United States Government Accountability Office

GAO Report to Congressional Requesters

HIV/AIDS February 2006 

Changes Needed to 

Improve the 

Distribution of Ryan 

White CARE Act and 

Housing Funds 

 

GAO-06-332 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

February 2006

HIV/AIDS

Changes Needed to Improve the 

Distribution of Ryan White CARE Act and 

Housing Funds 

Highlights of GAO-06-332, a report to 

congressional requesters 

Among federal efforts to address

the HIV/AIDS epidemic are the 

CARE Act of 1990 and the Housing

Opportunities for Persons with 

AIDS program (HOPWA) 

administered by the Departments 

of Health and Human Services 

(HHS) and Housing and Urban

Development (HUD), respectively. 

Both use formulas based upon a 

grantee’s number of AIDS cases,

rather than HIV and AIDS cases, to

distribute funds to metropolitan 

areas, states, and territories. HIV 

cases must be incorporated with

AIDS cases in CARE Act formulas

not later than fiscal year 2007. 

GAO was asked to examine 

(1) how CARE Act and HOPWA 

funds are allocated among types of

services, (2) the extent of funding

distribution differences among 

CARE Act and HOPWA grantees, 

and how funding formula 

provisions contribute to these 

differences, and (3) what

distribution differences could 

result from incorporating HIV case

counts in CARE Act and HOPWA 

funding formulas. 

What GAO Recommends

If Congress wishes CARE Act and 

HOPWA funding to more closely 

reflect the distribution of persons 

living with AIDS, it should consider

taking actions that lead to more

comparable funding per case by

revising the funding formulas. HHS 

and HUD generally agreed with

GAO’s identification of issues in

the funding formulas. 

CARE Act and HOPWA grants are allocated by grantees for health care, 

housing assistance, and a variety of services for people with HIV/AIDS. 

These grants provide services for persons who have been diagnosed with 

HIV that has not progressed to AIDS as well as those for whom it has. In 

fiscal year 2003, more than half of Title I CARE Act funds awarded to eligible 

metropolitan areas (EMAs) were allocated for health care services such as

outpatient care and home health services, and over two-thirds of Title II 

CARE Act funds awarded to states and territories were allocated for 

medications. Two-thirds of HOPWA funds were used for direct housing costs 

for people with HIV/AIDS and their families. 

Multiple provisions in the CARE Act and HOPWA grant funding formulas as 

enacted result in funding not being comparable per AIDS case across 

grantees. First, both the CARE Act and HOPWA use measures of AIDS cases 

that do not accurately reflect the number of persons living with AIDS. For 

example, the statutory funding formulas require the use of cumulative AIDS 

case counts, which could include deceased cases. Second, AIDS cases within 

EMAs are counted once for determining funding under Title I of the CARE 

Act for EMAs and again under Title II for determining funding for the states 

and territories in which those EMAs are located. As a result, states with 

EMAs receive more total funding per case than states without EMAs. Third, 

CARE Act 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. For example, under Title I’s hold-harmless 

provision, one EMA continues to have deceased AIDS cases factored into its 

allocation because its hold-harmless funding dates back to the mid-1990s 

when formula funding was based on a count of AIDS cases from the 

beginning of the epidemic. 

If HIV case counts had been incorporated along with AIDS case counts in 

allocating fiscal year 2004 CARE Act and HOPWA grants, funding would 

have shifted among jurisdictions. Grantees in the South and the Midwest 

generally would have received more funding, although there would have 

been grantees that would have received increased funding and grantees that 

would have received decreased funding in every region of the country. 

Although CARE Act and HOPWA grantees have established HIV case 

reporting systems, differences between these systems—in their maturity and 

reporting methods, for instance—would impact the appropriateness of using 

HIV case counts in distributing CARE Act and HOPWA funding. GAO found 

that CARE Act and HOPWA fiscal year 2004 funding would have shifted to 

jurisdictions with more mature HIV reporting systems. 

www.gao.gov/cgi-bin/getrpt?GAO-06-332.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Marcia Crosse 

at (202) 512-7119 or crossem@gao.gov. 
Contents 

Letter 1

Background 6

Results in Brief 14

CARE Act and HOPWA Funds Allocated for Health Care, Housing 

Assistance, and a Variety of Other Services 17

Multiple Provisions Contribute to Disproportionate Distribution of 

CARE Act and HOPWA Formula Funding 21

Funding Effect of Using HIV Case Counts Would Depend on 

Multiple Factors 45

Conclusions 63

Matters for Congressional Consideration 64

Agency Comments and Our Evaluation 65

Appendix I Objectives, Scope, and Methodology 69 

Objectives 69

Scope and Methodology 69

Appendix II CARE Act Title I Awards, Fiscal Year 2004 80 

Appendix III CARE Act Title II Awards, Fiscal Year 2004 82 

Appendix IV HOPWA Formula Grantees and Award Amounts, 

Fiscal Year 2004 84 

Appendix V HOPWA Base Funding Allocations Using Cumulative 

and Living AIDS Cases, Fiscal Year 2004 88 

Appendix VI Total CARE Act Title I and Title II Funding by 

State and Territory, Fiscal Year 2004 92 

Page i GAO-06-332 HIV/AIDS Funding
Appendix VII HRSA’s Title I EMAs, GAO-Identified Set of 

Comparable 2004 OMB-Defined Metropolitan Areas, 

and Changes 94 

Appendix VIII Estimated CARE Act Title I Funding Changes 

from Use of HIV Case Counts and ELCs with Holdharmless 99 

Appendix IX Estimated CARE Act Title II Base Funding Changes 

from Use of HIV Case Counts and ELCs with Holdharmless 101 

Appendix X Estimated CARE Act ADAP Base Funding Changes 

from Use of HIV Case Counts and ELCs with Holdharmless 103 

Appendix XI Estimated CARE Act Title I Base Funding Changes 

from Use of HIV Case Counts and ELCs without 

Hold-harmless 105 

Appendix XII Estimated CARE Act Title II Base Funding Changes 

from Use of HIV Case Counts and ELCs without 

Hold-harmless 107 

Appendix XIII Estimated CARE Act ADAP Base Funding Changes 

from Use of HIV Case Counts and ELCs without 

Hold-harmless 109 

Page ii GAO-06-332 HIV/AIDS Funding
Appendix XIV Estimated HOPWA Base Funding Changes from 

Use of HIV and Living AIDS Case Counts, Fiscal 

Year 2004 111 

Appendix XV Comments from the Department of Health and 

Human Services 115 

Appendix XVI Comments from the Department of Housing and 

Urban Development 120 

Appendix XVII GAO Contact and Staff Acknowledgments 127 

Related GAO Products 128 

Tables 

Table 1: CARE Act Programs, 2004 9

Table 2: Description of CARE Act Title I and Title II Formula 

Grants 11

Table 3: Relationship between ELCs in EMAs and Total CARE Act 

Title I and II Funding per ELC, Fiscal Year 2004 28

Table 4: Title II Emerging Communities in Fiscal Year 2004 30

Table 5: Title I Hold-harmless Funding, Fiscal Year 2004 33

Table 6: Grandfathered EMAs, Fiscal Year 2004 36

Table 7: States That Received Title II Hold-harmless Funding from 

Severe Need Set-aside, Fiscal Year 2004 39

Table 8: Fiscal Year 2004 HOPWA Formula Funding 40

Table 9: CDC Acceptance of HIV Case Counts and Year of 

Establishment of HIV-reporting Systems, December 2005 48

Table 10: Reported HIV Cases and ELCs as of June 2003 61

Table 11: U.S. Census Bureau Regions 78

Table 12: EMAs with Service Area Changes 94

Table 13: EMAs with No Service Area Changes 97

Page iii GAO-06-332 HIV/AIDS Funding
Figures 

Figure 1: Federal HIV/AIDS Funding by Category, Fiscal Year 2004 8

Figure 2: Allocation of CARE Act Title I Funds, Fiscal Year 2003 18

Figure 3: Allocation of CARE Act Title II Funds, Fiscal Year 2003 19

Figure 4: Allocation of CARE Act Title III Funds, Fiscal Year 2002 20

Figure 5: Allocation of HOPWA Funds, Fiscal Year 2003 21

Abbreviations 

ADAP AIDS Drug Assistance Program 

AIDS acquired immunodeficiency syndrome 

CARE Act Ryan White Comprehensive AIDS Resources Emergency 

 Act 

CDC Centers for Disease Control and Prevention 

ELC estimated living AIDS case 

EMA eligible metropolitan area 

EMSA eligible metropolitan statistical area 

HHS Department of Health and Human Services 

HIV human immunodeficiency virus 

HOPWA Housing Opportunities for Persons with AIDS program 

HRSA Health Resources and Services Administration 

HUD Department of Housing and Urban Development 

IOM Institute of Medicine 

MSA metropolitan statistical area 

OMB Office of Management and Budget 

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Page iv GAO-06-332 HIV/AIDS Funding
United States Government Accountability Office

Washington, DC 20548 

February 28, 2006 

The Honorable Michael B. Enzi 

Chairman 

Committee on Health, Education, Labor, and Pensions 

United States Senate 

The Honorable Mark E. Souder 

Chairman 

Subcommittee on Criminal Justice, Drug Policy 

 and Human Resources 

Committee on Government Reform 

House of Representatives 

The Honorable Tom A. Coburn 

United States Senate 

The Honorable Judd Gregg 

United States Senate 

It has been nearly 25 years since the first cases of acquired 

immunodeficiency syndrome (AIDS) in the United States were identified. 

Treatment advances in combination antiretroviral therapy during the 

1990s have significantly reduced AIDS mortality and slowed the 

progression from a positive human immunodeficiency virus (HIV) 

diagnosis to AIDS.1

 Yet the number of new HIV infections, which is 

estimated at 40,000 annually, has not decreased. The Centers for Disease 

Control and Prevention (CDC) estimate that between 1,039,000 and 

1,185,000 people in the United States were living with HIV/AIDS at the end 

of 2003. The number of people infected with HIV/AIDS is likely to have 

risen since then, and CDC estimates that, as of December 2004, it included 

415,193 individuals with AIDS. 

Among the federal government’s efforts to address the HIV/AIDS epidemic 

are the Ryan White Comprehensive AIDS Resources Emergency Act of 

HIV/AIDS Funding

 

1

HIV is the virus that causes AIDS. Throughout this report, we use the common term 

“HIV/AIDS” to refer to HIV disease, inclusive of cases that have progressed to AIDS. When 

we use these terms alone, HIV refers to the disease without the presence of AIDS, and 

AIDS refers exclusively to HIV disease that has progressed to AIDS. 

Page 1 GAO-06-332 
1990 (CARE Act)2

 and the Housing Opportunities for Persons with AIDS 

program (HOPWA). The CARE Act, which is administered by the 

Department of Health and Human Services’s (HHS) Health Resources and 

Services Administration (HRSA), established a number of grant programs 

through which funds are made available to states—including the District 

of Columbia—territories,3

 and metropolitan areas to provide health care, 

medications, and support services to individuals and families affected by 

HIV/AIDS. The AIDS Housing Opportunity Act, which was enacted in 1990 

and is administered by the Department of Housing and Urban 

Development (HUD), established HOPWA.4

 HOPWA provides housing 

assistance for low-income persons with HIV/AIDS and their families. In 

fiscal year 2004, over $2 billion was distributed through the CARE Act and 

$295 million was distributed through HOPWA. 

Under the CARE Act and HOPWA, funding is distributed through a 

combination of competitive grants and, in accordance with CDC data on 

the number of individuals diagnosed with AIDS, formula grants. 

Approximately 68 percent of CARE Act funding and 90 percent of HOPWA 

funding were distributed through formula grants in fiscal year 2004. The 

use of AIDS cases in the distribution of formula grants was prescribed 

because most jurisdictions tracked and reported AIDS cases instead of 

HIV cases when the grant programs were established. Because of concerns 

that a jurisdiction’s disease burden is not adequately reflected by only 

counting cases that have progressed to AIDS, the Ryan White CARE Act 

Amendments of 2000 required the use of HIV/AIDS case counts in the 

distribution of formula grants not later than fiscal year 2007.5

 We have 

reported that because CARE Act grants serve persons who have been 

diagnosed with HIV that has not progressed to AIDS as well as those for 

whom it has, it would be reasonable to distribute funds on the basis of the 

 

2

Pub. L. No. 101-381, 104 Stat. 576 (codified as amended at 42 U.S.C. §§ 300ff–300ff-111 

(2000)). Unless otherwise indicated, references to the CARE Act are to current law. 

3

In addition to the 50 states, the CARE Act authorizes grants to the District of Columbia, 

the Commonwealth of Puerto Rico, Guam, the Virgin Islands, American Samoa, the 

Commonwealth of the Northern Mariana Islands, the Republic of the Marshall Islands, the 

Federated States of Micronesia, and the Republic of Palau. Throughout this report, the 

term state refers to the 50 states and the District of Columbia, and territory refers to these 

listed territories. 

4

Pub. L. No. 101-625, tit. VIII, subtit. D, 104 Stat. 4079, 4375 (codified as amended at 42 

U.S.C. §§ 12901–12912 (2000)). Unless otherwise indicated, references to HOPWA are to the 

program as administered under current law. 

5

Pub. L. No. 106-345, § 206(b), 114 Stat. 1319, 1334–35. 

Page 2 GAO-06-332 HIV/AIDS Funding
total number of persons living with HIV/AIDS.6

 Incorporating HIV data 

along with AIDS data would result in targeting funds more accurately 

according to need. However, because there is a lack of HIV data that are 

sufficiently adequate and reliable to serve as a basis for CARE Act formula 

grant allocations, as of December 2005, HIV cases have not been used in 

the distribution of formula grants under the CARE Act. 

