding under Title I and Title II of the CARE Act. The 

Secretary cited a 2004 Institute of Medicine (IOM) report, which identified 

several limitations in the ability of states to provide adequate and reliable 

HIV case counts for use in CARE Act formula allocations.

9

Some CARE Act provisions have led to jurisdictions receiving different

amounts of funding per AIDS cases. The counting of AIDS cases within

EMAs once to determine Title I funding and once again to determine Title 

II funding results in states with EMAs receiving more funding per AIDS 

case than states without an EMA. In addition, Emerging Communities

grants are awarded to eligible communities that are separated into two

tiers based on each community’s AIDS cases reported in the most recent 5 

calendar years. Because one half of the total Emerging Communities grant 

award is allocated to each tier regardless of the total number of reported 

AIDS cases in each tier, a disproportionate amount of funding per case 

was distributed among the grantees in fiscal year 2004. 

CARE Act Funding 

Provisions Result in 

Disproportionate

Funding 

Counting AIDS Cases 

within EMAs Twice 

Results in Unequal

Funding per Case Across 

States 

States with EMAs receive more funding per AIDS case than jurisdictions 

without EMAs because cases within EMAs are counted twice. The number

of AIDS cases used to allocate CARE Act Title I base grants for EMAs is

also used in the allocation of 80 percent of Title II base grants for states. 

The remaining 20 percent is based on the number of AIDS cases in each 

state outside of any EMA. This 80/20 split was established by the CARE 

Act’s 1996 amendments to address the fact that states with EMAs received 

more funding per case than states without EMAs. However, even with the 

80/20 split, states with EMAs still receive more funding per AIDS case. 

States without an EMA receive no funding under the Title I distribution, 

 

i ll

8

42 U.S.C. § 300ff-13(a)(3)(D)(i)(2000).

9

Institute of Medicine of the National Academies, Measur ng What Matters: A ocation, 

Planning, and Quality Assessment for the Ryan White CARE Act (Washington, D.C.: The 

National Academies Press, 2004). 

Page 8 GAO-05-841T
and thus, when total Title I and Title II CARE Act funds are considered, 

states with EMAs receive more funding per AIDS case. 10 Appendix I shows 

the combined fiscal year 2004 funding for all Title I and Title II funding 

received by each state. 

Table 2 illustrates the effect of counting EMA cases twice by comparing 

the relationship between the percentage of a state’s AIDS cases that are

within an EMA’s jurisdiction and the amount of funding a state receives

per AIDS case. Table 2 shows that as the percentage of a state’s AIDS 

cases within EMAs increases, the total Title I and II funding per AIDS case 

also increases for the state. For example, states with no AIDS cases in 

EMAs received on average $3,592 per AIDS case. States with 75 percent or

more of their cases in EMAs received on average $4,955 per AIDS case, or 

38 percent more funding than states with no EMA. If the total Title I and 

Title II funding had been distributed equally per AIDS case among all

grantees, each state would have received $4,782 per AIDS case.

Table 2: Total CARE Act Title I and II Funding per AIDS Case, Fiscal Year 2004 

Percentage of state’s AIDS cases in EMAs Average funding per AIDS casea

None $3,592

Less than 50 percent 3,954

50 to 75 percent 4,717

75 percent or more 4,955

Source: GAO analysis of HRSA data. 

a

In order to isolate the effect of counting AIDS cases in EMAs twice, we excluded from our analyses 

the nine states and six territories that received minimum Title II base grant awards. Under Title II,

states with less than 90 cases receive no less than $200,000 in Title II base grant and states with 90 

or more cases receive at least $500,000.

The impact of counting EMA cases twice is that states with similar 

numbers of AIDS cases can receive different levels of combined Title I and 

Title II funding. For example, for fiscal year 2004 funding, Connecticut had 

5,363 AIDS cases while South Carolina had 5,563 AIDS cases. However, 

 10For EMAs that cross state boundaries, we estimated the amount of funding received by

each state. Using data obtained from HRSA, we calculated the number of AIDS cases from

each state in these EMAs. We then calculated the percentage of AIDS cases in each state 

and allocated the EMA funding to each state based on this percentage. For example, 

approximately 96 percent of the cases in the Boston EMA are in Massachusetts and 4 

percent are in New Hampshire. Consequently, we allocated 96 percent of the Boston EMA’s

funding to Massachusetts and 4 percent to New Hampshire. 

Page 9 GAO-05-841T
Connecticut had two EMAs that accounted for 91.3 percent of its cases

while South Carolina had none. Connecticut received $26,797,308 ($4,997 

per AIDS case) in combined Title I and Title II funding while South

Carolina, with 200 more cases, received $20,705,328 ($3,722 per AIDS 

case). Connecticut received 29 percent more funding than South Carolina,

a difference of $6,091,980, or $1,275 per AIDS case.

The Tiered Allocation of 

Title II Funds for Emerging 

Communities Results in 

Funding Disparities

Among States 

The two-tiered division of Emerging Communities grants results in 

disparities in funding per case among states. In addition to the base grants

for states, Title II provides a minimum of $10 million in supplemental

grants to states for communities with populations greater than 50,000 that

have a certain number of AIDS cases in the last 5 calendar years. The 

funding is equally split so that half the funding is divided among the first

tier of communities with 500 to 999 reported cases in the most recent 5 

calendar years while the other half is divided among a second tier of 

communities with 1,000 to 1,999 reported cases in that period. The funding 

is then allocated within each tier by the proportion of reported cases in the

most recent 5 calendar years in each community.

In fiscal year 2004, the two-tiered structure of Emerging Communities

funding led to large differences in funding per case because the total 

number of AIDS cases in each tier was not equal. Twenty-nine 

communities qualified for Emerging Communities grants in fiscal year 

2004. Four of these communities had between 1,000 and 1,999 reported 

cases and 25 communities had between 500 and 999 cases. This meant that 

4 communities with a total of 4,754 reported cases split $5 million while 25

communities with a total of 15,994 cases split the remaining $5 million.

This resulted in the 4 communities receiving $1,052 per reported case

while the other 25 received $313 per reported case. These 4 communities

received 236 percent more funding per case than the other 25. If the total 

$10 million Emerging Communities funding had been distributed equally 

per case among the communities, each would have received $482 per 

reported case. Table 3 lists the 29 emerging communities along with their 

AIDS case counts and funding. 

Page 10 GAO-05-841T
Table 3: Title II Emerging Communities in Fiscal Year 2004 

State Metropolitan area

AIDS cases reported in the 

most recent 5 calendar years

Emerging Communities funding per AIDS case

reported in the most recent 5 calendar years

Tenn. Memphis 1,588 $1,052

Tenn. Nashville 1,123 1,052

La. Baton Rouge 1,038 1,052

Ind. Indianapolis 1,005 1,052

S.C. Columbia 972 313

N.C. Charlotte 875 313

Del. Wilmington 801 313

Va. Richmond 783 313

N.C. Raleigh-Durham-Chapel Hill 775 313

Miss. Jackson 722 313

Ky. Louisville 705 313

N.Y. Rochester 681 313

Fla. Fort Pierce-Port St. Lucie 636 313

N.C. Greensboro—Winston-Salem 617 313

Ala. Birmingham 615 313

Okla. Oklahoma City 608 313

Pa. Pittsburgh 602 313

Mass. Springfield 588 313

N.J. Monmouth-Ocean 582 313

N.Y. Buffalo-Niagara Falls 581 313

S.C. Greenville 560 313

Ohio Columbus 558 313

Wisc. Milwaukee 558 313

Utah Salt Lake City 555 313

Fla. Sarasota 539 313

S.C. Charleston 538 313

Ohio Cincinnati 517 313

Fla. Daytona Beach 514 313

R.I. Providence 512 313

Total 20,748

Sources: GAO analysis of HRSA data. 

Note: The 5 most recent calendar years are from 1998-2002.

Page 11 GAO-05-841T
Titles I and II of the CARE Act both contain provisions that benefit certain

grantees by protecting their funding levels. Title I has a hold-harmless 

provision that guarantees that the Title I base grant allocated to an EMA 

will be at least as large as a legislated percentage of a previous year’s

funding. The Title I hold-harmless provision has primarily benefited one 

EMA. Title I also contains a grandfather clause that has resulted in a large 

number of EMAs maintaining funding despite no longer meeting the 

eligibility criteria. One hold-harmless provision for Title II ensures that the 

total of Title II and ADAP base grants awarded to a state will be at least as 

large as the total of these grants it received the previous year. This 

provision has had little impact thus far, but it has the potential to reduce 

the amount of funding to states with severe need in ADAPs because it is 

funded out of amounts reserved for that purpose. The hold-harmless 

provision and the grandfather clause in Title I and the hold-harmless 

provisions in Title II protect grantees from decreases in funding from one 

year to the next, but they also make it more difficult to shift funding in

response to geographic movement of the disease.

Hold-Harmless 

Provisions and 

Grandfather Clause 

Benefit Certain 

Grantees 

Title I Hold-Harmless 

Provision Has Primarily

Benefited One EMA 

In fiscal year 2004, the Title I hold-harmless provision primarily benefited 

the San Francisco EMA. The hold-harmless provision guarantees each 

EMA a specified percentage, as legislated by the CARE Act, of the base 

grant it received in a previous year regardless of how much a grantee’s

caseload may have decreased in the current year. An EMA’s base funding 

is determined according to its proportion of AIDS cases. If an EMA 

qualifies for hold-harmless funding, that amount is added to the base 

funding and distributed together as the base grant. The San Francisco

EMA received $7,358,239 in hold-harmless funding, or 91.6 percent of the 

hold-harmless funding that was distributed. The second largest beneficiary

was Kansas City, which received $134,485, or 1.7 percent of the holdharmless funding. Table 4 lists the fiscal year 2004 hold-harmless

beneficiaries. 