Various provisions governing CARE Act and HOPWA grants affect the 

distribution of funds. As Congress prepares to reauthorize CARE Act 

programs, you asked us to examine how funds are distributed under the 

CARE Act and HOPWA. We are reporting on (1) how CARE Act and 

HOPWA funds are allocated by grantees among the types of services each 

program supports; (2) the extent of funding differences among CARE Act 

and HOPWA grantees, and how specific CARE Act and HOPWA fundingformula provisions contribute to these differences; and (3) what 

distribution differences could result from using HIV cases in CARE Act 

and HOPWA funding formulas. 

To report on these issues, we reviewed the CARE Act of 1990, as well as 

the 1996 and 2000 CARE Act amendments, the AIDS Housing Opportunity 

Act of 1990, HRSA and HUD documents on CARE Act and HOPWA 

funding, HUD memoranda, Institute of Medicine (IOM) reports on the 

CARE Act, and other related reports. We analyzed data, spanning from 

2002 through 2004, obtained from HRSA, HUD, and CDC.7

 We also 

collected data on HIV case counts from state and local HIV/AIDS officials. 

We interviewed CDC, HRSA, HUD, and state officials, as well as officials 

from the National Alliance of State and Territorial AIDS Directors. 

To determine how grantees allocate CARE Act and HOPWA funds by type 

of service, we obtained information from HRSA and HUD on grantees’ use 

of funds. We analyzed these data and, where available, calculated the 

percentage of total spending represented by each category of service. To 

assess the reliability of HRSA and HUD data on allocations of CARE Act 

and HOPWA grant funds, we interviewed agency officials about the data 

 

6

GAO, Ryan White CARE Act: Opportunities to Enhance Funding Equity, 

GAO/T-HEHS-00-150 (Washington, D.C.: July 11, 2000), 6. 

7

Our analyses of CARE Act and HOPWA funding-formula provisions and the use of HIV 

cases in making CARE Act and HOPWA funding allocations include the states, Puerto Rico, 

and metropolitan areas eligible for funding. 

Page 3 GAO-06-332 HIV/AIDS Funding
and reviewed relevant documentation. We determined that the data were 

sufficiently reliable for the purposes of our report. 

In order to examine the effect of specific funding-formula provisions on 

the distribution of fiscal year 2004 funds by HRSA and HUD under the 

CARE Act and HOPWA to grantees, we first assessed the use of 2- and 

5-year cumulative AIDS case counts8

 and the use of estimated living AIDS 

cases (ELC) in CARE Act programs by comparing these measures with 

living AIDS case counts received from CDC. HRSA calculates a 

jurisdiction’s ELCs by using data from CDC on the reported AIDS case 

counts for the last 10 years and weighting those numbers to account for 

the likelihood of deaths. We then examined the effect of the following 

CARE Act formula provisions: the counting of ELCs in eligible 

metropolitan areas (EMA) for both Title I and Title II funding,9

 the dividing 

of Emerging Communities into two tiers for determining funding, the 

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

Title II hold-harmless provision that is funded from amounts that would 

otherwise be available for states with severe need in their drug programs. 

To examine the effect of each provision on the distribution of CARE Act 

and HOPWA funds, we measured differences either on a per case basis, by 

the amount of funding received, or both. To determine the effects of 

adopting the Office of Management and Budget’s (OMB) 2004 definitions 

of metropolitan statistical areas (MSA) on EMAs, we compared the 

boundaries of existing EMAs with those that would be created, and we 

determined the change in the number of ELCs that would be counted 

under Title I. In addition, we examined the effect of using living AIDS 

cases instead of cumulative AIDS cases10 in making HOPWA base grant 

distributions by comparing the actual funding distributions with simulated 

 

8

In this report, cumulative AIDS cases are the total number of AIDS cases, both living and 

dead, reported in a jurisdiction in a given period. 

9

The 1990 CARE Act added a new title XXVI to the Public Health Service Act. In general, 

because Part A of that new title, which authorizes grants to metropolitan areas, was 

established by Title I of the CARE Act, it is commonly referred to as Title I, and because 

part B, which authorizes grants to states and territories, was established by Title II of the 

CARE Act, it is commonly referred to as Title II. Titles III and IV of the Act established 

Parts C and D, respectively, authorizing grants for early intervention services as well as 

grants for services to women and children, among other things. Under Title I, a 

metropolitan area with a population of at least 500,000 and more than 2,000 reported AIDS 

cases in the last 5 calendar years is eligible to receive Title I funding, and is defined as an 

EMA. 

10Under HOPWA, cumulative AIDS cases are the total AIDS cases reported in a jurisdiction 

since the beginning of the epidemic in 1981. 

Page 4 GAO-06-332 HIV/AIDS Funding
distributions using living AIDS cases.11 We also assessed the effect of 

HOPWA bonus grants on funding for eligible metropolitan statistical areas 

(EMSA) by examining the size of these grants and which EMSAs received 

them.12

In our analyses we used funding per AIDS case to illustrate the effect of 

certain funding-formula provisions on the distribution of CARE Act and 

HOPWA funds. There are other considerations that could be included in 

funding formulas that could justify deviations from equal funding per case. 

For example, differing health care and housing costs across regions and 

differences in grantees’ capacities to fund services from local resources 

could be used as bases for distributing program funds and could justify 

such deviations.13 Currently, these considerations are not taken into 

account when distributing formula grants under either the CARE Act or 

HOPWA, and are not considered here. To assess the reliability of the HRSA 

and HUD data on the distribution of funds under the CARE Act and 

HOPWA, we asked agency officials about how the data were developed 

and reported. We also reviewed relevant documentation. We determined 

the data were sufficiently reliable for the purposes of our report. 

To show how CARE Act and HOPWA funding could be affected by 

including HIV cases in funding formulas, we examined how CARE Act and 

HOPWA fiscal year 2004 formula grants would have been affected by using 

 

11Under HOPWA there is a single formula grant for each grantee. It consists of funding 

determined using a base factor and funding determined using a bonus factor (which may be 

zero). In this report, we use the terms base grants and bonus grants to differentiate 

between funding determined using these factors. 

12Bonus grants are awarded to EMSAs that have a higher-than-average per capita incidence 

of AIDS over the previous year. Allocations are based on the number of cases in excess of 

the average AIDS incidence rates of EMSAs. 

13In our November 1995 report, we showed that differences under the CARE Act in funding 

per living AIDS case were not related to cost differences. For a discussion of this issue as 

well as criteria for distributing funds, see GAO, Ryan White CARE Act of 1990: 

Opportunities to Enhance Funding Equity, GAO/HEHS-96-26 (Washington, D.C.: Nov. 13, 

1995). 

Page 5 GAO-06-332 HIV/AIDS Funding
HIV cases in addition to living AIDS cases to determine formula funding.14

We undertook our analyses in light of the statutory requirement that HIV 

cases be used in CARE Act funding formulas not later than fiscal year 

2007. Our analyses, however, rely on data whose reliability has been 

questioned. The Secretary of Health and Human Services has determined 

that because of the problems associated with these data, they should not 

currently be used in determining CARE Act funding. We used these data in 

our analyses to give a general indication of the effect of using HIV cases in 

future formula allocations as required by the CARE Act. The extent to 

which the use of HIV cases could affect formula allocations cannot be 

determined by these analyses because jurisdictions use different methods 

to identify HIV cases, and it is unclear to what degree the resulting case 

counts are comparable. However, we think our approaches in these 

analyses are informative given the required incorporation of HIV cases into 

CARE Act funding formulas. To assess the reliability of the case-count 

data, we asked HRSA, HUD, CDC, state, and local officials a series of 

questions about how the data were collected and the methods used to 

ensure their accuracy. On the basis of the information provided regarding 

the verification of these data, we determined these data to be sufficiently 

reliable for the purposes of our analyses. Appendix I provides a more 

detailed explanation of the scope and methodology for this report. We 

performed our work from July 2004 through February 2006, in accordance 

with generally accepted government auditing standards. 

In 1990, Congress passed the CARE Act and HOPWA legislation to address 

the needs of jurisdictions, health care providers, and people with 

HIV/AIDS and their family members. Within the CARE Act and HOPWA 

legislation, there are provisions for determining the distribution of 

program funding. Furthermore, amendments in 1996 and 2000 changed 

some CARE Act provisions, and public debate continues on how best to 

measure the effect of HIV/AIDS within the United States, and how to 

distribute funding accordingly. 

Background 

 

14For our CARE Act analyses, we used ELCs as our measure of living AIDS cases. For 

HOPWA we used a measure of living AIDS cases calculated by subtracting the number of 

reported deaths among AIDS cases in a jurisdiction from the number of reported cases. In 

our analysis of HOPWA, we used living AIDS cases instead of cumulative AIDS cases, 

which is the measure currently required by law to be used to determine HOPWA base 

funding. Consequently, our analyses of HOPWA funding reflect the effect of using HIV and 

living AIDS cases instead of cumulative AIDS cases. We do not compare how allocations 

could be affected if HIV cases and cumulative cases were used to determine funding. 

Page 6 GAO-06-332 HIV/AIDS Funding
Over the course of the last quarter century, the HIV/AIDS epidemic has 

spread to every region of the country. CDC has estimated that in the 50 

states approximately 40,000 persons become infected with HIV annually. 

While AIDS cases remained concentrated in metropolitan areas through 

2004, AIDS prevalence rates in nonmetropolitan areas rose.15

HIV/AIDS in the United 

States 

The United States population living with HIV/AIDS is diverse. Racial and 

ethnic minorities have been disproportionately affected by HIV/AIDS since 

the beginning of the epidemic, but in 2004 African Americans accounted 

for more new AIDS cases, more of those estimated to be living with AIDS, 

and more of those who died with AIDS than any other racial or ethnic 

group. Latinos also account for a greater proportion of AIDS cases and 

deaths than their representation in the overall population. 

Despite the number of deaths from AIDS and the steady increase of AIDS 

prevalence, there have been successes in the fight against HIV/AIDS. 

Developments in treatment have enhanced care options and can extend 

the lives of those living with HIV/AIDS. The introduction of highly active 

antiretroviral therapy in 1996 was followed by a decline in the number of 

deaths and new AIDS cases in the United States for the first time since the 

beginning of the epidemic. 

The federal government’s efforts to address the domestic HIV/AIDS 

epidemic include providing federal funding for the following categories of 

activities—treatment and income support for individuals with HIV/AIDS, 

prevention efforts, and research. In fiscal year 2004, federal funding for 

domestic HIV/AIDS programs was nearly $16.3 billion. Of this total, about 

$2.1 billion was distributed through CARE Act programs, and $295 million 

was distributed through the HOPWA program. Medicaid was the largest 

source of federal assistance for HIV/AIDS health care, with $5.4 billion in 

federal funding. Other large sources of federal funding for HIV/AIDS are 

Medicare—$2.6 billion—and the National Institutes of Health—about 

$2.5 billion. Funding from other federal sources ranged from $1 million 

from the Department of Labor to more than $1 billion from the Social 

Security Disability Insurance Program. Figure 1 provides a breakdown of 

federal HIV/AIDS funding by category. 

 

15Prevalence reflects the number of people living with the disease. 

Page 7 GAO-06-332 HIV/AIDS Funding
Figure 1: Federal HIV/AIDS Funding by Category, Fiscal Year 2004 

The CARE Act The majority of CARE Act funds are distributed through four different 

programs, each contained in a separate title, to the states, EMAs, and other 

entities. Titles I and II of the act provide for formula grants (base grants) 

to EMAs and states according to each jurisdiction’s number of ELCs 

relative to all EMAs and states. These titles also provide for other grants to 

subsets of eligible jurisdictions either by formula or by a competitive 

process. For example, in addition to AIDS Drug Assistance Program 

(ADAP) base grants, Title II also authorizes grants for states and certain 

territories with demonstrated need for additional funding to support their 

ADAPs.16 These grants, known as Severe Need Grants, are funded through 

a set-aside of funds otherwise available for ADAP grants. Title II also 

authorizes funding for “Emerging Communities,” which are communities 

affected by AIDS that have not had a sufficient number of AIDS cases 

reported in the last 5 calendar years to be eligible for Title I grants as 

EMAs. In order to address the effect of the disease on racial and ethnic 

minorities, HRSA has used funds otherwise available under Title I and 

Title II for Minority AIDS Initiative grants to EMAs, states, and territories. 

EMAs may also receive Title I supplemental grants, which are awarded 

 

16In addition to the 50 states, these grants are authorized to the District of Columbia, the 

Commonwealth of Puerto Rico, Guam, and the Virgin Islands. 

Page 8 GAO-06-332 HIV/AIDS Funding
using a competitive application process based on the demonstration of 

severe need and other criteria.17 Table 1 describes the purposes and the 

grantees of each title. 

Table 1: CARE Act Programs, 2004 

CARE Act program Grantees Purpose 

Title I. Grants to Eligible 

Metropolitan Areas (EMAs) 

51 EMAsaSupport primary health care, medications, and a range of services, 

such as case management, substance abuse treatment, housing, 

mental health treatment, and nutritional counseling. 

Title II. Grants to States 

and Territories 

States and territories Support primary and home-based health care, insurance 

coverage, medications, support services, and early intervention 

services, such as HIV counseling, testing, and referral. Funding for 

AIDS Drug Assistance Programs provides medications, treatment 

adherence and support, and health insurance with prescription 

drug benefits. 