Page 12 GAO-05-841T
Table 4: Title I Hold Harmless Funding, Fiscal Year 2004

EMA 

Hold-harmless 

funding

Percentage of 

hold-harmless 

funding

Hold-harmless 

funding per

AIDS case

Base grant per

AIDS casea

Percent of base

grant due to holdharmless funding

San Francisco, Calif. $7,358,239 91.6% $1,020 $2,241 45.5%

Kansas City, Mo. 134,485 1.7 104 1,325 7.8

Santa Rosa, Calif. 22,614 0.3 47 1,268 3.7

Sacramento, Calif. 36,456 0.5 29 1,251 2.3

Minneapolis-St.Paul, Minn. 33,770 0.4 27 1,248 2.1

Bergen-Passaic, N.J. 55,288 0.7 26 1,248 2.1

Jersey City, N.J. 58,310 0.7 24 1,245 1.9

Oakland, Calif. 50,744 0.6 18 1,239 1.4

New Haven, Conn. 42,573 0.5 14 1,236 1.2

Tampa-St. Petersburg, Fla. 44,908 0.6 12 1,233 0.9

San Jose, Calif. 12,097 0.2 11 1,232 0.9

Boston, Mass. 60,284 0.8 10 1,231 0.8

Nassau-Suffolk, N.Y. 21,212 0.3 8 1,230 0.7

Middlesex-SomersetHunterdon, N.J. 8,315 0.1 7 1,228 0.5

Jacksonville, Fla. 12,825 0.2 6 1,228 0.5

San Juan, P.R. 41,011 0.5 6 1,228 0.5

Seattle, Wash. 9,844 0.1 4 1,225 0.3

Denver, Colo. 6,745 0.1 3 1,225 0.3

Cleveland, Ohio 4,616 0.1 3 1,224 0.2

West Palm Beach, Fla. 8,523 0.1 2 1,224 0.2

Newark, N.J. 10,975 0.1 2 1,223 0.1

All Other EMAs 0 0 0 1,221 0.0

Total $8,033,563b 100.0%

Source: GAO analysis of HRSA data. 

Note: An EMA’s base funding is determined according to its proportion of AIDS cases. If an EMA

qualifies for hold-harmless funding, that amount is added to the base funding and distributed together 

as the base grant.

a

This was calculated by dividing the base formula funding received by each EMA by the number of

AIDS cases in the EMA. However, because of rounding error, some of the calculations are slightly 

different than if the base formula funding per AIDS case without a hold-harmless benefit ($1,221) is 

added to the hold-harmless funding per AIDS case.

b

Individual entries do not sum to total because of rounding.

The funding impact of the hold-harmless provision varies among the EMAs

that benefit but it can be substantial. In order to place hold-harmless 

Page 13 GAO-05-841T
funding in perspective, it is helpful to consider how much of an EMA’s 

Title I base grant was made up of hold-harmless funding. EMAs that did

not receive hold-harmless funding received approximately $1,221 in base 

grant funding per AIDS case. Fiscal year 2004 base grant funding per AIDS 

case in EMAs that received hold-harmless funding ranged from $1,223 

(Newark) to $2,241 (San Francisco). Thus, San Francisco received $1,020 

more in base grant funding per AIDS case than did EMAs that did not

receive hold-harmless funding. This hold-harmless funding represents 

approximately 46 percent of San Francisco’s base grant. Because of its 

hold-harmless funding, San Francisco, which had 7,216 AIDS cases in 

fiscal year 2004, received a base grant equivalent to what an EMA with

approximately 13,245 AIDS cases (84 percent more) would have received 

based on the proportion of cases. Kansas City, the second largest holdharmless grantee, received about what an EMA with 9 percent more AIDS 

cases would have received. 

The San Francisco EMA’s 2004 hold-harmless funding was linked to 

cumulative AIDS cases used to determine fiscal year 1995 funding. In fiscal

year 2004 San Francisco was guaranteed to receive 89 percent of its fiscal 

year 2000 Title I base grant, but San Francisco’s 2000 allocation was also

held harmless under the 1996 CARE Act reauthorization. Under the 1996 

reauthorization, EMAs were guaranteed 95 percent of their 1995 base grant 

in fiscal year 2000.11 San Francisco was the only EMA to qualify for holdharmless funding in 2000 because it was the only EMA that would have 

received less than 95 percent of its fiscal year 1995 base grant. This means 

that in fiscal year 2004 San Francisco was guaranteed approximately 

85 percent of its fiscal year 1995 base grant of $19,126,679.12 Prior to the 

1996 reauthorization, funding was distributed among EMAs on the basis of

the cumulative count of diagnosed AIDS cases (that is, all cases reported 

in an EMA both living and deceased since the beginning of the epidemic in 

1981). Because the application of the Title I hold-harmless provision for 

San Francisco dates back to the 1996 reauthorization, San Francisco’s 

 11The amounts guaranteed in the Title I hold-harmless provisions differed in the 1996 and 

2000 CARE Act reauthorizations. In the 1996 reauthorization the guaranteed amounts

ranged from 95 to 100 percent of the 1995 base grant. In the 2000 reauthorization the

guaranteed amounts ranged from 85 to 98 percent of the 2000 base grant. 

12The guaranteed amount is calculated by multiplying the two percentages (89 and 95)

together. In other words, in fiscal year 2004 San Francisco was guaranteed to receive at

least 89 percent of its fiscal year 2000 Title I base grant. Its fiscal year 2000 Title I base

grant was guaranteed to be no less than 95 percent of its fiscal year 1995 Title I base grant. 

Page 14 GAO-05-841T
Title I base grant is determined in part by the number of cumulative cases 

in the San Francisco EMA as of 1995. 

Grandfathering Maintains 

Eligibility for EMAs That

No Longer Meet Certain 

Eligibility Criteria

More than one half of the EMAs received Title I funding in fiscal year 2004 

even though they were below Title I eligibility thresholds.13 These EMAs’

eligibility was protected under a CARE Act grandfather clause. Under a 

grandfather clause established by the 1996 amendments to the CARE Act,

once a metropolitan area’s eligibility is established, the area remains 

eligible for Title I funding even if the number of reported cases in the most 

recent 5 calendar years drops below the statutory threshold. We found 

that in fiscal year 2004, 29 of the 51 EMAs did not meet the eligibility 

thresholds, but their Title I funding was protected by a grandfather clause 

(see table 5). The number of reported AIDS cases in the most recent 5

calendar years in the 29 EMAs ranged from 223 to 1,941. Title I funding

awarded to these 29 EMAs was about $116 million, or approximately 20 

percent of the total Title I funding. 

 13To be eligible for Title I funding, an area must have reported more than 2,000 AIDS cases

during the most recent 5 calendar years and have a population of at least 500,000. These 

criteria differ from those used to calculate funding allocations, which are determined using

the number of AIDS cases. AIDS cases are calculated by applying annual national survival

weights to the most recent 10 years of reported AIDS cases and adding the totals from each

year. In the 1990 CARE Act, EMAs were defined as a metropolitan area with a cumulative

count of more than 2,000 AIDS cases or a cumulative count of AIDS cases that exceeded 

one-quarter of one percent of its population. 

Page 15 GAO-05-841T
Table 5: Grandfathered EMAs, Fiscal Year 2004 

EMA 

Number of AIDS cases 

reported in the most recent 

5 calendar years

Total Title I 

funding

Riverside-San Bernardino, Calif. 1,941 $6,823,183

New Haven, Conn. 1,717 7,069,348

Oakland, Calif. 1,633 6,611,607

Nassau-Suffolk, N.Y. 1,560 5,951,789

Norfolk, Va. 1,502 4,820,201

Seattle, Wash. 1,459 5,842,615

Jacksonville, Fla. 1,423 4,863,093

Orange County, Calif. 1,422 5,233,329

St. Louis, Mo. 1,247 4,371,154

Jersey City, N.J. 1,226 5,884,194

Las Vegas, Nev. 1,182 4,473,401

Denver, Colo. 1,167 4,529,097

Austin, Tex. 1,149 3,800,250

Bergen-Passaic, N.J. 1,067 4,814,704

Hartford, Conn. 1,059 4,552,237

San Antonio, Tex. 1,034 3,833,443

Cleveland, Ohio 970 3,486,936

Portland, Oreg. 937 3,567,475

Fort Worth, Tex. 854 3,373,450

Kansas City, Mo. 822 3,240,813

Minneapolis, Minn. 794 3,093,915

Sacramento, Calif. 717 2,968,051

Ponce, P.R. 710 2,718,331

Middlesex-Somerset-Hunterdon, N.J. 682 2,723,697

San Jose, Calif. 656 2,656,550

Caguas, P.R. 411 1,816,647

Dutchess County, N.Y. 255 1,231,242

Vineland-Millville-Bridgeton, N.J. 238 847,898

Santa Rosa, Calif. 223 1,107,428

Total $116,306,348

Source: GAO analysis of CDC and HRSA data. 

Note: The 5 most recent calendar years are from 1998-2002.

Page 16 GAO-05-841T
As discussed earlier, some metropolitan areas are designated as emerging 

communities because their caseloads are not large enough to make them

eligible for Title I funding as EMAs. However, some emerging communities 

had more reported AIDS cases in the last 5 years than some of the EMAs

that have been grandfathered.14 For example, for fiscal year 2004 Memphis, 

a designated emerging community, had 1,588 reported AIDS cases during 

the most recent 5 calendar years, which is more than the number of cases 

reported in 26 EMAs. This results in variability in funding per case caused 

by grandfathering EMAs.