Title III. Early Intervention 

Services, Capacity 

Development, and 

Planning Grants 

Primary care providers, including 

health centers, city and county 

health departments, and outpatient 

medical centers 

Support comprehensive services including HIV counseling, testing, 

outpatient medical care, and case management; funds also go 

toward developing HIV service delivery systems and building 

capacity to provide services. 

Title IV. Services for 

Women, Infants, Children, 

Youth, and Their Affected 

Family Members 

Health care facilities, public health 

agencies, and community-based 

organizations that serve Title IV 

target populations 

Support family-centered and coordinated health care and support 

services that benefit children, youth, and women living with HIV, 

and their families. Also support initiatives to help identify HIVpositive pregnant women and ensure access to prenatal care that 

could prevent perinatal transmission. 

Special Projects of 

National Significance 

University and community clinics, 

evaluation centers,b

 local and state 

health departments, communitybased organizations, and nonprofit 

agencies 

Support the development of innovative models of HIV/AIDS care 

that can be replicated, such as interventions for HIV-positive 

substance abusers. 

AIDS Education and 

Training Center Program 

4 national centers and 11 regional 

centers with 130 associated sites 

Conduct education and training programs for health care providers 

treating people with HIV/AIDS. 

Dental Programs Dental education institutions, 

hospitals, and other institutions with 

dental education programs 

Improve access to oral health care and enhance dental training on 

caring for people with HIV/AIDS through the Dental 

Reimbursement Program and Community-Based Dental 

Partnership grants. 

Source: HRSA. 

a

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

AIDS cases in the last 5 calendar years is eligible to receive a formula base grant. As a result of the 

CARE Act Amendments of 1996, EMAs that were eligible for Title I grants in that year are 

grandfathered: they will be eligible for grants under Title I even if their number of AIDS cases drops 

below the threshold for eligibility. App. II contains a list of the EMAs. 

b

Evaluation centers support Special Projects grantees and coordinate the evaluation of initiatives 

under the Special Projects of National Significance program. 

 

17All EMAs received a supplemental grant in fiscal year 2004. 

Page 9 GAO-06-332 HIV/AIDS Funding
The Ryan White CARE Act Amendments of 199618 and the Ryan White 

CARE Act Amendments of 200019 modified the original funding formulas. 

For example, prior to the 1996 amendments, the CARE Act required that 

for purposes of determining grant amounts a metropolitan area’s caseload 

be measured by a cumulative count of AIDS cases recorded in the 

jurisdiction since reporting began in 1981. The 1996 amendments required 

the use of ELCs instead of cumulative AIDS cases.20 Because this switch 

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

a longer history of the disease than other jurisdictions, due in part to a 

higher proportion of deceased cases, the 1996 CARE Act amendments 

added a hold-harmless provision under Title I, as well as under Title II, 

that limit the extent a grantee’s funding can decline from one year to the 

next. 

CARE Act Amendments 

Metropolitan areas heavily affected by HIV/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.21 To adjust 

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

Title II base grants that takes into account the number of ELCs that reside 

within a state but outside of any EMA. Under this distribution formula, 

80 percent of the Title II base grant is based upon a state’s proportion of 

all ELCs, and 20 percent of the base grant is based on a states’ proportion 

of ELCs outside of EMAs relative to all such ELCs. A second provision 

included in 1996 protected the eligibility of EMAs. The 1996 amendments 

provided that a jurisdiction designated as an EMA for that fiscal year 

would be “grandfathered” so it would continue to receive Title I funding 

even if its reported number of AIDS cases dropped below the threshold for 

eligibility. Table 2 describes CARE Act formula grants for Titles I and II. 

 

18Pub. L. No. 104-146, 110 Stat. 136. 

19Pub. L. No. 106-345, 114 Stat. 1319. 

20HRSA calculates a jurisdiction’s ELCs by using data from CDC 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 measure as our estimate of living AIDS cases in our analyses of CARE 

Act funding-formula provisions and the use of HIV cases in CARE Act funding formulas. 

21See GAO, Ryan White CARE Act of 1990: Opportunities Are Available to Improve 

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

Page 10 GAO-06-332 HIV/AIDS Funding
Table 2: Description of CARE Act Title I and Title II Formula Grants 

Formula grant Eligible grantees Distribution Minimum grant Hold-harmless provisiona

Title I Base Grant Metropolitan areas with 

500,000 or more in 

population and with 

more than 2,000 

reported AIDS cases in 

the most recent 

5 calendar yearsb

 

Distributed among 

EMAs according to 

each EMA’s proportion 

of ELCs relative to all 

EMAs. 

No Grant annually declines to 98%, 

95%, 92%, and 89% of the base 

year grant, respectively.c

 In the fifth 

and all subsequent years, EMA 

receives 85% of base year grant. 

The funds necessary to meet the 

hold-harmless requirement are 

deducted from funds available for 

supplemental grants under Title I.d

Title II Base Grant States and territoriese Eighty percent of base 

grant funding divided 

among 

states/territories 

according to each 

grantee’s proportion of 

all ELCs. Twenty 

percent of base grant 

funding divided among 

states/territories 

according to each 

grantee’s ELCs located 

outside the EMAs 

within the 

state’s/territory’s 

borders relative to 

such ELCs in all 

states/territories. 

For states with fewer 

than 90 ELCs, 

$200,000; states with 90 

or more ELCs, 

$500,000; for territories, 

$50,000 

Grant declines by 1% per year from 

the fiscal year 2000 grant. In fifth 

year, grant is 95% of 2000 grant. 

Title II ADAP Base 

Grant 

States and certain 

territoriesf

 

Distributed according 

to each grantee’s 

proportion of all ELCs. 

No Grant declines by 1% per year from 

the fiscal year 2000 grant. In fifth 

year grant is 95% of 2000 grant. 

Title II ADAP 

Severe Need 

Grantg

States and certain 

territoriesf

 with a severe 

need for a grant to 

increase access to 

medications 

Distributed according 

to each grantee’s 

proportion of all ELCs: 

grantees must agree to 

match 25 percent of 

their severe need grant 

and not to impose 

eligibility requirements 

stricter than those in 

place on January 1, 

2000. 

No No 

Page 11 GAO-06-332 HIV/AIDS Funding
Formula grant Eligible grantees Distribution Minimum grant Hold-harmless provisiona

Title II Emerging 

Communities 

Grant 

States and territories 

with metropolitan areas 

that are not eligible for 

Title I, and that have 

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. 

Funding is distributed 

according to each 

community’s proportion 

of AIDS cases 

(reported in the most 

recent 5 calendar 

years) in Emerging 

Communities within the 

tier. 

Minimum of $5 million 

for each tier 

No 

Source: HRSA. 

Notes: HRSA has also awarded Minority AIDS Initiative grants to EMAs, states, and territories. HRSA 

characterizes Minority AIDS Initiative grants to EMAs as Title I grants and Minority AIDS Initiative 

grants to states and territories as Title II grants. These funds are allocated by formula. Title I funds 

have been used for grants to EMAs with greater than zero reported nonwhite AIDS cases in the most 

recent 2 calendar years. The funds are distributed among all EMAs according to each EMA’s 

proportion of nonwhite AIDS cases reported over the most recent 2 calendar years. Title II funds have 

been used for grants to states and territories with greater than zero reported nonwhite AIDS cases in 

the most recent 2 calendar years. The funds are distributed among all grantees according to each 

grantee’s proportion of nonwhite AIDS cases reported over the most recent 2 calendar years. There 

are no minimum-grant or hold-harmless provisions for these grants. 

a

If the distribution formula would otherwise result in a funding decrease from a prior year, a holdharmless provision may be triggered to mitigate the decrease in funding. 

b

A grandfather clause added in 1996 provides that areas eligible at that time continue to be eligible 

even if they no longer meet the eligibility critieria. 

c

The base year is the fiscal year prior to that in which the EMA first becomes eligible for holdharmless funding. 

d

Title I also includes supplemental grants, which are awarded to EMAs using a competitive application 

process based on the demonstration of severe need and other criteria. 

e

In addition to the 50 states, Title II base grants are authorized for the District of Columbia, the 

Commonwealth of Puerto Rico, Guam, the Virgin Islands, American Samoa, the Commonwealth of 

the Northern Mariana Islands, the Federated States of Micronesia, the Republic of Palau, and the 

Republic of the Marshall Islands. 

f

In addition to the 50 states, these grants are authorized for the District of Columbia, the 

Commonwealth of Puerto Rico, Guam, and the Virgin Islands. 

g

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

hold-harmless provision. Severe Need grants are funded by setting aside 3 percent of the funds 

earmarked specifically for ADAPs. 

Page 12 GAO-06-332 HIV/AIDS Funding
In determining a metropolitan area’s eligibility for Title I funding and for 

purposes of defining areas served under Title I, the CARE Act uses the 

OMB 1993 definitions of MSAs. OMB’s 1993 definitions were based on 

applying OMB’s 1990 standards for defining an MSA to data from the 1990 

census. OMB’s standards create a metropolitan classification scheme that 

includes rules for determining which counties (the basic building block of 

MSAs) would be designated as the central counties of metropolitan areas 

and which outlying counties would be associated with particular central 

counties. The 1996 CARE Act amendments froze the metropolitan areas to 

those specified in the 1993 OMB definitions.22

Metropolitan Statistical Areas 

The 2000 amendments provided for HIV case counts to be incorporated in 

the Title I and Title II funding formulas 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.23 They also required that HIV 

data be used no later than the beginning of fiscal year 2007. In June 2004 

the Secretary of Health and Human Services determined that HIV data 

were not yet ready to be used for the purposes of distributing formula 

funding under Title I and Title II of the CARE Act. The Secretary cited a 

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

to provide adequate and reliable HIV case counts for use in distributing 

CARE Act grants.24

HIV Case Counts 

HOPWA HOPWA is the only federal program dedicated to providing housing 

assistance to persons living with HIV/AIDS and their families. Funding 

under HOPWA supports a variety of services, including rental assistance 

and the acquisition, rehabilitation, and construction of housing units. 

HOPWA funds also provide for supportive services, such as health care, 

substance abuse treatment, and case management. In fiscal year 2004, 

$295 million was distributed through HOPWA. 

 

22In 2005, OMB issued 2004 MSA definitions using fundamentally revised standards issued 

in 2000 and data from the 2000 census. In an attempt to make the classification of areas 

simpler and more transparent than the previous standards, OMB’s 2000 standards 

introduced new terminology and employed new criteria for identifying central counties and 

their outlying counties, and did not seek to conform with past standards nor to preserve 

past metropolitan status. 

2342 U.S.C. §§ 300 ff-13(a)(3)(D)(i) and 300ff-28(a)(2)(D)(i) (2000). 

24Institute of Medicine of the National Academies, Measuring What Matters: Allocation, 

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

National Academies Press, 2004). 

Page 13 GAO-06-332 HIV/AIDS Funding
Ninety percent of HOPWA funds are distributed through formula grants to 

states, Puerto Rico, and metropolitan areas. The remaining 10 percent of 

HOPWA funds are provided through competitive grants to states, Puerto 

Rico, local governments, and nonprofit organizations. Formula grants 

under HOPWA incorporate cumulative AIDS case counts, rather than an 

estimate of persons living with AIDS, such as ELCs as used in the CARE 

Act. Seventy-five percent of HOPWA formula funding is awarded through 

base grants to EMSAs, which are jurisdictions with more than 500,000 

people and more than 1,500 cumulative AIDS cases, and to states and 

Puerto Rico that have more than 1,500 cumulative AIDS cases outside 

EMSAs. The remaining 25 percent of HOPWA formula funding is awarded 

through bonus grants for EMSAs that meet the eligibility threshold but 

also demonstrate a higher-than-average per capita incidence of AIDS. 

These grants are based on the number of cases in excess of the average 

AIDS incidence rates of EMSAs. HUD first used OMB’s new MSA 

definitions in determining EMSAs for fiscal year 2004 funding. 

CARE Act and HOPWA grants are used for health care, housing assistance, 

and a variety of services for people with HIV/AIDS. In fiscal year 2003, 

more than half of the approximately $600 million in Title I CARE Act funds 

were allocated by grantees for health care services such as outpatient care 

and home health services, and over two-thirds of the approximately 

$1 billion in Title II funds were allocated by states and territories for 

medications. Over three-quarters of the approximately $194 million in 

Title III fiscal year 2002 funds were allocated for health care services. In 

fiscal year 2003, about $68 million in Title IV grants was provided for 

health care and support services for children, youth, and women with 

HIV/AIDS and their families. Also in fiscal year 2003, about $74 million in 

funding was provided in total for dental programs, projects that support 

innovative models of HIV/AIDS care, and AIDS Education and Training 

Centers for health care providers. HOPWA funds were used for a variety of 

housing-related expenses, such as rental assistance, and support services. 

In fiscal year 2003, two-thirds of the approximately $249 million in HOPWA 

funds were used for direct housing costs, such as rental assistance, for 

people with HIV/AIDS and their families. 

Results in Brief 

Multiple provisions in the CARE Act and HOPWA grant funding formulas 

result in funding not being distributed according to the current 

distribution of the disease. Grantees do not receive the same level of 

CARE Act or HOPWA funding per person living with AIDS because various 

formula provisions affect the proportional allocation of funding. 