Title II Hold-Harmless 

Funding Could Diminish

ADAP Severe Need Grants 

in the Future 

A Title II hold-harmless provision could diminish ADAP Severe Need grant

amounts in the future because the provision and the grants are funded 

from the same set-aside of funds. If larger amounts are needed to fund the 

hold-harmless provision in the future, the Severe Need grant states could 

get less than the grant amounts they would otherwise receive. 

Fiscal year 2004 was the first time that any states triggered this Title II 

hold-harmless provision, which was established by the 2000 amendments. 

Severe Need grants are funded by setting aside three percent of the total 

CARE Act Title II funding for ADAPs.

15 The Title II hold-harmless

provision, also funded by the 3 percent set-aside for Severe Need grants, 

guarantees that the total of Title II and ADAP base grants made to a state 

will be at least as large as the grants made the previous year. In fiscal year 

2004 eight states became eligible for this hold-harmless funding. To

provide these jurisdictions with hold-harmless funding, HRSA officials told

us they used funds from the 3 percent set-aside for Severe Need grants. In 

2004, the 3 percent set-aside for Severe Need grants was $22.5 million. Of

these funds, $1.6 million, or 7 percent, was used to provide this Title II

 14Both EMA eligibility and emerging community funding are based on the number of AIDS

cases reported in the most recent 5 calendar years.

15To be eligible for a Severe Need grant, a state must have met at least one of four eligibility 

criteria as of January1, 2000. It must have limited (1) the eligibility of ADAP clients to those

with incomes at or below 200 percent of the federal poverty level, (2) the number of ADAP 

clients by using medical eligibility restrictions, (3) the number of antiretroviral drugs

covered in its drug formulary, or (4) the number of opportunistic infection medications to

less than 10 in its drug formulary. (Opportunistic infections are illnesses such as parasitic, 

viral, and fungal infections, and some types of cancer, some of which usually do not cause 

disease in people with normal immune systems.) Having met the eligibility criteria, a state

can then apply for the Severe Need grants each year by agreeing to provide the statutorily

required 25 percent state match through state funds or in-kind services. 

Page 17 GAO-05-841T
hold-harmless protection. (See table 6.) The remaining $20.8 million, or 93 

percent of the set-aside amount, was distributed in Severe Need grants. 

Table 6: States that Received Title II Hold-Harmless Funding from Severe Need SetAside; Fiscal Year 2004 

State Hold-harmless amount 

Arkansas $23,705

Kansas 22,168

New Mexico 55,171

North Dakota 1,820

Oklahoma 96,423

Tennessee 1,300,502

Utah 119,695

Vermont 128

Total $1,619,612

Source: HRSA.

The potential exists for this Title II hold-harmless provision to diminish 

the size of Severe Need grants in the future if larger amounts are needed to 

fund the hold-harmless protections. The total amount of Severe Need grant

funds available in fiscal year 2004 to distribute among the eligible states

was less than it would have been without the hold-harmless deduction. In

fiscal year 2004 not all 25 of the states eligible for Severe Need grants 

made the required match in order to receive the grant. Consequently, the 

size of the severe need grants received by each state was not less than 

what they would have received if all eligible states made the match. In 

future years, if all of the eligible states make the match, and if there are 

also states that qualify to receive hold-harmless funds, the Severe Need 

grant states would get less than the amounts they would have otherwise 

received. 

Page 18 GAO-05-841T
If HIV case counts had been used with AIDS case counts in allocating Title 

II base funding, about half of the states would have received increased 

funding and the other half would have received less funding.

16 Under the 

2000 CARE Act reauthorization, HIV case counts are required to be 

included in CARE Act funding formulas no later than fiscal year 2007. 

While all states have established HIV case reporting systems, there are 

currently characteristics of these systems that limit the use of HIV case 

counts in the distribution of CARE Act funds. In order to gauge the 

funding impact of using the data as they currently exist, we developed two 

theoretical approaches for doing so. Using these two approaches, we

found that some fiscal year 2004 Title II base funding would have shifted 

to southern states if HIV case counts had been used with AIDS case counts

in the distribution of funds.17 We also found that funding would tend to

shift to jurisdictions with older HIV reporting systems, regardless of their 

location. Changes in funding due to the inclusion of HIV cases would be

largely offset, at least initially, if the funding formulas retained holdharmless and minimum grant provisions. 

Funding Impact of 

Using HIV Case 

Counts Would Depend

on the Adequacy of 

HIV Reporting 

Systems and the

Number of Reported 

HIV Cases 

Current HIV Case 

Reporting Systems Have 

Limitations for Providing 

Case Counts for Funding 

Allocations 

In its 2004 report, IOM identified several limitations in the ability of states

to provide HIV case counts for use in CARE Act funding allocations.

18

Among these limitations, IOM found that the maturity of HIV case 

reporting systems varies widely across states. The earliest HIV reporting 

systems were established in Colorado, Minnesota, and Wisconsin in 1985, 

while five jurisdictions implemented their systems since 2003. Case 

reporting systems need time to become fully mature and operational, and 

it takes time to make practitioners aware of the requirement to report new 

HIV cases and the methods for doing so. Existing cases also need to be

reported and entered into the system. States with newer systems may not

have collected and entered data on existing cases, and, consequently, may 

underreport the number of HIV cases in the state. Underreporting of HIV 

 

l

16We chose Title II base grants to illustrate the effect of using HIV case counts in funding 

formulas. All of our analyses were conducted using estimated living AIDS cases. 

17The Census Bureau lists the following jurisdictions as being in the South: Alabama,

Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland,

Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and 

West Virginia. 

18Institute of Medicine of the National Academies, Measuring What Matters: A location, 

Planning, and Quality Assessment for the Ryan White CARE Act (Washington, D.C.: The 

National Academies Press, 2004), pp. 87-134. 

Page 19 GAO-05-841T
cases could result in jurisdictions receiving less funding than they would 

be entitled to based on the actual number of HIV and AIDS cases. 

IOM also found that differences in how states report HIV case counts to

CDC could preclude their use in the distribution of CARE Act funds. Some

state HIV case reporting systems are name-based while others are codebased. Currently, CDC will only accept name-based case counts.19

Therefore, state-reported HIV cases that use codes rather than names 

would not be counted in allocating CARE Act funds, if HIV case counts

were used in funding formulas. Twelve states, the District of Columbia, 

and Philadelphia, PA, have some form of a code-based system rather than 

a name-based system.

20 CDC does not accept the code-based data 

principally because methods have not been developed to make certain that 

a code-reported HIV case is only being counted once across all reporting 

jurisdictions.21 Table 7 shows whether state HIV case counts are accepted

by CDC and the year in which each state established its HIV reporting 

system. 

 19CDC has established a set of performance standards for accepting case counts from HIV

reporting systems. These standards include that case reporting be complete (greater than

or equal to 85 percent of cases are reported) and timely (greater than or equal to 66 percent

of cases reported within 6 months of diagnosis) and that evaluation studies demonstrate 

that the approach used to conduct surveillance must result in accurate case counts (less

than or equal to 5 percent of reported cases are duplicates). As of June 2005, CDC has

determined that the only systems which have been evaluated that meet these standards use 

confidential, name-based reporting. Some jurisdictions use codes instead of names to 

secure the privacy of the individuals being counted.

20Pennsylvania has a name-based reporting system for all areas of the state except

Philadelphia. The city received special permission to establish a code-based system. 

Philadelphia implemented such a system in 2004, but it is separate from the Pennsylvania 

reporting system. 

21CDC also has other concerns about code-based reporting. For example, code-based

reporting places a greater burden on health care providers because submitted codes are 

frequently incomplete and require extensive follow-up by surveillance personnel with 

providers to resolve potential duplicate reports on the same person. 

Page 20 GAO-05-841T
Table 7: CDC Acceptance of State HIV Case Counts and Year of Establishment of 

State HIV Reporting Systems 

CDC-accepted Not accepted

Alabama (1988) 

Alaska (1999) 

Arizona (1987) 

Arkansas (1989) 

Colorado (1985) 

Connecticut (2005)a

Florida (1997) 

Georgia (2004) 

Idaho (1986) 

Indiana (1988) 

Iowa (1998) 

Kansas (1999) 

Kentucky (2004) 

Louisiana (1993) 

Michigan (1992) 

Minnesota (1985) 

Mississippi (1988) 

Missouri (1987) 

Nebraska (1995) 

Nevada (1992)

New Hampshire

(2005)b

New Jersey (1992) 

New Mexico (1998)

New York (2000) 

North Carolina (1990) 

North Dakota (1988) 

Ohio (1990) 

Oklahoma (1988) 

Pennsylvania (2002)c

Puerto Rico (2003) 

South Carolina (1986) 

South Dakota (1988) 

Tennessee (1992) 

Texas (1999) 

Utah (1989) 

Virginia (1989) 

West Virginia (1989) 

Wisconsin (1985) 

Wyoming (1989) 

California (2002)

Delaware (2001) 

District of Columbia 

(2001) 

Hawaii (2001) 

Illinois (1999) 

Maine (1999) 

Maryland (1994) 

Massachusetts 

(1998) 

Montana (2000) 

Oregon (2001) 

Rhode Island 

(2000) 

Vermont (2000) 

Washington 

(1999) 

Sources: CDC, IOM, Connecticut, Kentucky, and Philadelphia. 

a

Connecticut established mandatory name-based HIV reporting in 2005. Previously, name-based 

reporting was only required for pediatric cases.

b

New Hampshire established mandatory name-based HIV reporting in 2005. Previously, HIV cases

could be reported using the patient name, a code, or no identifier at all.

c

Name-based HIV reporting has been established in all parts of Pennsylvania except Philadelphia.

Philadelphia was given permission by the state to establish code-based HIV reporting, and the

system began in 2004, but data from Philadelphia are not accepted by CDC.