Page 14 GAO-06-332 HIV/AIDS Funding
• We found that both the CARE Act and HOPWA use measures of AIDS 

cases that do not accurately reflect the number of persons living with 

AIDS. Some CARE Act grants and HOPWA base grant funding are based 

on case counts that could include deceased cases because the eligibility 

and allocations are determined using cumulative case counts. In addition, 

the CARE Act’s use of ELCs, which are determined using the most recent 

10 years of reported AIDS cases, to distribute the majority of formula 

funding does not take into account that many AIDS patients now live 

longer than 10 years after their disease is reported. 

• We found that certain CARE Act Title I and II provisions related to 

metropolitan areas result in variability in the amounts of funding per ELC 

among grantees. For instance, the counting of ELCs within EMAs once for 

determining Title I base grants and once again for determining Title II base 

grants results in states with a higher proportion of ELCs in EMAs and 

Puerto Rico, which has a similar percentage, receiving more total Title I 

and Title II funding per ELC than states with no EMA or with 

comparatively few ELCs located in EMAs. Also, the division of Emerging 

Communities into two tiers based on their numbers of reported AIDS 

cases in the past 5 years leads to funding disparities among grantees. This 

divergence occurs because funding is divided equally between the two 

tiers regardless of the number of communities or the number of reported 

AIDS cases in each tier. In fiscal year 2004, the 4 communities in the first 

tier received $1,052 per reported case while the 25 communities in the 

second tier received $313 per reported case. 

• We found that because of CARE Act hold-harmless provisions under 

Titles I and II and the grandfather clause for EMAs under Title I, the 

funding of certain grantees is protected. For example, the CARE Act Title I 

hold-harmless provision results in the San Francisco EMA’s funding being 

based in part on deceased cases in the EMA in 1995. In addition, a Title II 

hold-harmless provision, which has had little effect thus far, has the 

potential to reduce the amount of funding to grantees with severe need for 

drug treatment funds because the hold-harmless provision is funded from 

amounts set aside for ADAP Severe Need grants. The Title I grandfather 

clause protected the funding of more than half of EMAs. 

The Ryan White CARE Act Amendments of 2000 required the use of 

HIV/AIDS case counts in the distribution of formula grants not later than 

fiscal year 2007. If case counts from HIV-reporting systems had been used 

along with a measure of the number of persons living with AIDS in 

distributing fiscal year 2004 CARE Act and HOPWA grants, funding would 

have shifted among jurisdictions. Although CARE Act and HOPWA 

grantees have established HIV case-reporting systems, differences 

between these systems—in their maturity and reporting methods, for 

instance—would have affected the distribution of CARE Act and HOPWA 

Page 15 GAO-06-332 HIV/AIDS Funding
funds based on HIV/AIDS case counts. Recently established HIV-reporting 

systems might not have captured an accurate count of a grantee’s HIV 

cases in part because cases diagnosed prior to the establishment of the 

reporting system might not have been reported and entered into the 

system. Also, because CDC does not accept case reports that are reported 

using a code rather than a person’s name to protect their anonymity, those 

states with code-based systems would not have had their HIV cases 

counted when funding distributions were made. Accordingly, we 

developed two approaches to assess the effect of using the HIV case 

counts, as they currently exist, on CARE Act and HOPWA formula grants. 

While the extent to which funding may have shifted cannot be determined 

given the different methods jurisdictions use to identify HIV cases, we 

think these approaches are informative given the required corporation of 

HIV cases into CARE Act funding formulas. Using these approaches, we 

found that up to 13 percent of CARE Act formula funding would have 

shifted among grantees if HIV cases were included in the funding formulas 

and the hold-harmless provisions analyzed and minimum-grant provision 

were maintained. Larger changes for individual grantees would have 

occurred with some grantees more than doubling their funding. Grantees 

in the South and Midwest would generally have received more funding 

from using HIV cases in funding formulas. However, there would have 

been grantees that would have received increased funding and grantees 

that would have received decreased funding in every region of the country. 

If, in addition to using HIV data, the hold-harmless provisions we analyzed 

and minimum-grant provisions were eliminated, the redistribution of 

program funds would have been more dramatic. Up to 24 percent of 

funding would have shifted. HOPWA base funding would also have shifted 

if HIV and living AIDS cases were used to distribute funding. In fiscal year 

2004, up to 15 percent of HOPWA base funding would have shifted among 

grantees, with six grantees more than doubling their funding. Differences 

in HIV case-reporting systems would affect the distribution of funding, and 

we found that funding would have tended to shift to jurisdictions with 

older HIV-reporting systems. Jurisdictions with older HIV-reporting 

systems tend to have more reported HIV cases compared with their 

number of AIDS cases than do jurisdictions with newer reporting systems. 

If Congress wishes CARE Act and HOPWA funding to more closely reflect 

the distribution of persons living with AIDS, it should take actions that 

lead to more-comparable funding per case by revising the funding 

formulas. In accordance with achieving more-comparable funding per 

AIDS case, we raise a number of matters for consideration when Congress 

reviews the CARE Act and HOPWA. 

Page 16 GAO-06-332 HIV/AIDS Funding
We provided a draft of this report to HHS and HUD. HHS and HUD 

generally agreed with our identification of issues in the funding formulas. 

While HHS also generally agreed with our matters for congressional 

consideration, it expressed concern that our discussion of the Title I 

grandfather provision in the CARE Act could be interpreted as suggesting 

that the metropolitan areas that continue to receive grants because of this 

provision need not be funded. However, these areas could still receive 

funding through their respective states or territories, which receive funds 

under Title II. HUD concurred with our matter for congressional 

consideration that HOPWA formula grant eligibility and base grant funding 

be based on a measure of living AIDS cases. 

CARE Act and 

HOPWA Funds 

Allocated for Health 

Care, Housing 

Assistance, and a 

Variety of Other 

Services 

The CARE Act and HOPWA grants fund a variety of treatment and support 

services for people with HIV/AIDS. For fiscal year 2003, Title I grantees 

allocated more than half of the approximately $600 million in Title I grants 

for health care services such as outpatient care and home health care, and 

over 70 percent of the approximately $1 billion in Title II funds were 

allocated for medications. Almost 80 percent of the approximately 

$194 million in Title III fiscal year 2002 funds were allocated for health 

care services such as physician office visits and HIV counseling and 

testing.25 In fiscal year 2003, there was also about $68 million in funding for 

Title IV grantees and about $74 million for other programs, such as Special 

Projects of National Significance. Two-thirds of the approximately 

$249 million in HOPWA fiscal year 2003 funds were used to assist with 

housing costs for people with HIV/AIDS and their families. 

For fiscal year 2003, HRSA provided about $600 million in grants to EMAs 

under Title I of the CARE Act to support services for people with 

HIV/AIDS. Grantees allocated the largest portion of these funds, about 

52 percent, for health care services such as outpatient care, home health 

care, rehabilitation care, and medications. About 12 percent of these Title I 

health care services funds were allocated for substance abuse treatment 

and counseling services. For the same year, Title I grantees allocated 

about 36 percent of those funds for case management and support 

services. Support services include child care, client advocacy, and 

emergency financial assistance, among others. The remaining 12 percent 

More Than Half of Title I 

Fiscal Year 2003 Funding 

Was Allocated for Health 

Care Services 

 

25Fiscal year 2002 allocations were the most recent funding data available for Title III. 

Page 17 GAO-06-332 HIV/AIDS Funding
of Title I funding was allocated for administration, planning councils, and 

program support.26 (See fig. 2.) 

Figure 2: Allocation of CARE Act Title I Funds, Fiscal Year 2003 

Administration, planning councils, and 

program support 

52% Case management and 

support services

36%

12%

Health care services

Source: GAO analysis of HRSA data.

Note: About $600 million was allocated under Title I. 

Over Two-thirds of Title II 

Fiscal Year 2003 Funding 

Was Allocated for 

Medications 

HRSA provided approximately $1 billion to states and territories under 

Title II in fiscal year 2003. Title II grantees allocated the majority of these 

funds, about 71 percent, for medications, which includes ADAP 

medications, non-ADAP medications, and pharmacy assistance for CARE 

Act clients. Ten percent of Title II funds were allocated for health care 

services, similar to those provided under Title I. Grantees allocated about 

3 percent of Title II health care services funds for substance abuse 

treatment services. Case management and support services similar to 

those provided under Title I accounted for approximately 10 percent of the 

Title II funds. The remainder of Title II funds, about 9 percent, was 

 

26The CARE Act requires that grantees’ administrative costs not exceed 5 percent of the 

Title I funds awarded. Each EMA must establish a planning council, which sets spending 

priorities according to local unmet needs. 

Page 18 GAO-06-332 HIV/AIDS Funding
allocated for program administration, planning, and evaluation.27 (See 

fig. 3.) 

Figure 3: Allocation of CARE Act Title II Funds, Fiscal Year 2003 

9% Administration, planning, and 

program evaluation

10%

10%

71% Medicationsa

Case management and support

services

Health care services

Source: GAO analysis of HRSA data.

Notes: Approximately $1 billion was allocated under Title II. 

a

Medications includes ADAP medications, non-ADAP medications, and pharmacy assistance. 

Over Three-quarters of 

Title III Fiscal Year 2002 

Funding Was Allocated for 

Health Care Services 

Under Title III of the CARE Act, HRSA provided about $194 million in 

grants to certain public and nonprofit primary care providers in support of 

early intervention services for people with HIV/AIDS for fiscal year 2002. 

Title III grantees allocated about 79 percent of these funds for health care 

services such as physician office visits, HIV counseling and testing, and 

employing primary care personnel. Health care services also included 

outpatient mental health care and substance abuse treatment. Title III 

grantees allocated another 13 percent for other activities, including case 

management and HIV patient education. The remaining 8 percent was 

allocated for administration.28 (See fig. 4.) 

 

27The CARE Act requires that grantees not use more than 10 percent of Title II funds for 

administration. The combined funding for administration, planning, and program 

evaluation may not exceed 15 percent of a Title II grantee’s award. 

28The CARE Act requires that grantees not use more than 10 percent of Title III funds for 

administration costs, including planning and evaluation. 

Page 19 GAO-06-332 HIV/AIDS Funding
Figure 4: Allocation of CARE Act Title III Funds, Fiscal Year 2002 

79% Health care services

13%

8%

Other services

Administration

Source: HRSA.

Note: About $194 million was allocated under Title III. 

Grants made under Title IV of the CARE Act address the specific needs of 

women, infants, children, and youth living with HIV/AIDS. The funds cover 

primary and specialty medical care, psychosocial services, case 

management, and other activities. For fiscal year 2003, HRSA provided 

about $68 million for Title IV programs. Other CARE Act programs include 

the Special Projects of National Significance Program, funded at about 

$25 million for fiscal year 2003; the AIDS Education and Training Centers 

Program, funded at about $36 million for fiscal year 2003; and the 

HIV/AIDS Dental Reimbursement Program and Community-Based Dental 

Partnership program funded at nearly $10 million and $3 million 

respectively for fiscal year 2003. 

For fiscal year 2003, HOPWA grantees spent about $249 million to support 

housing services for people with HIV/AIDS. The largest portion of these 

funds, about 66 percent, was spent on direct housing costs, such as rental 

assistance, and housing facility operating costs. Support services 

accounted for 25 percent of the funds. HOPWA-funded support services 

include case management, health care, alcohol and drug abuse treatment, 

and child care, among others. Housing information services and 

permanent housing placement costs accounted for 4 percent of HOPWA 

funds, while grant administration was 5 percent of the total. (See fig. 5.) 

CARE Act Grants Funded 

Other Activities in Fiscal 

Year 2003 

Two-thirds of HOPWA 

Fiscal Year 2003 Funds 

Were Spent on Housing 

Costs 

Page 20 GAO-06-332 HIV/AIDS Funding
Figure 5: Allocation of HOPWA Funds, Fiscal Year 2003 

5%

4%

66% 25%

Source: GAO analysis of HUD data.

Housing information services

and permanent housing

placement costs

Support services

Direct housing costs

Grant administration

Notes: About $249 million was spent under HOPWA. 

Provisions in the CARE Act and HOPWA funding formulas result in a 

distribution of funds among grantees that does not reflect the relative 

distribution of AIDS cases in these jurisdictions.29 CARE Act grantees do 

not receive the same amount of funding per ELC, and HOPWA grantees do 

not receive the same amount of funding per living AIDS case. We found 

that provisions affected the proportional allocation of funding as follows: 

(1) the AIDS case-count provisions in the CARE Act and HOPWA each 

result in a distribution of funding that is not reflective of the distribution of 

persons living with AIDS, (2) CARE Act provisions related to metropolitan 

areas result in variability in the amounts of funding per ELC among 

grantees, (3) the CARE Act hold-harmless provisions and grandfather 

clause protect the funding of certain grantees, and (4) the ineligibility of 

grantees other than EMSAs for HOPWA bonus funding restricts the 

distribution of these funds and limits HUD’s ability to fund areas outside of 

Multiple Provisions 

Contribute to 

Disproportionate 

Distribution of CARE 

Act and HOPWA 

Formula Funding 

 

29Unless otherwise indicated, we use the term grantees to indicate the jurisdictions on 

which our analyses are based, that is, the states, Puerto Rico, and metropolitan areas. 

Page 21 GAO-06-332 HIV/AIDS Funding
EMSAs with high rates of new AIDS cases. We also considered the 

provision in the 1996 CARE Act amendments that froze the EMA 

boundaries to 1993 OMB definitions. We found that the boundaries for 

more than half of current EMAs would change if OMB’s 2004 MSA 

definitions were adopted for purposes of CARE Act funding. 