The Use of HIV Case

Counts in Funding 

Formulas Would Change 

the Distribution of CARE 

Act Funds 

While we are aware of some of the limitations of HIV data, we used two 

approaches to examine the potential impact of using HIV cases in addition 

to AIDS cases on fiscal year 2004 Title II base grant distributions. We 

conducted this analysis in light of the CARE Act requirement that HIV case

counts be used for the distribution of Title I and Title II formula grants no 

later than fiscal year 2007. Some CARE Act fiscal year 2004 funding would 

have shifted if HIV and AIDS case counts had been used to allocate the 

Page 21 GAO-05-841T
funds. Our analyses indicate that at most 14 percent of CARE Act Title II

base funding would have shifted, with southern states being the primary 

beneficiaries. Changes could have resulted from the number of reported 

HIV cases and AIDS cases in each jurisdiction or differences in state HIV

case reporting systems. However, many of the funding changes in our 

model would have been negated if we had applied hold-harmless and 

minimum grant provisions.

We used two approaches to examine the impact of using HIV cases in 

addition to AIDS cases22 on funding for Title II base grants in the 50 states, 

the District of Columbia, and Puerto Rico. We chose Title II base grants to 

illustrate the effect of using HIV case counts in funding formulas. Under 

the first approach, we used HIV case counts in addition to AIDS case 

counts for the 36 jurisdictions from which CDC accepted HIV data.

23 We 

then supplemented these data with only the AIDS case counts CDC 

received from the other jurisdictions because CDC does not accept their 

HIV data. Consequently, for some states and metropolitan areas we used

HIV and AIDS case counts, but for others we used only AIDS case counts. 

This approach reflects the data that would be used if funding allocations

were based on the HIV and AIDS case counts currently received by CDC. 

Under the second approach, we used the same HIV and AIDS case counts 

for the 36 jurisdictions as our first approach, but supplemented these data

with the HIV case counts collected by the other 15 states and the District

of Columbia from which CDC did not accept HIV data. We obtained these 

HIV case counts directly from these jurisdictions. For both approaches, we

calculated the percentage of cases in each jurisdiction and estimated the 

fiscal year 2004 Title II base grant that each would have received. Our 

initial analyses assume that funding was distributed equally per AIDS case 

and that there were no hold-harmless or minimum grant provisions. We 

then estimated the impact of the hold-harmless and minimum grant

provisions. Although there are limitations associated with each of the 

Methodological Approaches

Used

 22We used estimated living AIDS cases in these analyses, which is the measure used by 

HRSA in determining Title II base grants. 

23In these analyses, Connecticut, Kentucky, and New Hampshire are classified as not having

their HIV case counts accepted by CDC. Our analyses were conducted using fiscal year

2004 allocations, which were based on case reports as of June 30, 2003. At that time, 

Connecticut had name-based HIV reporting for only pediatric cases, but established namebased reporting for all cases in 2005. Kentucky had code-based reporting at that time and 

established name-based reporting in 2004. New Hampshire established mandatory namebased reporting in 2005, but previously accepted reports using the patient name, a code, or

no identifier. 

Page 22 GAO-05-841T
approaches, they indicate the general impact of using HIV and AIDS cases 

to distribute all CARE Act formula funding. 

Both approaches indicated that there would be some shifting of funds if

HIV and AIDS case counts had been used to allocate CARE Act Title II

base grants, with southern jurisdictions generally being among the areas 

that would have received increased funding. Under the first approach—

using HIV and AIDS cases from 36 jurisdictions and only AIDS cases from

16 jurisdictions—about 14 percent or $38.9 million of Title II base grants

would have shifted among grantees. Twenty-seven grantees would have 

received additional funding in their Title II base grants if HIV and AIDS 

cases had been used to allocate funding instead of just AIDS cases. Of the 

27 that would have received more funding, 12 were in the South. 

Jurisdictions outside the South that would have received more funding 

include Colorado, New Jersey, and Ohio. All 3 would have each received 

more than $2 million in additional funding. Funding increases would have 

ranged from less than $50,000 in Iowa to almost $5 million in North 

Carolina, or from less than 5 to almost 100 percent. Twenty-five grantees 

would have received less funding. California, Georgia, and Illinois would 

have received the largest decreases in Title II base grants. Decreases 

would have ranged from about $100,000 in Idaho and Wyoming to almost

$12 million in California. Percentage decreases would have ranged from

less than 5 percent in New York to almost 80 percent in Montana. 

Impact on Title II Base Grants 

The second approach — including the code-based HIV counts — yields a 

smaller shift in funding. Under this approach, approximately 10 percent or 

$28.4 million of fiscal year 2004 Title II base grants would have shifted. Of

the 26 grantees that would have received additional funding, 11 are in the 

South. Funding increases for the 26 grantees that would have received 

additional funding would have ranged from less than $50,000 in Maine to 

about $4 million in North Carolina, or from 5 percent in Washington to 80

percent in Colorado. Among the states benefiting from this funding 

approach, Maryland, North Carolina, and Virginia would each have

received increases of more than $2 million. Twenty-six grantees would 

have received less funding. California, New York, and Georgia, would have

received the largest decreases. Decreases would have ranged from less 

than $50,000 in Iowa to $5 million in California. Percentage decreases

would have ranged from less than 5 percent in Florida, Illinois, New

Mexico, and Utah to 65 percent in North Dakota. Appendix II shows the 

results of these analyses for each state. 

Page 23 GAO-05-841T
One explanation for the changes in funding allocations when HIV and 

AIDS cases are used instead of only AIDS cases is the maturity of state HIV

case reporting systems. We found that those states that would benefit from

the use of HIV cases tend to be those with the oldest HIV case reporting 

systems. Those states with the oldest reporting systems include 11

southern states whose HIV reporting systems were implemented prior to

1995. As shown in table 8, states with long histories of collecting HIV case 

counts tend to have many more HIV cases compared with their number of

AIDS cases than do states with less mature reporting systems. This is 

likely because states with newer systems do not have reports on many

cases of HIV diagnosed before their reporting systems were established.24

This can be illustrated by comparing Wisconsin and Delaware, 2 states 

with similar numbers of AIDS cases. Wisconsin began reporting HIV cases

in 1985 while Delaware began in 2001. As of June 2003, the 909 reported 

HIV cases in Delaware was about 40 percent less than the 1,518 reported

AIDS cases. In Wisconsin, there were about 50 percent more reported HIV 

cases and AIDS cases, or 2,287 HIV cases and 1,507 AIDS cases. This

variability could be reduced as Delaware identifies more preexisting HIV 

cases. However, the variability between HIV cases and AIDS cases would 

remain if there was a difference in the actual number of HIV cases. 

Differences in Case Reporting 

Systems Would Affect

Distributions

Table 8: Comparison of Reported HIV and AIDS Cases as of June 2003 

HIV case reporting 

system start date Number of statesa

Ratio of HIV cases to 

AIDS cases

1985-1991 21 1.42

1992-1998 11 1.01

1999-2002 17 .68

Source: GAO analysis of CDC, HRSA, and state data. 

a

Georgia and Puerto Rico implemented their HIV reporting systems after 2002. Kentucky changed 

from a code-based to a name-based system in 2004 and was unable to provide HIV case data. In this 

table, Connecticut is classified as having established its reporting system in 2001 (and so is included 

in the 1999-2002 time period) since state officials provided us HIV case counts based on the system

in operation as of June 2003. In this table, New Hampshire is classified as having established its

reporting system in 1990 (and so is included in the 1985-1991 time period) because state officials 

provided us HIV case counts based on the system in operation as of June 2003.

 24Other factors may also affect the ratio of HIV to AIDS cases in a reporting system. For

example, some states with newer reporting systems were among the first to be affected by 

the HIV epidemic. This could mean that in those states there are relatively more AIDS cases

and the ratio of HIV to AIDS cases would be lower than in states more recently 

experiencing an HIV epidemic.

Page 24 GAO-05-841T
Under either approach, jurisdictions that would receive increased funding

allocations because of the use of HIV and AIDS case counts might do so 

because other jurisdictions did not yet have an accurate measure of HIV 

case counts. The larger the proportion of HIV cases within the total

number of HIV and AIDS cases in a jurisdiction, the more a jurisdiction 

would benefit from the use of HIV cases in funding allocations. However, 

this increased funding could simply be the effect of a state’s older

reporting system, and not necessarily due to actual differences in the 

number of HIV cases. IOM has reported that it could take from 18 months 

to several years after the implementation of an HIV reporting system 

before there would be valid estimates of the number of people living with

HIV. However, table 8 suggests that it could take even longer to get 

accurate case counts. The data in table 8 suggest that as an HIV case 

reporting system matures, it will record a higher ratio of HIV cases to AIDS

cases. One state official we spoke with said that it could take 5 to 6 years 

before a reporting system’s HIV case counts were complete. 

Changes in Funding Would 

be Limited Initially if 

Certain Formula

Provisions Were 

Maintained

Changes in funding caused by shifting to HIV cases and AIDS cases would 

be negated, at least initially, if the current hold-harmless or minimum grant 

amounts were maintained. Consider the situation in which a state received 

$2 million in its Title II CARE Act base grant award based on its AIDS case

count. In the following year, the formula is changed so that HIV and AIDS 

cases are used to determine funding allocations, and the state is then only

entitled to $1 million. However, there is a hold-harmless provision that 

guarantees the state 98 percent of what it received the previous year. The 

state would receive 98 percent of its $2 million allocation, or $1.96 million, 

largely offsetting the reduction in funding due to the shift to HIV and AIDS 

cases. Minimum award amounts could also affect the impact of using HIV 

and AIDS counts. If a jurisdiction qualified for $100,000 formula funding 

using HIV and AIDS case counts, but the minimum award was $500,000, 

the jurisdiction would not receive less funding because of the change to 

HIV and AIDS counts. 

Under our first approach, 5 percent of Title II base grants would shift 

among grantees if the hold-harmless and minimum grant provisions were 

maintained while 14 percent would shift if they were not included. Under 

our second approach, 4 percent would shift instead of 10 percent.

California, which would have had large reductions under both approaches 

if the hold-harmless provision was not maintained, would have had no

change in funding under either approach if the current hold-harmless 

provisions were maintained. Appendix III shows the results of these 

analyses for each state. 

Page 25 GAO-05-841T
Among state ADAP programs, there is wide variation in the eligibility 

criteria used to determine who is covered for ADAP services and in the 

funding sources available beyond each state’s Title II ADAP base grant. 

States have flexibility in determining their ADAP program eligibility 

standards, including the income eligibility ceilings for ADAP clients, caps

on spending per client, and the HIV and AIDS drugs included in their 

formulary. As a result, an individual eligible for ADAP services in one state

may not be eligible in another. There is also wide variability in the 

additional funding sources that ADAPs may receive to help fund their 

programs. Beyond each state’s Title II ADAP base grant for providing HIV 

and AIDS medications and related services, additional ADAP funding 

sources may include Title II Severe Need grants, non-federal transfers of

Title II state or Title I EMA funds, state contributions, and other funding 

sources. States with waiting lists for ADAP services do not fit any 

particular pattern of eligibility criteria and funding sources. 

State ADAP Eligibility 

Criteria and Funding 

Sources Vary Widely 

Eligibility Criteria

Contribute to Coverage 

Differences Among States 

States set different eligibility criteria for their ADAP programs, so a person 

with HIV or AIDS at a certain income level and needing medication 

assistance may be an eligible ADAP client in one state, but not in another. 

Eligibility also varies among state Medicaid programs, which may provide 

HIV and AIDS services and drug assistance. The interaction between these

two programs can affect which clients are eligible for ADAP services, and 

many individuals seeking ADAP coverage may not be aware that they are 

eligible for drug assistance through Medicaid. 

One eligibility requirement where there is considerable variation among 

state ADAPs is the client income ceiling. The income ceilings among 52 

state ADAPs for fiscal year 2004 ranged from the most restrictive at 125

percent of the federal poverty level,25 or $11,638, in North Carolina to the 

most generous at 556 percent, or $51,764, in Massachusetts. Eleven states 

had eligibility ceilings at 200 percent or less of the poverty level. 

Another eligibility criterion where there is wide variation among state 

ADAPs is the number of HIV and AIDS drugs covered under a state 

program’s drug formulary. The number of drugs included in ADAP 

formularies in fiscal year 2004 varied widely from Colorado with 20 drugs 

 25The 2004 Department of Health and Human Services’ federal poverty level for a single

person was $9,310; the poverty levels are higher for Alaska ($11,630) and Hawaii ($10,700).

Poverty level is not defined for Puerto Rico. 

Page 26 GAO-05-841T
to four state ADAPs—Massachusetts, New Hampshire, New Jersey, and 

Washington—with open drug formularies.26 Thirty-nine ADAPs had 100 or 

fewer drugs, including 15 with fewer than 50 drugs on their formularies. 

The CARE Act allows states to purchase health insurance to cover HIV and

AIDS drugs for their clients. HRSA requires an ADAP to demonstrate that 

the insurance includes coverage for drugs comparable to those on the

state’s ADAP formulary.27

Determining whether an individual is eligible for state ADAP or state

Medicaid services is important because the ADAPs serve as the 

individual’s HIV and AIDS drug assistance program of last resort. Medicaid

programs provide HIV and AIDS health care services, including

medications, to eligible disabled individuals with low incomes. If an

individual is eligible for a state’s Medicaid drug assistance, the state ADAP 

should not provide the same services under its program. Twenty-three

ADAPs reported requiring clients to have been denied Medicaid eligibility 

before the ADAP will cover them. To ensure that a prospective or current

ADAP client is not eligible to be served by Medicaid, 42 of the 52 state 

ADAPs reported in ADAP grant year 200428 that they used a case manager

review process to monitor an ADAP client’s Medicaid eligibility, and 40 of

the 52 ADAPs also reported using computer access to eligibility 

determinations to verify a client’s Medicaid and ADAP eligibility. 

Because it is important to ensure continuing therapy for HIV and AIDS 

clients once they begin taking medications, states may limit the number of

ADAP clients they serve to prevent a budget shortfall. This could result in 

eligible clients being on an ADAP waiting list. States also use a variety of 

ADAP eligibility restrictions to limit the number of clients they serve. Of

the 52 state ADAPs, 36 reported eligibility restrictions for ADAP grant year 

2004, and 20 of the 36 used more than one. The restrictions most used 

were (1) an annual cap on individual incomes by 20 ADAPs, (2) a 

limitation on an individual’s assets by 16 ADAPs, (3) capping ADAP 

enrollment by 7 ADAPs, (4) sliding scale copayments paid by individuals

by 7 ADAPs, and (5) capping the amount expended per client for all HIV 

 26In the state ADAP profile reports for ADAP grant year 2004, Massachusetts, New

Hampshire, and New Jersey each reported having 1,000 drugs on their ADAP formularies,

and Washington reported it had 125 drugs on its formulary. 

27In fiscal year 2003, 20 states reported that they used either funds from their Title II base

($3 million) or ADAP ($23.5 million) grants to purchase health care insurance.

28ADAP grant year 2004 covers the period April 1, 2004 through March 31, 2005. 

Page 27 GAO-05-841T
and AIDS drugs by 6 ADAPs. Appendix IV provides a state-by-state

summary of the reported restrictions. 

A Large Percentage of 

ADAPs’ Funds Received 

from Sources Other than 

the ADAP Base Grant 

In addition to their Title II ADAP base grants, 46 of the 52 states ADAPs 

received funding from other sources for their programs in fiscal year 2004.

There were five sources of additional funding across these 46 state ADAPs:

(1) $20.8 million in Title II Severe Need grants (including $4.5 million in 

state match funds), (2) $26.9 million from Title II state funding transfers, 

(3) $10.9 million from Title I EMA funding transfers, (4) $194.8 million in 

state contributions, and (5) $169.3 million in other funds. When the

additional funding source totals are compared among states as a 

percentage of the ADAP’s CARE Act base grant, and as an amount per 

AIDS case, there is a significant range among the states. Appendix V

provides a state-by-state summary of additional ADAP funding and the 

base grant and per AIDS case comparisons. 

State ADAPs that received funding from sources other than their Title II

base grant award include

• Sixteen of the 25 states eligible for ADAP Severe Need grants received 

grant amounts ranging from about $37,000 in Montana to about $6 million

in Texas. States eligible for these grants must agree to match 25 percent of

the funds.29

• Eighteen ADAPs reported receiving transfers from their states’ Title II

base grants ranging from about $65,000 in Maryland to $12.2 million in 

California. 

• Nine of the 24 states with EMAs reported receiving Title I fund transfers 

from their EMAs for their ADAPs ranging from more than $65,000 for 

Nevada to about $6 million for New York. 

• Thirty-five ADAPs reported receiving state contributions from their states

ranging from about $8,000 in Ohio to about $64 million in California. 

• Thirty-two ADAPs reported other funding sources ranging from about

$7,000 in Montana to $64.5 million in New York. Other funding sources 

include additional funds from drug rebates30 and HRSA approved carryover 

of ADAP CARE Act funds from one year to the next. 

 29According to HRSA, Puerto Rico is not required to provide matching funds for Severe

Need grants. 

30ADAPs can receive drug rebates through (1) the federal Section 340B drug discount 

program, (2) their states’ negotiated rebates, or (3) the National Alliance of State and 

Territorial AIDS Directors’ negotiated rebates.

Page 28 GAO-05-841T
Among states with additional funding sources, there is a significant range 

in amounts per AIDS case and percentages of the ADAP base grants. The 

highest amount of additional funding received per AIDS case was $3,604, 

or 171 percent of the base grant in Idaho and the lowest was $61 per AIDS 

case, or 3 percent of the base grant in the District of Columbia. ADAPs in

six states did not receive any additional funding—Iowa, New Hampshire, 

New Mexico, Tennessee, Utah, and Wyoming. 

During fiscal years 2002 through 2004, some states had people eligible for 

their ADAPs’ services on waiting lists and the states with ADAP waiting 

lists have remained relatively static in fiscal years 2002 through 2004. 

Sixteen, or about one-third, of the 52 states had ADAP waiting lists for at

least 1 month during these 3 years. Seven of the 16 states had ADAP 

waiting lists in all 3 years. (See table 9.)

Table 9: States with ADAP Waiting Lists in at Least 1 Month of a Fiscal Year, Fiscal 

Years 2002-04

Eligibility Criteria and 

Funding Sources Also Vary 

Among States with Waiting 

Lists 

State FY2002 FY2003 FY2004

1 Alabama • • •

2 Alaska • •

3 Arkansas •

4 Colorado • •

5 Georgia •

6 Idaho • •

7 Indiana • • •

8 Iowa •

9 Kentucky • • •

10 Montana • • •

11 Nebraska • •

12 North Carolina • • •

13 Oregon • • •

14 South Dakota • • •

15 West Virginia • •

16 Wyoming •

Total 8 13 14 

Source: HRSA and GAO analysis. 