CARE Act and HOPWA 

Grants Are Not Distributed 

Solely in Proportion to 

Number of Persons Living 

with AIDS 

Funds distributed under Title I of the CARE Act are not distributed 

proportionally per ELC across EMAs.30 In fiscal year 2004, the total 

funding for all Title I grants to EMAs was about $595 million. If this 

funding had been distributed solely by a grantee’s proportion of ELCs, 

each EMA would have received $2,443 per ELC. However, Title I 

provisions affect the grant awards so that funding is not distributed strictly 

on a proportional basis, but instead is allocated in part according to the 

number of ELCs and in part on other bases, such as the amounts awarded 

in a prior year, as reflected in the hold-harmless funding. Total funding for 

EMAs also reflects Minority AIDS Initiative grants and supplemental 

grants. In fiscal year 2004, total Title I funding for the 51 EMAs ranged 

from $2,130 per ELC case in Riverside–San Bernardino to $4,137 in San 

Francisco, with an average of $2,380. Excluding San Francisco, West Palm 

Beach had the highest Title I funding per ELC at $2,515. Appendix II lists 

the EMAs and amounts awarded under Title I for fiscal year 2004. 

CARE Act Title II funding is also not distributed proportionally per ELC. In 

fiscal year 2004, the total funding for all Title II grants was about 

$1.051 billion. If this funding had been distributed solely according to the 

proportion of ELCs, each grantee would have received $3,053 per ELC. 

However, minimum-award requirements and hold-harmless provisions 

affect the distribution of Title II funds. In addition, grants for Emerging 

Communities as well as the Minority AIDS Initiative are not determined 

proportionally by the number of ELCs. Total Title II funding for fiscal year 

2004 ranged from $2,793 for the District of Columbia to $7,275 for South 

Dakota, with an average of $3,559. Appendix III shows the grantees and 

amounts awarded under Title II for fiscal year 2004. 

 

30ELCs are the 10-year weighted estimate of living AIDS cases as specified in the CARE Act. 

HRSA calculates a jurisdiction’s ELCs by using data from CDC on the reported AIDS case 

counts for the last 10 years. Data for each of the 10 years are adjusted to take into account 

the number of deaths in each year. However, rather that simply subtracting the number of 

deceased cases in each jurisdiction, the number of reported cases is adjusted by the 

national average death rate among AIDS cases. 

Page 22 GAO-06-332 HIV/AIDS Funding
HOPWA formula funding is also disproportionate across grantees. In fiscal 

year 2004, about $263 million was allocated by formula to 117 grantees. 

Seventy-five percent of this funding was distributed according to the 

number of cumulative AIDS cases31 in a jurisdiction and 25 percent was 

distributed based on the rate of new AIDS cases in EMSAs. If this funding 

had been distributed proportionally by the number of cumulative AIDS 

cases across jurisdictions each grantee would have received $306 per 

cumulative case. However, 26 grantees received bonus grants that are 

based on the rate of new AIDS cases in an EMSA, not the number of 

cumulative AIDS cases. Therefore, the actual amounts grantees received 

ranged from $230 per cumulative AIDS case for 91 grantees to $626 per 

case in Baton Rouge, with an average of $260. We also determined how 

much funding each grantee received per living AIDS case.32 We found that 

grantees received an average of $573 per living AIDS case, with funding 

ranging from $387 per case in Nashville to $1,290 per case in Baton Rouge. 

These funding differences are due to the use of cumulative AIDS cases to 

distribute base grant funding and because bonus grants are distributed 

according to the rate of new cases in EMSAs.33 Appendix IV identifies the 

fiscal year 2004 HOPWA formula grantees and award amounts. 

 

31In this report, cumulative AIDS cases are the total number of AIDS cases, both living and 

dead, reported in a jurisdiction in a given period. Under HOPWA, cumulative AIDS cases 

encompass all reported cases since the beginning of the epidemic in 1981. By statute, 

75 percent of HOPWA formula funding is allocated on the basis of cumulative AIDS cases. 

32In the absence of a measure of living AIDS cases used for HOPWA funding, we used a 

measure of living AIDS cases calculated by subtracting the number of reported deaths 

among AIDS cases in a jurisdiction from the number of reported cases. This measure of 

living AIDS cases is used for illustrative purposes only. 

33Until fiscal year 2006, bonus funding was based on the per capita incidence of AIDS over a 

1-year period. As a result, the amount of bonus funding a grantee received could vary 

significantly from year to year. With respect to fiscal year 2006 funding, HUD’s 

appropriation act included a provision to help mitigate this variability by changing to the 

use of data reported over a 3-year period. Pub. L. No. 109-115, § 303(d), 119 Stat. 2396, 2460 

(2005). 

Page 23 GAO-06-332 HIV/AIDS Funding
HOPWA and the CARE Act both use measurements of AIDS cases that do 

not reflect an accurate count of people currently living with AIDS. To 

determine eligibility for HOPWA formula grants and to distribute base 

funding, allocations are determined using a measure of AIDS cases that is 

based on the number of living and deceased AIDS cases reported in the 

jurisdiction since the beginning of the AIDS epidemic in 1981. Also, 

eligibility and distribution of certain CARE Act grants are based on the 

number of reported AIDS cases over either the last 2- or 5-year period,34

which likely does not reflect all live cases and could include deceased 

AIDS cases. In addition, Title I, Title II, and ADAP base grants are 

calculated using ELCs, which can underestimate the number of living 

cases because many persons with AIDS now live longer than 10 years after 

their cases are reported. 

Eligibility for HOPWA formula grants is determined by the number of 

cumulative AIDS cases in a metropolitan area, state, and Puerto Rico, and 

base funding allocations (which represent 75 percent of total HOPWA 

formula funding) to grantees are determined by the grantee’s proportion of 

the total number of cumulative AIDS cases. As we reported in 1995, the 

use of cumulative case counts is an inappropriate caseload measure 

because it includes all AIDS cases, living and dead, reported to CDC for 

the jurisdiction since the beginning of the epidemic in 1981.35

Provisions in HOPWA and 

CARE Act Funding 

Formulas Incorporate 

Measures of AIDS Cases 

That Do Not Reflect an 

Accurate Count of Persons 

Living with AIDS 

HOPWA Grants 

Because the HOPWA funding formula includes deceased persons, the 

distribution of funds does not reflect the current distribution of people 

living with AIDS. Using estimates of living AIDS cases obtained from CDC, 

we calculated how base funding for grantees would have changed in fiscal 

year 2004 if these estimates had been used instead of the cumulative case 

counts. Each of the 117 grantees would have received approximately 

$537 per living AIDS case. We found that 25 grantees received more 

funding in fiscal year 2004 using cumulative case counts than they would 

have received if the number of living AIDS cases had been used. The 

additional funding received by the grantees ranged from approximately 

$2,000 in San Jose to $4,020,000 in New York City. Conversely, if the 

number of living cases had been used, 92 grantees would have received 

increased funding. The funding increases would have ranged from $1,000 

in Springfield, Massachusetts, to $1,120,000 in the District of Columbia. 

 

34Eligibility for Minority AIDS Initiative grants and grant amounts are determined using the 

last 2 years of reported AIDS cases. 

35GAO/HEHS-96-26, 6. 

Page 24 GAO-06-332 HIV/AIDS Funding
Areas that receive more funding from the use of cumulative case counts 

include jurisdictions in California, Michigan, New Jersey, and New York. 

(App. V contains information on funding using cumulative AIDS counts 

and living AIDS cases.) 

Use of cumulative case counts rather than living cases can lead to areas 

with similar numbers of living AIDS cases receiving markedly different 

amounts of funding. For example, as of March 31, 2003, Oakland and New 

Orleans both reported 3,374 living AIDS cases.36 However, in fiscal year 

2004 Oakland received $221,000 more ($66 more per living AIDS case) in 

HOPWA base funding than did New Orleans. Atlanta and Houston also 

have similar numbers of living AIDS cases (8,557 and 8,579 respectively). 

However, in fiscal year 2004 Houston received $806,000 more ($93 more 

per case) in HOPWA base funding than did Atlanta. 

The use of cumulative case counts is not limited to the HOPWA program. 

Deceased cases can also be included when determining eligibility for 

CARE Act funding. Eligibility for Title I funding and Title II Emerging 

Communities grants is based on cumulative totals of AIDS cases reported 

in the most recent 5-year period, not on the number of ELCs. Funding 

amounts for Emerging Communities grants are also determined using the 

most recent 5 years of reported cases. In addition, HRSA determines 

eligibility and funding amounts of Minority AIDS Initiative grants 

according to the number of reported AIDS cases in the most recent 2-year 

period. 

CARE Act Grants 

The use of the cumulative number of reported cases over a certain period 

to determine eligibility and allocate funding results in funding not being 

distributed according to the current distribution of the disease. For 

example, because Emerging Communities funding is determined by using 

5-year cumulative case counts, allocations could be based in part on 

deceased cases, that is, people for whom AIDS was reported in the past 

5 years but who have since died. In addition, these case counts do not take 

into account living cases in which AIDS was diagnosed more than 5 years 

earlier. Consequently, 5-year cumulative case counts can substantially 

misrepresent the number of AIDS patients in these communities. For 

example, while the 5-year cumulative case count in Buffalo for 

 

36We used living AIDS case counts as of March 31, 2003, because this date was the cutoff 

for reporting AIDS cases to be used for determining fiscal year 2004 HOPWA formula 

funding. 

Page 25 GAO-06-332 HIV/AIDS Funding
determining fiscal year 2004 Emerging Communities eligibility and funding 

was 581 cases, the number of ELCs was 956. Similarly, the 5-year 

cumulative case count in Charleston, South Carolina, was 538, but the 

number of ELCs was 758. 

The use of ELCs as provided for in the CARE Act can also lead to 

inaccurate estimates of living AIDS cases. Currently, Title I, Title II, and 

ADAP base funding, which constitute the majority of formula funding, are 

distributed according to ELCs. ELCs are an estimate of living AIDS cases 

calculated by applying annual national survival weights to the most recent 

10 years of reported AIDS cases and adding the totals from each year. This 

method for estimating cases was first included in the CARE Act 

Amendments of 1996. At that time, this approach captured the vast 

majority of living AIDS cases. However, some persons with AIDS now live 

more than 10 years after their case is first reported, and they are not 

accounted for by this formula.37 Thus, like the 2- and 5-year reported case 

counts, ELCs can misrepresent the number of living AIDS cases in an area 

in part by not taking into account those persons living with AIDS whose 

cases were reported more than 10 years earlier. For example, fiscal year 

2004 Title I base funding for the Atlanta EMA was based on 7,589 ELCs, 

but CDC estimated that there were 8,560 reported living AIDS cases in the 

EMA.38 Similarly, funding for the Seattle EMA was based on 2,468 ELCs 

while CDC estimated that there were 3,273 reported living cases.39

 

37When determining CARE Act funding for fiscal year 2004, HRSA used a survival weight of 

.28 for AIDS cases that had been reported 10 years earlier. This figure represents the 

proportion of persons who had been reported with AIDS 10 years earlier and were known 

to be alive. 

38The estimate of reported living AIDS cases was calculated by subtracting the number of 

reported deaths among AIDS cases from the number of reported AIDS cases since the 

beginning of the epidemic. 

39For an assessment of three methods for estimating the number of persons living with 

AIDS, including the method used for the CARE Act, see Centers for Disease Control and 

Prevention, “AIDS Cases and Persons Living with AIDS,” HIV/AIDS Surveillance 

Supplemental Report, vol. 8, no. 3 (2002). 

Page 26 GAO-06-332 HIV/AIDS Funding
The counting of ELCs within EMAs once to determine the amount of the 

base grant under Title I and once again to determine the amount of the 

Title II base grant results in states with EMAs and Puerto Rico receiving 

more total Title I and Title II funding per ELC than states without EMAs.40

In addition, the formula for awarding Title II Emerging Communities 

grants results in different levels of funding per AIDS case across grantees. 

When total Title I and Title II funding is considered, states with EMAs and 

Puerto Rico receive more funding per ELC than states without EMAs 

because cases within EMAs are counted twice, once in connection with 

Title I base grants and once for Title II base grants. Eighty percent of 

Title II base grants is determined by the total number of ELCs in the state 

or territory. The remaining 20 percent is based on the number of ELCs in 

each jurisdiction outside of any EMA. This 80/20 split was established by 

the 1996 CARE Act amendments to address the concern that grantees with 

EMAs received more total Title I and Title II funding per case than 

grantees without EMAs. However, even with the 80/20 split, states with 

EMAs and Puerto Rico receive more total Title I and Title II funding per 

ELC than states without EMAs. States without EMAs receive no funding 

under Title I, and thus, when total Title I and Title II funds are considered, 

states with EMAs and Puerto Rico receive more funding per ELC.41

Appendix VI shows the combined Title I and Title II fiscal year 2004 

funding received by each state and Puerto Rico. 

CARE Act Funding 

Provisions for 

Metropolitan Areas Result 

in Disproportionate 

Funding 

Counting ELCs within EMAs 

Twice Results in 

Disproportionate Funding per 

ELC across States and Puerto 

Rico 

Table 3 illustrates the effect of counting EMA cases twice by comparing 

the relationship between the percentage of a state’s and Puerto Rico’s 

ELCs that are within EMAs and the amount of total Title I and Title II 

funding they receive per ELC. Table 3 shows that as the percentage of a 

state’s or Puerto Rico’s ELCs within EMAs increases, the total Title I and II 

funding per ELC also increases. For example, states with no ELCs in 

EMAs received on average $3,592 per ELC. States with 75 percent or more 

of their cases in EMAs and Puerto Rico42 received on average $4,955 per 

 

40There are three EMAs in Puerto Rico: Caguas, Ponce, and San Juan. 

41For 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 ELCs from each 

state in these EMAs. We then calculated the percentage of ELCs in each state and allocated 

the EMA funding to each state according to this percentage. For example, approximately 

96 percent of the ELCs 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. 

42Approximately 80 percent of Puerto Rico’s ELCs are in EMAs. 

Page 27 GAO-06-332 HIV/AIDS Funding
ELC, or 38 percent more funding than states with no EMA. If the total 

Title I and Title II funding had been distributed proportionally per ELC 

among all states and Puerto Rico, each grantee would have received 

$4,782 per ELC. 

Table 3: Relationship between ELCs in EMAs and Total CARE Act Title I and II 

Funding per ELC, Fiscal Year 2004 

Percentage of states’ and 

Puerto Rico’s ELCs in EMAs Average funding per ELCa

None $3,592

Less than 50 percent 3,954

50 to 75 percent 4,717

More than 75 percent 4,955

Source: GAO analysis of HRSA data. 

a

We excluded from our analyses the nine states that received the minimum Title II base grant awards. 

Under Title II, states with fewer 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 effect of counting EMA cases twice is that grantees with similar 

numbers of ELCs can receive different levels of combined Title I and 

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

5,363 ELCs while South Carolina had 5,563 ELCs. However, Connecticut 

had two EMAs that accounted for 91.3 percent of its ELCs while South 

Carolina had none. Connecticut received $26,797,308 ($4,997 per ELC) in 

combined Title I and Title II funding while South Carolina, with 200 more 

cases, received $20,705,328 ($3,722 per ELC). Connecticut received 

29 percent more funding than South Carolina, a difference of $6,091,980, or 

$1,275 per ELC. (See app. VI.) 

The two-tiered division of Emerging Communities results in disparities in 

funding among metropolitan areas. Title II provides for a minimum of 

$10 million to states with metropolitan areas that have 500 to 1,999 AIDS 

cases reported in the last 5 calendar years but do not qualify for funding 

under Title I as EMAs.43 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 for a 

second tier of communities with 1,000 to 1,999 reported cases in that 

The Two-tiered Division of 

Emerging Communities Results 

in Funding Disparities Among 

Metropolitan Areas 

 

43Under Title I, a metropolitan area with a population of at least 500,000 and more than 

2,000 reported AIDS cases in the last 5 calendar years is eligible to receive funding. 

Page 28 GAO-06-332 HIV/AIDS Funding
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. The 

two tiers and the 50/50 split were meant to ensure that a significant 

portion of the Emerging Communities funding was allocated to the 

communities with the largest number of new cases. 

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

funding led to large differences in funding per reported AIDS case in the 

last 5 calendar years among the Emerging Communities because the total 

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

communities qualified for Emerging Communities funds in fiscal year 

2004. Four of these communities had 1,000 to 1,999 reported AIDS cases in 

the last 5 calendar years and 25 communities had 500 to 999 cases. This 

distribution meant that the 4 communities with a total of 4,754 reported 

cases in the last 5 calendar years split $5 million while the remaining 

25 communities with a total of 15,994 reported cases in the last 5 calendar 

years also split $5 million. These case counts 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 reported case than the other 25. If the total 

$10 million funding for Emerging Communities grants had been distributed 

equally per reported case among the communities, each would have 

received $482 per reported case. Table 4 lists the 29 Emerging 

Communities along with their reported AIDS case counts over the most 

recent 5 years and their funding. 

Page 29 GAO-06-332 HIV/AIDS Funding
Table 4: Title II Emerging Communities in Fiscal Year 2004 

Emerging Community 

AIDS cases 

reported in the 

most recent 

5 calendar years 

Emerging Communities 

funding per AIDS case 

reported in the most recent 

5 calendar years

Memphis, Tenn. 1,588 $1,052

Nashville, Tenn. 1,123 1,052

Baton Rouge, La. 1,038 1,052

Indianapolis, Ind. 1,005 1,052

Columbia, S.C. 972 313

Charlotte, N.C. 875 313

Wilmington, Del. 801 313

Richmond, Va. 783 313

Raleigh–Durham–Chapel Hill, N.C. 775 313

Jackson, Miss. 722 313

Louisville, Ky. 705 313

Rochester, N.Y. 681 313

Fort Pierce–Port St. Lucie, Fla. 636 313

Greensboro–Winston-Salem, N.C. 617 313

Birmingham, Ala. 615 313

Oklahoma City, Okla. 608 313

Pittsburgh, Pa. 602 313

Springfield, Mass. 588 313

Monmouth-Ocean, N.J. 582 313

Buffalo–Niagara Falls, N.Y. 581 313

Greenville, S.C. 560 313

Columbus, Ohio 558 313

Milwaukee, Wis. 558 313

Salt Lake City, Utah 555 313

Sarasota, Fla. 539 313

Charleston, S.C. 538 313

Cincinnati, Ohio 517 313

Daytona Beach, Fla. 514 313

Providence, R.I. 512 313

Total 20,748

Source: GAO analysis of HRSA data. 

Note: Emerging Communities are metropolitan areas not eligible for Title I grants and that have 500–

1,999 reported AIDS cases in the most recent 5 calendar years. The 5 most recent calendar years 

are 1998–2002. 

Page 30 GAO-06-332 HIV/AIDS Funding
Similar to the counting of ELCs in EMAs for both Title I and Title II base 

grant funding, AIDS cases reported in the past 5 calendar years in 

Emerging Communities are counted more than once for determining 

Title II funding. For example, these cases are counted once for 

determining Title II base funding and again for Emerging Communities 

grants. Title II grantees with Emerging Communities receive an average of 

$3,443 per ELC while grantees without an Emerging Community receive 

about $3,089.44 The Emerging Communities funding accounted for about 

$125 per ELC of this difference. Other Title II funds that are also not 

distributed proportionally by the number of ELCs, such as the Minority 

AIDS Initiative grants, account for the rest of the difference.45

Hold-harmless Provisions 

and Grandfather Clause 

Protect Funding of Certain 

CARE Act Grantees 

Titles I and II of the CARE Act both contain provisions that protect certain 

grantees’ funding levels. Title I has a hold-harmless provision that 

guarantees that the Title I base grant to an EMA will be at least as large as 

a statutorily specified percentage of a previous year’s funding. The Title I 

hold-harmless provision has primarily protected the funding of one EMA. 

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

number of EMAs maintaining their eligibility for grants despite no longer 

meeting the eligibility criteria. Title II has a hold-harmless provision that 

ensures that the total of Title II and ADAP base grants awarded to a 

grantee will be at least as large as the total of these grants a grantee 

received the previous year. This provision has the potential of reducing the 

amount of funding to grantees that had demonstrated severe need for drug 

treatment funds because it is funded out of amounts that would otherwise 

be used for that purpose. 

The San Francisco EMA has been the primary recipient of Title I holdharmless funding. An EMA’s base funding is determined according to its 

proportion of ELCs. The hold-harmless provision guarantees each EMA a 

statutorily specified percentage of the base grant it received in a previous 

year regardless of how much its proportion of the number of ELCs in all 

One EMA Has Been the 

Primary Recipient of Title I 

Hold-harmless Funding 

 

44We excluded from our analyses the nine states that received minimum Title II base grant 

awards. 

45HRSA provides Minority AIDS Initiative grants according to the number of nonwhite 

reported AIDS cases in the most recent 2-year period. 

Page 31 GAO-06-332 HIV/AIDS Funding
EMAs may have decreased in the current year.46 If an EMA qualifies for 

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

distributed together as the base grant. In fiscal year 2004, the San 

Francisco EMA received $7,358,239 in hold-harmless funding, or 

91.6 percent of the hold-harmless funding that was distributed.47 The 

second largest recipient was Kansas City, which received $134,485, or 

1.7 percent of the hold-harmless funding under Title I. Table 5 lists the 

EMAs that received hold-harmless funding in fiscal year 2004.48

 

46The hold-harmless provision is triggered when, because of its current number of ELCs, an 

EMA would not receive at least a specified level of base funding. Hold-harmless funding 

under Title I is calculated using a base year. The base year is the year preceding the fiscal 

year in which the hold-harmless provision is triggered for a particular EMA. Because the 

hold-harmless provision can first be triggered in different years in different EMAs, the base 

year can differ among EMAs. Under the CARE Act Amendments of 2000, an EMA is 

guaranteed not less than 98 percent of its base grant in the first year the hold-harmless is 

triggered, 95 percent in the second year, 92 percent in the third year, 89 percent in the 

fourth year, and 85 percent in the fifth or subsequent years. 

47The funds used to meet the Title I hold-harmless requirement are deducted from the funds 

otherwise available for supplemental grants before these grants are awarded. Supplemental 

grants are awarded by HRSA to EMAs using a competitive process based on the 

demonstration of severe need and other criteria. 

48San Francisco was the only EMA that received hold-harmless funding from fiscal year 

1999 through fiscal year 2002. In fiscal year 2003, 19 additional EMAs qualified for holdharmless funding. Twenty-one EMAs received hold-harmless funding in fiscal year 2004. 

Eleven EMAs qualified in both fiscal years 2003 and 2004. 

Page 32 GAO-06-332 HIV/AIDS Funding
Table 5: Title I Hold-harmless Funding, Fiscal Year 2004 

EMA 

Hold-harmless 

funding

Percent of holdharmless fundingHold-harmless 

funding per ELC

Base grant per 

ELCa

Hold-harmless 

as a percent of 

base grant

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 $8,033,563b100.0%b

Source: GAO analysis of HRSA data. 

Notes: An EMA’s base funding is determined according to its proportion of ELCs. 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 amount was calculated by dividing the base grant, including any hold-harmless funding, 

received by each EMA by the number of ELCs in the EMA. 

b

Individual entries do not sum to total because of rounding. 

The effect of the hold-harmless provision varies among the EMAs that 

receive hold-harmless funding, but it can be substantial. In order to place 

hold-harmless 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 

Page 33 GAO-06-332 HIV/AIDS Funding
that did not receive hold-harmless funding received approximately $1,221 

in base grant funding per ELC in fiscal year 2004. Fiscal year 2004 base 

grant funding per ELC in EMAs that received hold-harmless funding 

ranged from $1,223 (Newark) to $2,241 (San Francisco). Thus, the San 

Francisco EMA received $1,020 more in base grant funding per ELC 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 ELCs in fiscal year 2004, received a base grant equivalent to what an 

EMA with approximately 13,245 ELCs (84 percent more) would have 

received. Kansas City, the second largest hold-harmless grantee, received 

about what an EMA with 9 percent more ELCs would have received. 

Forty-eight of the 51 EMAs would have received more funding if there had 

been no hold-harmless provision and if the $8 million that was actually 

used for hold-harmless funding had been distributed in the same 

proportions as the supplemental grants.49 Although 21 EMAs received 

hold-harmless funding in fiscal year 2004, only 3 (San Francisco, Kansas 

City, and Santa Rosa) received more funding because of the hold-harmless 

provision than they would have received through supplemental grants in 

the absence of the hold-harmless provision. Without the hold-harmless 

funding, San Francisco would have received $960 less per ELC, Kansas 

City $70 less, and Santa Rosa $15 less. 

In fiscal year 2004 the San Francisco EMA was guaranteed to receive 

89 percent of its fiscal year 2000 Title I base grant under the hold-harmless 

provision. However, the amount of San Francisco’s 2000 Title I base grant 

had been determined by formulas specified in the CARE Act Amendments 

of 1996, which guaranteed EMAs 95 percent of their 1995 base grant in 

fiscal year 2000.50 San Francisco was the only EMA to qualify for holdharmless funding in 2000 because it was the only EMA that would have 

 

49This analysis shows how the hold-harmless funding would have been distributed if it had 

been allocated in the same proportions as the supplemental grant funding. For example, 

Newark received about 2.5 percent of the funds available for supplemental grants and, 

consequently, we allocated 2.5 percent of the $8,033,563 hold-harmless funding to Newark. 

It is not possible to determine the exact effect of the hold-harmless provision on the 

amount of supplemental funding for each EMA because it is not known how the funds 

would have been distributed in the absence of the hold-harmless awards. 

50The CARE Act Amendments of 1996 guaranteed amounts ranging from 95 to 100 percent 

of the 1995 base grant. The CARE Act Amendments of 2000 guaranteed amounts ranging 

from 85 to 98 percent of the grant received in a base year. The base year varies by EMA. 

Page 34 GAO-06-332 HIV/AIDS Funding
received less than 95 percent of its fiscal year 1995 base grant. Taken 

together, the hold-harmless provisions mean that in fiscal year 2004 San 

Francisco was guaranteed approximately 85 percent of its fiscal year 1995 

base grant of $19,126,679.51 Prior to the CARE Act Amendments of 1996, 

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 San 

Francisco’s Title I funding reflects the application of hold-harmless 

provisions under the 1996 amendments, as well as under current law, San 

Francisco’s Title I base grant is determined in part by the number of 

deceased cases in the San Francisco EMA as of 1995. 

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

even though they were below Title I eligibility thresholds.52 The eligibility 

of these EMAs was protected based on a CARE Act grandfather clause. 

Under a grandfather clause established by the CARE Act Amendments of 

1996, metropolitan areas eligible for funding for fiscal year 1996 remain 

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 

threshold of more than 2,000 reported AIDS cases during the most recent 

5 calendar years but nonetheless retained their status as EMAs (see table 

6). 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. 