Page 29 GAO-05-841T
The funding sources and eligibility criteria for states with waiting lists 

have varied just as considerably as for states without waiting lists, and 

there is no clear pattern between a state’s funding sources or eligibility 

criteria and the existence of a waiting list. While 33 states that received 

additional funds did not have an ADAP waiting list in 2004, 13 of the 14 

states with waiting lists also received additional funding beyond their 

ADAP base grant. For example, for 

• Title II Severe Need grants: Eight of the 16 states that received Severe 

Need grants had waiting lists. Three of the 9 eligible states that did not 

apply for Severe Need grants in 2004—Alaska, Iowa, and South Dakota—

also had ADAP waiting lists.

• Title I EMA transfers: One state ADAP of the nine that received a Title I 

transfer—Colorado—had an ADAP waiting list. 

• Title II state transfers: Eight of the 18 ADAPs receiving Title II transfers

had waiting lists. 

• State funds: Nine of the 35 ADAPs that received state funds had waiting 

lists. 

• Other funding: Of the 32 ADAPs reporting other funding sources, 10 had

ADAP waiting lists. 

Of the 14 states with ADAP waiting lists, 5 were among the top 10 for 

additional funding per AIDS case received—Idaho (1), South Dakota (2),

Oregon (3), North Carolina (7), and Colorado (8). The remaining 9 states 

with waiting lists and their per AIDS case ranks were Montana (12),

Alabama (18), Nebraska (23), Indiana (24), West Virginia (28), Kentucky 

(33), Arkansas (34), Alaska (42), and Iowa with no additional funds. 

There also seems to be no clear pattern between eligibility criteria—such 

as a low income eligibility ceiling or a limited drug formulary—and a 

waiting list of clients that a state ADAP deems eligible but is unable to 

serve. For example, for 

• Client income eligibility levels: North Carolina with the most restrictive 

level at 125 percent of the poverty level had a waiting list, and 

Massachusetts with the most generous level at 556 percent had no waiting 

list. 

• Eligibility restrictions: Among the seven ADAPs that capped their

ADAP enrollment, six had waiting lists. Five ADAPs that capped the 

amount they expend per client for all HIV and AIDS drugs included two 

states with waiting lists.

• Drug formularies: Among the 39 ADAPs with 100 or fewer drugs on their 

formularies, 13 had waiting lists. 

Page 30 GAO-05-841T
When eligible clients are on state ADAP waiting lists, there are limited 

medication assistance options available to help them until they can be 

served by the ADAP. HRSA officials told us that case managers, who are 

not ADAP employees, are to assist ADAP-eligible clients in accessing 

options to act as stopgaps until clients can be provided ADAP services. 

Among the options are pharmaceutical manufacturers’ patient assistance 

programs that provide free or cost-reduced drugs and non-ADAP 

pharmacy assistance programs provided by some EMAs using their Title I 

funds.31

The services provided under the Care Act have filled important gaps in 

communities throughout the country, but as Congress reviews this act, we

believe it is important to understand how variable this funding can be.

Today I have highlighted a few of the issues that are relevant to this

review. For each of these issues, we found that the provisions of the CARE 

Act have impacted the extent to which funds have been distributed in 

proportion to the incidence of HIV and AIDS. It is clear that the level of

funding available per case is quite variable depending upon where an 

individual lives. The way cases from EMAs are counted twice, the tiered 

allocation of funds to Emerging Communities, the hold-harmless

provisions, and the grandfathering of EMAs have all resulted in 

considerably more funding going to some communities than others with

equivalent numbers of cases. The inclusion of HIV cases in the funding 

formulas, while improving on the basis for funding allocations by 

reflecting cases that have not progressed to AIDS, would also result in 

variable funding depending upon the type and maturity of the reporting 

system used in each state. In addition, the flexibility given to states to shift 

funds, establish eligibility criteria, place limits on the medications covered, 

and cap enrollment, has resulted in great variability for ADAP services 

depending upon where an individual lives. 

Mr. Chairman, this completes my prepared statement. I would be happy to 

respond to any questions you or other members of the subcommittee may

have at this time. 

Concluding

Observations 

 31In fiscal year 2003, 33 EMAs in 16 states used $33.3 million of their Title I funds to provide 

HIV and AIDS pharmaceutical assistance. 

Page 31 GAO-05-841T
For future contacts regarding this testimony, please call Marcia Crosse at

(202) 512-7118. Other individuals who made key contributions include 

Robert Copeland, Louise Duhamel, Cathy Hamann, James McClyde, Opal

Winebrenner, and Craig Winslow.

Contact and

Acknowledgments 

Page 32 GAO-05-841T
Appendix I: Combined CARE Act Title I and 

Title II Funding by State, Fiscal Year 2004 

Page 33 GAO-05-841T

State/territory 

Combined Title I and 

Title II awards AIDS cases

Percent of AIDS cases 

in EMAs 

Total Title I and Title II 

awards per AIDS case

Alabama $12,142,447 3,320 0% $3,657

Alaskaa974,705 224 0 4,351

Arizona 18,635,537 3,978 73.5 4,685

Arkansas 4,933,831 1,466 0 3,366

California 223,607,373 42,479 88.9 5,264

Colorado 12,949,158 2,658 75.0 4,872

Connecticut 26,797,308 5,363 91.4 4,997

Delaware 5,340,795 1,518 0 3,518

District of Columbia 33,288,417 6,561 100.0 5,074

Florida 182,771,752 38,101 77.3 4,797

Georgia 54,483,301 11,226 67.6 4,853

Hawaii 3,298,130 988 0 3,338

Idahoa1,019,352 220 0 4,633

Illinois 60,837,359 12,203 87.9 4,985

Indiana 11,402,950 3,095 0 3,684

Iowa 2,067,375 619 0 3,340

Kansas 3,881,999 959 34.2 4,048

Kentucky 7,170,005 1,937 0 3,702

Louisiana 29,740,454 6,555 48.1 4,537

Mainea1,333,909 395 0 3,377

Maryland 61,230,030 12,203 93.6 5,018

Massachusetts 34,432,147 6,960 83.2 4,947

Michigan 24,046,130 5,215 68.8 4,611

Minnesota 7,139,028 1,427 88.7 5,003

Mississippi 9,454,950 2,747 0 3,442

Missouri 16,501,234 3,512 76.8 4,699

Montanaa847,196 147 0 5,763

Nebraska 1,887,660 525 0 3,596

Nevada 10,757,214 2,246 83.3 4,789

New Hampshirea1,864,452 358 69.0 5,208

New Jersey 80,222,837 16,531 84.8 4,853

New Mexico 3,338,463 982 0 3,400

New York 298,549,361 59,226 88.6 5,041

North Carolina 22,668,734 6,083 0.1 3,727

North Dakotab292,543 43 0 6,803

Appendix I: Combined CARE Act Title I and 

Title II Funding by State, Fiscal Year 2004 
Appendix I: Combined CARE Act Title I and 

Title II Funding by State, Fiscal Year 2004 

State/territory 

Combined Title I and 

Title II awards AIDS cases

Percent of AIDS cases 

in EMAs 

Total Title I and Title II 

awards per AIDS case

Ohio 20,249,202 5,171 29.2 3,916

Oklahoma 6,343,022 1,687 0 3,760

Oregon 9,084,990 2,003 68.9 4,536

Pennsylvania 59,766,256 12,840 67.4 4,655

Puerto Rico 53,026,882 10,711 79.9 4,951

Rhode Island 3,189,276 906 0 3,520

South Carolina 20,705,328 5,563 0 3,722

South Dakotaa705,706 97 0 7,275

Tennessee 21,178,234 5,080 0 4,169

Texas 118,965,938 23,922 74.5 4,973

Utah 3,235,191 882 0 3,668

Vermonta 883,059 181 0 4,879

Virginia 32,149,863 6,872 63.2 4,678

Washington 17,349,313 3,776 69.8 4,595

West Virginia 2,335,062 618 11.3 3,778

Wisconsin 5,603,506 1,507 0.4 3,718

Wyomingb360,347 76 0 4,741

Sources: GAO analysis of HRSA data. 

a

State received a Title II base award of $500,000, the minimum it could receive based on the number

of AIDS cases in the state.

b

State received a Title II base award of $200,000, the minimum it could receive based on the number

of AIDS cases in the state.

Page 34 GAO-05-841T
Appendix II: Estimated Funding Changes

Using HIV and AIDS Cases without HoldHarmless and Minimum Grant Provisions

Page 35 GAO-05-841T

Change in Title II case funding if CDCaccepted HIV case counts and AIDS case 

counts were used to distribute funding

Change in Title II base funding if HIV case 

counts from all states and AIDS case counts 

were used to distribute funding 

State/territory Dollar change Percent change Dollar change Percent change

Alabama $2,480,000 61 $1,950,000 48

Alaskaa-270,000 -55 -290,000 -58

Arizona 1,220,000 38 810,000 25

Arkansas 840,000 47 630,000 35

California -11,790,000 -38 -5,020,000 -16

Colorado 2,090,000 99 1,700,000 80

Connecticut -1,360,000 -36 -1,420,000 -38

Delaware -750,000 -41 -230,000 -13

District of Columbia -1,520,000 -35 -1,800,000 -42

Florida 2,920,000 10 -150,000 -1

Georgia -3,550,000 -38 -4,090,000 -43

Hawaii -490,000 -41 -180,000 -15

Idahoa-80,000 -17 -120,000 -24

Illinois -3,210,000 -36 -70,000 -1

Indiana 1,170,000 31 760,000 20

Iowa 20,000 2 40,000 6

Kansas 210,000 21 -110,000 -11

Kentucky -960,000 -41 -1,070,000 -45

Louisiana 2,070,000 33 1,340,000 22

Mainea-210,000 -43 40,000 9

Maryland -3,030,000 -36 3,000,000 35

Massachusetts -1,920,000 -37 510,000 10

Michigan 1,160,000 27 660,000 15

Minnesota 660,000 64 500,000 49

Mississippi 1,580,000 47 1,180,000 35

Missouri 1,260,000 45 880,000 32

Montanaa-390,000 -79 -170,000 -34

Nebraska 140,000 23 80,000 13

Nevada 830,000 50 600,000 35

New Hampshirea-310,000 -63 -122,000 -24

New Jersey 2,510,000 20 1,120,000 9

New Mexico 50,000 4 -60,000 -5

New York -600,000 -1 -4,640,000 -11

Appendix II: Estimated Funding Changes 

Using HIV and AIDS Cases without HoldHarmless and Minimum Grant Provisions 
Appendix II: Estimated Funding Changes