Grandfathering Maintains 

Eligibility for EMAs That No 

Longer Meet Certain Eligibility 

Criteria 

 

51The guaranteed amount is calculated by multiplying the two percentages (89 and 95) 

together. 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. 

52To be eligible for Title I funding, a metropolitan area must have reported a cumulative 

total of 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 base grant 

funding allocations, which are determined using the number of ELCs. 

Page 35 GAO-06-332 HIV/AIDS Funding
Table 6: 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 1998–2002. 

Page 36 GAO-06-332 HIV/AIDS Funding
The number of EMAs ineligible for Title I funds in the absence of the 

grandfather clause reflects the combination of the decline in the number 

of new AIDS cases following the advent of more effective therapies and 

the more restrictive eligibility standards adopted in the CARE Act 

Amendments of 1996.53 No metropolitan areas have become eligible for 

Title I funding since 1999, when Las Vegas and Norfolk received their 

initial funding, because no additional metropolitan areas have reported 

enough new cases to meet the AIDS case-count-eligibility threshold. This 

decline in the number of new cases reflects the general pattern of AIDS 

case counts in the country. While the number of people living with AIDS 

has been increasing as persons with AIDS live longer, the number of new 

AIDS cases reported each year throughout the country decreased from 

about 1993 until about 1999 and has since leveled off. In addition, six of 

the EMAs not meeting the current eligibility threshold became eligible on 

the basis of their case rates, under the 1990 thresholds, rather than their 

number of cases. These include Caguas, Dutchess County, Santa Rosa, and 

Vineland-Millville-Bridgeton, the four EMAs with the fewest reported 

cases. In addition, the Jersey City and Ponce EMAs also became eligible on 

the basis of their case rates. 

As discussed earlier, some metropolitan areas are designated as Emerging 

Communities under Title II because their numbers of reported AIDS cases 

in the most recent 5 calendar years 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 

EMAs that were eligible for Title I funding because of the grandfather 

clause.54 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. The overall effect is that Emerging Communities received less 

funding than EMAs with comparable numbers of reported AIDS cases in 

the most recent 5 calendar years. For example, Baton Rouge, with 1,038 

reported cases, received $1,091,976 in Emerging Communities funding 

 

53The AIDS case eligibility thresholds contained in the 1990 statute were either that an area 

had a cumulative total of more than 2,000 AIDS cases (that is, more than 2,000 cases living 

or deceased) or greater than 25 AIDS cases per 100,000 population reported to CDC. This 

standard was changed in 1996 to the current threshold of more than 2,000 reported AIDS 

cases during the most recent 5 calendar years and a population of 500,000 or more. 

54Both EMA eligibility and Emerging Community funding are based on the number of AIDS 

cases reported in the most recent 5 calendar years. 

Page 37 GAO-06-332 HIV/AIDS Funding
while the San Antonio EMA, with 1,034 reported cases, received $3,833,443 

in Title I funding. 

A Title II hold-harmless provision established by the CARE Act 

Amendments of 2000 could diminish ADAP Severe Need grant amounts in 

the future because the hold-harmless payments and the grants are funded 

from the same 3 percent set-aside of Title II funds available for drug 

treatment programs. If larger amounts are needed to meet this holdharmless provision in the future, grantees that have demonstrated a severe 

need for drug treatment funds could get less than the amounts they would 

otherwise receive.55

Title II Hold-harmless Funding 

Could Diminish ADAP Severe 

Need Grants in the Future 

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

hold-harmless provision funded with amounts that would otherwise be 

used for Severe Need grants. Severe Need grants are funded with a 

3 percent set-aside of the funds appropriated specifically for ADAPs. 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 grantee will be at least as large as the total the previous 

year.56 Eight states became eligible for this hold-harmless funding in fiscal 

year 2004. 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 hold-harmless protection. (See table 7.) The remaining 

$20.8 million, or 93 percent of the set-aside amount, was distributed in 

Severe Need grants. 

 

55To be eligible for a Severe Need grant, a jurisdiction must have met one of four eligibility 

criteria as of January 1, 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 

fewer 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.) In addition, a jurisdiction must 

also have agreed to provide a 25 percent match and not impose eligibility requirements 

more restrictive than those in place on January 1, 2000. According to HRSA, grantees have 

provided funds or in-kind services to meet the matching requirement. 

5642 U.S.C. § 300ff-28(a)(2)(I)(ii)(VI) (2000). Title II also contains a hold-harmless provision 

that requires HRSA to consider separately Title II base grants and ADAP base grants. For 

the Title II base grants, this hold-harmless provision is funded by proportionately reducing 

the size of the Title II base grants made to other jurisdictions that did not qualify for this 

hold-harmless funding or receive a minimum grant . The ADAP portion would be funded by 

reducing the size of the ADAP base grants made to those grantees that did not qualify for 

ADAP base grant hold-harmless funding. 42 U.S.C. § 300ff-28(a)(2)(H) (2000). 

Page 38 GAO-06-332 HIV/AIDS Funding
Table 7: 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 further in the future if larger amounts are 

needed to fund this hold-harmless protection. The total amount of Severe 

Need grant funds available in fiscal year 2004 to distribute among the 

eligible grantees was less than it would have been without the holdharmless payments. However, in fiscal year 2004 not all 25 of the Title II 

grantees eligible for Severe Need grants made the required match. 

Consequently, the Severe Need grants were not as small as they would 

otherwise have been because of the application of the hold-harmless 

provision. In future years, if all of the eligible Title II grantees make the 

match, and if there are also grantees that qualify to receive hold-harmless 

funds under this provision, grantees with severe need for ADAP funding 

would get less than the amounts they would otherwise receive. 

Page 39 GAO-06-332 HIV/AIDS Funding
The structure of the HOPWA program restricts states and Puerto Rico 

from receiving HOPWA bonus grant funding for areas outside EMSAs.57

Bonus grants, which totaled about $66 million in fiscal year 2004, are 

awarded only to the EMSAs in which the AIDS epidemic is spreading most 

rapidly.58 In fiscal year 2004, EMSAs with more than 19.5 new AIDS cases 

per 100,000 people over the past year qualified for bonus grants. In fiscal 

year 2004, 26 EMSAs qualified for bonus grants (see table 8). 

HOPWA Provision 

Restricts Bonus Grant 

Eligibility for Some 

Grantees 

Table 8: Fiscal Year 2004 HOPWA Formula Funding 

EMSA Base funding Bonus funding

Bonus funding 

as a percent of 

base funding

Total HOPWA formula 

funding when 

calculated per 

cumulative AIDS casea

Total HOPWA formula 

funding when calculated 

per living AIDS case

Atlanta, Ga. $4,262,000 $637,000 15% $264 $573

Baltimore, Md. 3,940,000 3,996,000 101 463 1,039

Baton Rouge, La. 666,000 1,147,000 172 626 1,290

Bridgeport, Conn. 752,000 27,000 4 238 476

Charleston, S.C. 411,000 7,000 2 234 480

Chicago, Ill. 5,622,000 2,716,000 48 341 805

Columbia, S.C. 626,000 644,000 103 466 824

Detroit, Mich. 1,624,000 355,000 22 280 749

District of Columbia 5,626,000 6,176,000 110 482 939

Fort Lauderdale, Fla. 3,337,000 2,903,000 87 430 954

Jackson, Miss. 449,000 275,000 61 371 728

Jacksonville, Fla. 1,195,000 369,000 31 301 623

Memphis, Tenn. 920,000 1,214,000 132 533 1,000

Miami, Fla. 6,149,000 4,566,000 74 400 934

New Haven, Conn. 937,000 295,000 31 302 605

New Orleans, La. 1,785,000 1,207,000 68 385 887

 

57States and Puerto Rico, as well as EMSAs, receive HOPWA base grants that are 

determined by the grantee’s proportion of the total number of cumulative AIDS cases. CDC 

reported that there were 5.4 AIDS cases per 100,000 people in nonmetropolitan areas in 

2000 and 6.2 cases per 100,000 people in these areas in 2004. 

58Twenty-five percent of HOPWA formula funding is distributed through bonus grants. Until 

fiscal year 2006, bonus funding was based on the per capita incidence of AIDS over a oneyear period. As a result, the amount of bonus funding a grantee received could vary 

significantly from year to year. With respect to fiscal year 2006 funding, HUD’s 

appropriation act included a provision to help mitigate this variability by changing to the 

use of data reported over a 3-year period. 

Page 40 GAO-06-332 HIV/AIDS Funding
EMSA Base funding Bonus funding

Bonus funding 

as a percent of 

base funding

Total HOPWA formula 

funding when 

calculated per 

cumulative AIDS casea

Total HOPWA formula 

funding when calculated 

per living AIDS case

New York, N.Y. 33,487,000 26,868,000 80 414 1,099

Newark, N.J. 4,297,000 885,000 21 277 828

Philadelphia, Pa. 4,340,000 3,292,000 76 404 799

Orlando, Fla. 1,660,000 1,529,000 92 441 913

Wake County, N.C. 345,000 7,000 2 234 408

San Francisco, Calif. 6,698,000 1,864,000 28 294 1,130

San Juan, P.R. 4,585,000 2,555,000 56 358 1,000

Tampa, Fla. 2,221,000 168,000 8 247 569

West Palm Beach, Fla. 2,019,000 1,817,000 90 436 933

Wilmington, Del. 566,000 232,000 41 325 624

All other grantees b0 0 230 c

Source: GAO analysis of CDC and HUD data. 

a

Cumulative AIDS cases are the total number of AIDS cases, both living and dead, reported in the 

jurisdiction since the beginning of the epidemic in 1981. 

b

Varies by number of cumulative AIDS cases. 

c

Varies by number of living AIDS cases. 

Bonus funding can be an important component of an EMSA’s HOPWA 

formula funding. Bonus grants exceeded base funding amounts in five 

EMSAs (Baltimore, Maryland; Baton Rouge, Louisiana; Columbia, South 

Carolina; Memphis, Tennessee; and the District of Columbia), and were 

more than 50 percent of base funding in another nine. EMSAs that did not 

receive bonus funding received approximately $230 per cumulative AIDS 

case in fiscal year 2004 formula funding. Because grantees other than 

EMSAs were not eligible for the bonus funding, they also received $230 per 

cumulative case. However, the 26 EMSAs that received bonus funding 

were allocated an average of $367 per cumulative case in total formula 

funding, ranging from $234 to $626 per case. If all of the formula funding 

had been allocated on the basis of cumulative AIDS cases, instead of 

allocating base grants by cumulative cases and bonus grants by incidence 

rates, each grantee would have received $306 per case. The last column in 

table 8 shows that EMSAs that received bonus funding also received more 

Page 41 GAO-06-332 HIV/AIDS Funding
funds per living AIDS case.59 These EMSAs received an average of 

approximately $816 per living case, ranging from $408 per case in Wake 

County, North Carolina, to $1,290 per case in Baton Rouge, Louisiana. 

Those grantees that did not receive bonus funding received about $503 per 

living case, ranging from $387 to $627 per case. (See app. IV). 

The Use of Revised OMB 

Metropolitan Area 

Definitions Would Change 

Most EMA Boundaries, but 

Increase in ELCs within 

EMAs Would Be Minimal 

Title I EMA boundaries were made permanent by the 1996 amendments to 

the CARE Act, and they have not been altered to conform to OMB’s 2004 

definitions of metropolitan areas.60 Since existing Title I and Title II 

organizational and administrative arrangements within states and EMAs 

are connected to current EMA boundaries, changing EMA boundaries to 

conform to OMB 2004 metropolitan areas could disrupt those 

arrangements. On the other hand, adopting the 2004 OMB definitions for 

EMAs would reflect the same metropolitan areas for which statistical 

agencies make data available to the public and reflect the 2000 decennial 

census demographic data. OMB recommends that policymakers review 

and consider the appropriateness of the new definitions of metropolitan 

area boundaries for program purposes. 

If OMB’s 2004 definitions of metropolitan area61 boundaries were used to 

establish the area to be considered when defining an EMA under Title I,62

the service area boundaries would change for the majority of the current 

 

59These funding levels were calculated by dividing a grantee’s fiscal year 2004 formula 

allocation by the number of living cases in the jurisdiction. If the funding had been 

allocated proportionally on the basis of living AIDS cases, each grantee would have 

received $716 per case. 

60OMB’s new MSA standards and definitions represent a major break with the classification 

scheme used in the past. In some instances OMB retained a term that was used in the past, 

such as MSA, but OMB has altered the meaning. As a result, 2004 MSA boundaries of some 

EMAs are very different from those in 1993. 

61We use the term “metropolitan area” here in a generic sense to refer to both the MSA 

(metropolitan statistical area) and the metropolitan division (OMB’s newly defined term for 

a subdivision of the very largest MSAs). 

62If Title I EMA boundaries were reconfigured to conform with new OMB definitions, those 

areas outside of EMAs that are currently served by governments under Title II would also 

be changed. Though the effect on areas outside EMAs can be inferred from the changes to 

EMAs, we do not explicitly report those results here. 