Using HIV and AIDS Cases without HoldHarmless and Minimum Grant Provisions

Change in Title II case funding if CDCaccepted HIV case counts and AIDS case 

counts were used to distribute funding

Change in Title II base funding if HIV case 

counts from all states and AIDS case counts 

were used to distribute funding 

State/territory Dollar change Percent change Dollar change Percent change

North Carolina 4,910,000 66 3,910,000 53

North Dakotab -124,000 -62 -130,000 -65

Ohio 2,360,000 43 1,700,00 31

Oklahoma 980,000 48 730,000 36

Oregon -630,000 -38 -290,000 -17

Pennsylvania -2,370,000 -22 -3,120,000 -29

Puerto Rico -2,970,000 -36 -3,460,000 -42

Rhode Island -450,000 -41 -180,000 -16

South Carolina 2,280,000 34 1,540,000 23

South Dakotaa-290,000 -58 -310,000 -62

Tennessee 2,160,000 35 1,480,000 24

Texas 840,000 4 -1,010,000 -5

Utah 40,000 4 -50,000 -5

Vermonta-370,000 -74 -260,000 -53

Virginia 3,040,000 51 2,260,000 38

Washington -1,170,000 -38 160,000 5

West Virginia 170,000 24 90,000 13

Wisconsin 910,000 50 690,000 37

Wyomingb-90,000 -47 -100,000 -51

Sources: GAO analysis of CDC and HRSA data for fiscal year 2004. 

Notes: Rounded to nearest $10,000. For this testimony, we chose Title II base grants to illustrate the 

effect of using HIV case counts in funding formulas.

a

State received a Title II base award of $500,000, the minimum it could receive based on the number

of AIDS cases in the state.

b

State received a Title II base award of $200,000, the minimum it could receive based on the number

of AIDS cases in the state.

Page 36 GAO-05-841T
Appendix III: Estimated Funding Changes

Using HIV and AIDS Cases with HoldHarmless and Minimum Grant Provisions

Page 37 GAO-05-841T

Change in Title II base funding if CDCaccepted HIV case counts and AIDS case 

counts were used to distribute funding

Change in Title II base funding if HIV case 

counts from all states and AIDS case counts 

were used to distribute funding 

State/territory Dollar change Percent change Dollar change Percent change

Alabama $1,120,000 28 $960,000 24

Alaskaa0 0 0 0

Arizona 610,000 19 410,000 13

Arkansas 290,000 17 230,000 13

California 0 0 0 0

Colorado 1,530,000 72 1,340,000 63

Connecticut -150,000 -4 -150,000 -4

Delaware -410,000 -22 -410,000 -22

District of Columbia -940,000 -22 -940,000 -22

Florida -1,380,000 -5 -2,930,000 -10

Georgia -1,350,000 -14 -1,350,000 -14

Hawaii -70,000 -6 -70,000 -6

Idahoa0 0 0 0

Illinois -1,780,000 -20 -790,000 -9

Indiana 130,000 4 20,000 1

Iowa -90,000 -11 -90,000 -11

Kansas 0 0 0 0

Kentucky -400,000 -17 -400,000 -17

Louisiana 660,000 11 370,000 6

Mainea0 0 0 0

Maryland -1,650,000 -20 2,050,000 24

Massachusetts -620,000 -12 10,000 0

Michigan 350,000 8 120,000 3

Minnesota 460,000 45 370,000 36

Mississippi 550,000 17 430,000 13

Missouri 710,000 26 530,000 19

Montanaa0 0 0 0

Nebraska -20,000 -3 -40,000 -6

Nevada 520,000 31 390,000 23

New Hampshirea0 0 0 0

New Jersey 600,000 5 0 0

New Mexico -70,000 -6 -70,000 -6

New York -1,730,000 -4 -1,730,000 -4

Appendix III: Estimated Funding Changes 

Using HIV and AIDS Cases with HoldHarmless and Minimum Grant Provisions 
Appendix III: Estimated Funding Changes

Using HIV and AIDS Cases with HoldHarmless and Minimum Grant Provisions

Change in Title II base funding if CDCaccepted HIV case counts and AIDS case 

counts were used to distribute funding

Change in Title II base funding if HIV case 

counts from all states and AIDS case counts 

were used to distribute funding 

State/territory Dollar change Percent change Dollar change Percent change

North Carolina 2,340,000 32 2,050,000 28

North Dakotab 300,000 150 300,000 150

Ohio 890,000 16 660,000 12

Oklahoma 340,000 17 270,000 13

Oregon -130,000 -8 -130,000 -8

Pennsylvania -1,840,000 -17 -1,840,000 -17

Puerto Rico -320,000 -4 -320,000 -4

Rhode Island -30,000 -2 -30,000 -2

South Carolina 390,000 6 180,000 3

South Dakotaa0 0 0 0

Tennessee 420,000 7 220,000 4

Texas 1,140,000 -6 -1,140,000 -6

Utah -60,000 -6 -60,000 -6

Vermonta0 0 0 0

Virginia 1,510,000 26 1,200,000 20

Washington -200,000 -7 -180,000 -6

West Virginia -13,000 -2 -40,000 -5

Wisconsin 340,000 18 270,000 15

Wyomingb300,000 150 300,000 150

Sources: GAO analysis of CDC and HRSA data for fiscal year 2004. 

Notes: Rounded to nearest $10,000. For this testimony, we chose Title II base grants to illustrate the 

effect of using HIV case counts in funding formulas.

a

State received a Title II base award of $500,000, the minimum it could receive based on the number

of AIDS cases in the state.

b

State received a Title II base award of $200,000, the minimum it could receive based on the number

of AIDS cases in the state.

Page 38 GAO-05-841T
Appendix IV: ADAP Program Eligibility

Restrictions Reported by 52 ADAPs, ADAP

Grant Year 2004 

Page 39 GAO-05-841T

Restrictions

ADAPs

Capped 

enrollment 

Fixed 

copayment

Sliding 

scale 

copayment

Asset 

limitation

Annual 

income

cap 

Capped HIV/ 

AIDS 

expenditures 

per patient 

Capped HIV/ AIDS 

expenditures or had 

wait lists or both for 

protease inhibitor

drugs 

Alabama

Alaska

Arizona

Arkansas • •

California • •

Colorado • • • •

Connecticut

Delaware • •

District of Columbia • •

Florida • •

Georgia • •

Hawaii •

Idaho • •

Illinois •

Indiana

Iowa

Kansas •

Kentucky • •

Louisiana •

Maine

Maryland • •

Massachusetts •

Michigan

Minnesota • •

Mississippi •

Missouri •

Montana •

Nebraska

Nevada • •

New Hampshire

New Jersey •

Appendix IV: ADAP Program Eligibility 

Restrictions Reported by 52 ADAPs, ADAP 

Grant Year 2004 
Appendix IV: ADAP Program Eligibility

Restrictions Reported by 52 ADAPs, ADAP

Grant Year 2004 

Restrictions

ADAPs

Capped 

enrollment 

Fixed 

copayment

Sliding 

scale 

copayment

Asset 

limitation

Annual 

income

cap 

Capped HIV/ 

AIDS 

expenditures 

per patient 

Capped HIV/ AIDS 

expenditures or had 

wait lists or both for 

protease inhibitor

drugs 

New Mexico • •

New York • •

North Carolina • •

North Dakota •

Ohio •

Oklahoma • •

Oregon • • •

Pennsylvania •

Puerto Rico 

Rhode Island •

South Carolina •

South Dakota • •

Tennessee •

Texas •

Utah • •

Vermont

Virginia

Washington • •

West Virginia 

Wisconsin

Wyoming

Total 7 2 7 16 20 5 2

Source: HRSA and state ADAP profile reports.

Note: The ADAP 2004 grant year covers April 1, 2004, through March 31, 2005.

Page 40 GAO-05-841T
Appendix V: Additional ADAP Funding and its

Percentage of the CARE ACT Title II ADAP

Base Grants and per AIDS Case by State

Page 41 GAO-05-841T

Table 10: Additional ADAP Funding Sources, Fiscal Year 2004 

 Title II Severe Need grant 

State ADAP 

ADAP 

Severe 

Need grant 

State matching

funds for

Severe Need 

grant 

Title II nonADAP base 

grant transfer

Title I EMA 

transfer State funding 

Other 

funding 

sources

Total 

additional 

ADAP funding

Alabama $824,913 $206,228 $0 B $2,500,000 $0 $3,531,141

Alaska 0 0 0 B 50,000 0 50,000

Arizona 0 0 0 0 1,000,000 78,546 1,078,546

Arkansas A A 0 B 330,810 393,000 723,810

California A A 12,168,628 0 63,934,245 47,370,750 123,473,623

Colorado 660,427 165,107 136,000 560,254 934,134 3,212,522 5,668,444

Connecticut A A 0 0 606,678 0 606,678

Delaware A A 0 B 0 832,382 832,382

D.C. A A 0 0 400,000 0 400,000

Florida A A 1,916,336 0 9,000,000 0 10,916,336

Georgia 2,789,298 697,324 0 1,540,022 11,305,339 0 16,331,983

Hawaii A A 0 B 440,535 0 440,535

Idaho 54,663 13,666 261,150 B 163,461 300,000 792,940

Illinois A A 0 0 7,000,000 5,619,843 12,619,843

Indiana A A 2,720,419 B 0 102,331 2,822,750

Iowa 0 0 0 B 0 0 0

Kansas A A 0 B 400,000 550,000 950,000

Kentucky 481,282 120,320 100,000 B 90,000 199,462 991,064

Louisiana 1,628,705 407,176 0 0 0 422,638 2,458,519

Maine 0 0 0 B 57,638 125,327 182,965

Maryland A A 65,250 105,925 0 2,100,000 2,271,175

Massachusetts A A 0 104,819 747,990 1,900,000 2,788,809

Michigan A A 0 0 0 5,500,000 5,500,000

Minnesota A A 0 0 1,100,000 2,743,522 3,843,522

Mississippi A A 1,093,008 B 750,000 0 1,843,008

Missouri A A 771,167 1,549,422 669,000 1,913,547 4,921,136

Montana 36,525 9,131 178,548 B 0 7,120 231,324

Nebraska 130,445 32,611 74,000 B 115,938 160,000 512,994

Nevada A A 0 65,250 1,350,947 0 1,416,197

New Hampshire A A 0 B 0 0 0

New Jersey A A 0 0 0 13,050,000 13,050,000

New Mexico A A 0 B 0 0 0

Appendix V: Additional ADAP Funding and 

its Percentage of the CARE Act Title II ADAP 

Base Grants and per AIDS Case by State 
Appendix V: Additional ADAP Funding and its

Percentage of the CARE ACT Title II ADAP

Base Grants and per AIDS Case by State

 Title II Severe Need grant 

State ADAP 

ADAP 

Severe 

Need grant 

State matching

funds for

Severe Need 

grant 

Title II nonADAP base 

grant transfer

Title I EMA 

transfer State funding 

Other 

funding 

sources

Total 

additional 

ADAP funding

New York A A 2,524,145 5,870,000 33,000,000 64,500,000 105,894,145

North Carolina 1,511,429 377,857 0 B 8,355,195 3,338,000 13,582,481

North Dakota 0 0 85,400 B 0 32,000 117,400

Ohio A A 0 300,000 7,843 20,000 327,843

Oklahoma 419,165 104,791 486,486 NA 786,000 361,000 2,157,442

Oregon A A 0 0 300,000 5,650,000 5,950,000

Pennsylvania A A 0 0 10,452,000 6,044,000 16,496,000

Puerto Rico 2,661,337 0a3,455,671 0 2,093,000 0 8,210,008

Rhode Island A A 0 B 0 700,000 700,000

South Carolina 1,382,225 345,556 0 B 500,000 0 2,227,781

South Dakota 0 0 330,744 B 0 0 330,744

Tennessee 0 0 0 B 0 0 0

Texas 5,943,843 1,485,961 500,000 0 28,538,504 0 36,468,308

Utah 0 0 0 B 0 0 0

Vermont 0 0 0 B 175,000 130,000 305,000

Virginia 1,707,470 426,867 0 0 2,612,200 0 4,746,537

Washington A A 0 800,487 4,842,484 925,000 6,567,971

West Virginia 153,553 38,388 75,000 B 0 180,000 446,941

Wisconsin 374,441 93,610 0 B 186,658 855,317 1,510,026

Wyoming A A 0 B 0 0 0

Total $20,759,721 $4,524,593 $26,941,952 $10,932,179 $194,795,599 $169,334,307 $427,288,351

Source: HRSA and GAO analysis. 

A State was not eligible for a grant.

B State did not have an EMA.

a

Puerto Rico is not required to provide match funds.

Page 42 GAO-05-841T
Appendix V: Additional ADAP Funding and its

Percentage of the CARE ACT Title II ADAP

Base Grants and per AIDS Case by State

Table 11: Additional ADAP Funding as Percentage of ADAP Base Grant and per AIDS Case, Fiscal Year 2004 

State ADAP 

Total additional ADAP 

funding ADAP base grant

Total additional ADAP 

funding as percentage

of the ADAP base grant 

Total additional ADAP 

funding per AIDS case

Alabama $3,531,141 $7,004,635 50% $1,064

Alaska 50,000 472,602 11% 223

Arizona 1,078,546 8,392,903 13% 271

Arkansas 723,810 3,116,716 23% 494

California 123,473,623 89,623,465 138% 2,907

Colorado 5,668,444 5,607,928 101% 2,133

Connecticut 606,678 11,315,018 5% 113

Delaware 832,382 3,202,722 26% 548

D.C. 400,000 13,842,594 3% 61

Florida 10,916,336 80,386,630 14% 287

Georgia 16,331,983 23,684,951 69% 1,455

Hawaii 440,535 2,084,512 21% 446

Idaho 792,940 464,163 171% 3,604

Illinois 12,619,843 25,746,254 49% 1,034

Indiana 2,822,750 6,529,924 43% 912

Iowa 0 1,305,985 0% 0

Kansas 950,000 2,045,495 46% 991

Kentucky 991,064 4,086,741 24% 512

Louisiana 2,458,519 13,829,935 18% 375

Maine 182,965 833,383 22% 463

Maryland 2,271,175 25,746,254 9% 186

Massachusetts 2,788,809 14,684,416 19% 401

Michigan 5,500,000 11,002,763 50% 1,055

Minnesota 3,843,522 3,010,727 128% 2,693

Mississippi 1,843,008 5,795,703 32% 671

Missouri 4,921,136 7,409,723 66% 1,401

Montana 231,324 310,145 75% 1,574

Nebraska 512,994 1,107,661 46% 977

Nevada 1,416,197 4,738,678 30% 631

New Hampshire 0 755,319 0% 0

New Jersey 13,050,000 34,877,598 37% 789

New Mexico 0 2,127,024 0% 0

New York 105,894,145 124,956,784 85% 1,788

North Carolina 13,582,481 12,834,095 106% 2,233

Page 43 GAO-05-841T
Appendix V: Additional ADAP Funding and its

Percentage of the CARE ACT Title II ADAP

Base Grants and per AIDS Case by State

State ADAP 

Total additional ADAP 

funding ADAP base grant

Total additional ADAP 

funding as percentage

of the ADAP base grant 

Total additional ADAP 

funding per AIDS case

North Dakota 117,400 92,543 127% 2,730

Ohio 327,843 10,909,930 3% 63

Oklahoma 2,157,442 3,655,707 59% 1,279

Oregon 5,950,000 4,225,989 141% 2,971

Pennsylvania 16,496,000 27,090,216 61% 1,285

Puerto Rico 8,210,008 22,598,388 36% 767

Rhode Island 700,000 1,911,506 37% 773

South Carolina 2,227,781 11,736,984 19% 400

South Dakota 330,744 204,654 162% 3,410

Tennessee 0 12,018,438 0% 0

Texas 36,468,308 50,471,351 72% 1,524

Utah 0 1,980,565 0% 0

Vermont 305,000 382,007 80% 1,685

Virginia 4,746,537 14,498,751 33% 691

Washington 6,567,971 7,966,718 82% 1,739

West Virginia 446,941 1,303,875 34% 723

Wisconsin 1,510,026 3,179,514 47% 1,002

Wyoming 0 160,347 0% 0

Total $427,288,351 $ 727,320,929 59% -

Source: HRSA and GAO analysis. 

Page 44 GAO-05-841T
Appendix V: Additional A

Percentage of the CARE A

Base Grants and per AID

DAP Funding and its

CT Title II ADAP

S Case by State

Page 45 GAO-05-841T

Related GAO Products 

Ryan White CARE ACT: Title I Funding for San Francisco. 

t i t

li i f i ti i f

i t

f t

t i ti

f t i l l

t

l - it i

it l l t

t

t i ti

GAO/HEHS-00-

189R. Washington, D.C.: August 24, 2000. 

Ryan White CARE Act: Opportunities to Enhance Funding Equity. GAO/THEHS-00-150. Washington, D.C.: July 11, 2000. 

HIV/AIDS: Use of Ryan Whi e CARE Act and Other Ass s ance Grant

Funds. GAO/HEHS-00-54. Washington, D.C.: March 1, 2000. 

HIV/AIDS Drugs: Funding Imp cat ons o New Comb na on Therap es or 

Federal and State Programs. GAO/HEHS-99-2. Washington, D.C.: October 

14, 1998. 

Revis ng Ryan Whi e Funding Formulas. GAO/HEHS-96-116R. Washington,

D.C.: March 26, 1996. 

Ryan White CARE Act o 1990: Oppor unities to Enhance Funding Equity. 

GAO/HEHS-96-26. Washington, D.C.: November 13, 1995. 

Ryan White CARE Act: Access o Services by M nori es, Women, and 

Substance Abusers. GAO/T-HEHS-95-112. Washington, D.C.: July 17, 1995. 

Ryan White CARE Act o 1990: Oppor unit es Are Avai ab e to Improve 

Funding Equi y. GAO/T-HEHS-95-126. Washington, D.C.: April 5, 1995. 

Fol ow up on Ryan Wh e Test mony. GAO/HEHS-95-119R. Washington, 

D.C.: March 31, 14, 1995.

Ryan White CARE ACT of 1990: Opportun ies Are Avai ab e o Improve 

Funding Equi y. GAO/T-HEHS-95-91. Washington, D.C.: February 22, 1995.

Ryan White Funding Formulas. GAO/HEHS-95-79R. Washington, D.C.: 

February 14, 1995. 

Ryan White CARE Act: Access o Services by M nori es, Women, and 

Substance Abusers. GAO/HEHS-95-94. Washington, D.C.: January 13, 1995.

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