Page 42 GAO-06-332 HIV/AIDS Funding
EMAs.63 To demonstrate the changes involved in reconfiguring EMA 

boundaries to conform to the new metropolitan areas, we chose a method 

that could be used for this conversion. As described in appendix I, the 

method we chose would combine new metropolitan areas so as to 

minimize changes to current EMA boundaries.64

If our method of converting EMA boundaries to metropolitan areas using 

the 2004 definitions were incorporated in the CARE Act funding formulas, 

the service area boundaries of more than half of current EMAs would 

change. In addition, 5 EMAs would be consolidated to 2, reducing the total 

number of EMAs from 51 to 48.65 We found that 31 of the 51 current EMAs 

would add, lose, or both add and lose counties in their service areas. For 

example, the Atlanta EMA would add 8 counties, the Las Vegas EMA 

would lose 2 counties, and the Newark EMA (New Jersey) would both add 

2 counties and lose 1 other county. Overall, 17 counties would no longer 

be part of an EMA and 53 counties that were not previously included in an 

 

63While we focus on Title I of the CARE Act, the Title II Emerging Communities program 

also uses metropolitan area definitions and it would also be affected if the new OMB 

definitions were applied. We also exclude HOPWA from this subsection because these new 

OMB definitions have already been used to determine fiscal year 2004 HOPWA grant 

funding. For HOPWA, HUD implemented a different method than we use for the analysis 

here. HUD provided no grandfathering of eligibility for previously designated EMSAs and 

instead, among all newly defined metropolitan areas, HUD selected those whose data 

qualified them to be eligible for HOPWA funding. In contrast, in our method we assume a 

policy whereby the 51 current EMAs would retain their eligibility for CARE Act Title I 

grants without needing to qualify on the basis of their number of ELCs or population size, 

and we selected only those new metropolitan areas (or combinations of those areas) that 

most closely correspond to the geographic area of each of the 51 existing Title I EMAs. 

64App. I provides further explanation of the methodology we used for selecting those 

combinations of metropolitan areas that would minimize changes to current EMAs. As 

shown in the tables in app. VII, our conversion method would equate some EMAs with 

more than one newly defined metropolitan area in order to minimize any change in 

boundaries that would occur. For example, we equate the New Haven EMA with two newly 

defined units (the New Haven MSA and the Bridgeport MSA) because the two units 

together have boundaries identical to the New Haven EMA. 

65The Bergen-Passaic, Jersey City, and New York City EMAs would be consolidated into the 

new New York City EMA (with no change to the geographic area encompassed and no 

change to the numbers of ELCs served). The Caguas and San Juan EMAs would be 

consolidated into the new San Juan EMA (with a net increase of 6 counties and 4 percent in 

ELCs.) Increases or decreases in the number of outlying counties included in metropolitan 

area boundaries would mostly have small effect on the numbers of ELCs because such 

outlying counties have many fewer ELCs than the more populous central counties. In those 

instances where EMAs would be consolidated, the changes to boundaries would be 

substantial, though there would be little or no net change in numbers of ELCs within those 

boundaries. 

Page 43 GAO-06-332 HIV/AIDS Funding
EMA would be added to the service area of a newly reconfigured EMA. 

Service area boundaries of 20 current EMAs would not change if the new 

OMB metropolitan area definitions were adopted. (See app. VII.) 

Changing the service area boundaries of current Title I EMAs to reflect the 

new OMB metropolitan area definitions would result in most EMAs having 

a change in the number of ELCs within their boundaries, and the total net 

effect would be an increase of ELCs counted under Title I of less than 

1 percent. Any ELCs that would no longer be counted under Title I would 

continue to be considered for purposes of Title II base grants as ELCs 

outside an EMA. Our analysis of the change in ELCs resulting from a 

change in EMA boundaries to the new OMB definitions shows that 19 of 

the 51 current EMAs would have less than a 2 percent change in their 

number of ELCs, and 23 EMAs would have no change in the number of 

ELCs in their service area. In total, these 42 EMAs represent about 

88 percent of the total number of Title I ELCs. Of the remaining 9 EMAs, 

3 EMAs would experience a gain or loss of more than 9 percentage points 

in their ELCs. The Dutchess County EMA (New York) would have about a 

93 percentage-point increase in ELCs (a gain of 486 in the number of 

ELCs) as a result of adding Orange County to its service area. In New 

Jersey, Middlesex would have a 79 percentage-point increase in ELCs (a 

gain of 979 in the number of ELCs) by adding Monmouth and Ocean 

Counties. The Boston EMA would have about a 9 percentage-point 

decrease (a loss of 554 in the number of ELCs) because Bristol County 

(Massachusetts) would be reassigned from the Boston EMA to the 

Providence (Rhode Island) metropolitan area, which is not an EMA. 

Because the overall change in the number of Title I ELCs that would result 

from EMA service area boundary changes under the new OMB definitions 

would be an increase of less than 1 percent (a net gain of 1,742 in the 

number of ELCs), a minimal overall effect on funding per ELC would be 

expected. 

Page 44 GAO-06-332 HIV/AIDS Funding
CARE Act and HOPWA funding would have shifted among grantees if HIV 

case counts had been used with a measure of persons living with AIDS to 

allocate fiscal year 2004 formula grants. While all states and Puerto Rico 

have established HIV case-reporting systems, IOM identified 

characteristics of these systems that limit their appropriateness for the 

distribution of CARE Act and HOPWA funds.66 We found that up to 

13 percent of CARE Act funding would have shifted if HIV case counts had 

been used with ELCs in the distribution of fiscal year 2004 funds and if the 

hold-harmless and minimum-grant provisions we considered were 

maintained.67 Larger changes for individual grantees would have occurred 

with some grantees more than doubling their funding. Grantees in the 

South and Midwest would generally have received more funding from 

using HIV cases in funding formulas.68 However, there would have been 

grantees that would have received increased funding and grantees that 

would have received decreased funding in every region of the country. 

Larger funding shifts would have occurred without these CARE Act holdharmless and minimum-grant provisions. HOPWA funding would also have 

shifted if HIV cases along with living AIDS cases had been used to 

determine funding rather than cumulative AIDS case counts. Differences 

in HIV case-reporting systems would affect funding allocations, and we 

found that funding would have tended to shift to jurisdictions with older 

HIV-reporting systems. Jurisdictions with older HIV-reporting systems 

tend to have more reported HIV cases compared with their number of 

AIDS cases than do jurisdictions with newer reporting systems. 

Funding Effect of 

Using HIV Case 

Counts Would Depend 

on Multiple Factors 

 

66Institute of Medicine, Measuring What Matters, 87–134. While IOM examined only the 

CARE Act, its findings regarding the use of HIV data for determining funding allocations 

are also relevant for HOPWA. 

67In our analyses, we considered the Title I hold-harmless provision and the Title II holdharmless provisions that are funded by proportional reductions in Title II base grants and 

ADAP base grants. We did not include the Title II hold-harmless provision funded by 

amounts otherwise available for Severe Need grants. 

68See app. I for a listing of the four U.S. Census Bureau regions and the jurisdictions that 

constitute each region. Because Puerto Rico is not included in any of these four regions, we 

excluded it from our regional analyses. 

Page 45 GAO-06-332 HIV/AIDS Funding
In order to monitor HIV infection, the states and Puerto Rico have 

established HIV case-reporting systems under which individuals who have 

been diagnosed with HIV are reported to health departments by physicians 

and other practitioners.69 In 2000 we reported that HIV cases accounted for 

a much smaller percent of total HIV/AIDS cases in states with newer HIVreporting systems.70 In its 2004 report, IOM updated our earlier analysis 

and identified several limitations in the ability of these jurisdictions to 

provide accurate HIV case counts to CDC for use in CARE Act funding 

allocations. Among these limitations, IOM found that the maturity of HIV 

case-reporting systems continued to vary widely across grantees. The 

earliest HIV-reporting systems were established in Colorado, Minnesota, 

and Wisconsin in 1985, followed by most southern and other midwestern 

states prior to 1995. The newest systems were established after 2003 in six 

states and Philadelphia, Pennsylvania.71 Case-reporting systems need 

several years to become fully operational. Practitioners need to be made 

aware of the requirement to report new HIV cases and the methods for 

doing so. Existing cases also need to be reported by practitioners and 

entered into the system. Grantees with newer systems may not have 

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

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

states with newer HIV-reporting systems would result in grantees 

receiving less funding than they would be entitled to receive according to 

the actual number of HIV/AIDS cases. 

Current HIV Casereporting Systems Have 

Limitations for Providing 

Case Counts for Funding 

Allocations 

IOM also found that differences in how jurisdictions report HIV case 

counts to CDC preclude HRSA’s use of those case counts in the 

distribution of CARE Act funds.72 While some HIV case-reporting systems 

 

69HIV case-reporting systems are generally either name- or code-based. In name-based 

systems, cases are collected by name while in a code-based system cases are collected 

using a coded identifier. Currently, 38 states and Puerto Rico have name-based systems 

while 8 states have code-based systems. In the remaining 5 states, names are collected and 

converted to codes by public health authorities. 

70GAO/T-HEHS-00-150. 

71Name-based HIV reporting has been established in all parts of Pennsylvania except 

Philadelphia since 2002. Philadelphia was given permission by the state to establish codebased HIV reporting, and the system began in 2004. However, in August 2005, the 

Philadelphia Board of Health voted to implement a name-based HIV-reporting system. This 

system went into effect in October 2005. Philadelphia is in the process of having its HIV 

surveillance data certified by CDC; once certified, its data will be accepted by CDC. 

72HRSA uses AIDS case counts provided by CDC for determining CARE Act formula 

funding. All states and territories report AIDS cases by name. 

Page 46 GAO-06-332 HIV/AIDS Funding
are code-based, CDC will only accept name-based case counts as no codebased system has met its quality criteria as of January 2006.73 Therefore, 

HIV cases reported using codes rather than names would not be counted 

in distributing CARE Act funds, if HIV case counts were used in funding 

formulas. As of December 2005, thirteen states have some form of a codebased system rather than a name-based system.74 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.75 Table 9 shows the 39 jurisdictions 

where HIV case counts are accepted by CDC and the 13 jurisdictions 

where they are not accepted, and the year in which each jurisdiction 

established its HIV-reporting system. 

 

73CDC has established a set of performance standards for accepting case counts from HIVreporting 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 must result in accurate case counts (less than or equal to 5 percent of 

reported cases are duplicates). 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. In July 2005, CDC began recommending that all states and territories adopt 

confidential name-based surveillance systems to report HIV infections. 

74Two of the 13 states, Illinois and Maine, established name-based HIV reporting in January 

2006. 

75CDC 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 with providers to resolve potential 

duplicate reports on the same person. 

Page 47 GAO-06-332 HIV/AIDS Funding
Table 9: CDC Acceptance of HIV Case Counts and Year of Establishment of HIVreporting Systems, December 2005 

Accepted Not accepted 

Colorado (1985) Maryland (1994) 

Minnesota (1985) Massachusetts (1999) 

Wisconsin (1985) Illinois (1999)d

Idaho (1986) Maine (1999)e

South Carolina (1986) Washington (1999) 

Arizona (1987) Montana (2000) 

Missouri (1987) Rhode Island (2000) 

Alabama (1988) Vermont (2000) 

Indiana (1988) Delaware (2001) 

Mississippi (1988) District of Columbia (2001) 

North Dakota (1988) Hawaii (2001) 

Oklahoma (1988) Oregon (2001) 

South Dakota (1988) California (2002) 

Arkansas (1989) 

Utah (1989) 

Virginia (1989) 

West Virginia (1989) 

Wyoming (1989) 

North Carolina (1990) 

Ohio (1990) 

Michigan (1992) 

Nevada (1992) 

New Jersey (1992) 

Tennessee (1992) 

Louisiana (1993) 

Nebraska (1995) 

Florida (1997) 

Iowa (1998) 

New Mexico (1998) 

Alaska (1999) 

Kansas (1999) 

Texas (1999) 

New York (2000) 

Pennsylvania (2002)a

Georgia (2003) 

Page 48 GAO-06-332 HIV/AIDS Funding
Accepted Not accepted 

Puerto Rico (2003) 

Kentucky (2004) 

Connecticut (2005)b

New Hampshire (2005)c

Sources: CDC, IOM, Connecticut, Kentucky, and Philadelphia. Connecticut, Kentucky, and Philadelphia provided us with updated 

information about their HIV case-reporting systems. 

Notes: Currently, CDC will only accept name-based case counts. 

a

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

since 2002. Philadelphia was given permission by the state to establish code-based HIV reporting, 

and the system began in 2004. However, in August 2005, the Philadelphia Board of Health voted to 

implement a name-based HIV-reporting system. This system went into effect in October 2005. 

Philadelphia is in the process of having its HIV surveillance data certified by CDC; once certified, its 

data will be accepted by CDC. 

b

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

reporting was only required for pediatric cases. 

c

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. 

d

Illinois established name-based HIV reporting in January 2006. It is in the process of having its HIV 

surveillance data certified by CDC and, once certified, its data will be accepted by CDC. 

e

Maine established name-based HIV reporting in January 2006. It is in the process of having its HIV 

surveillance data certified by CDC and, once certified, its data will be accepted by CDC. 

The Use of HIV Case 

Counts in Funding 

Formulas Would Have 

Changed the Distribution 

of Fiscal Year 2004 CARE 

Act and HOPWA Funds 

While we are aware of differences in the HIV data across jurisdictions, 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 not 

later than fiscal year 2007. We used two approaches to examine the 

potential effect of including HIV cases in addition to persons living with 

AIDS in fiscal year 2004 CARE Act and HOPWA funding formulas. We 

found that some CARE Act fiscal year 2004 funding would have shifted 

among grantees if HIV case counts and ELCs had been used to allocate the 

funds. While our analyses indicate that up to 13 percent of CARE Act 

funding would have shifted, larger changes for individual grantees would 

have occurred. Southern and midwestern grantees would generally have 

received more funding, but there would have been grantees that would 

have received increased funding and grantees that would have received 

decreased funding in every region of the country. Funding changes in our 

model would have been larger without the hold-harmless and minimumgrant provisions that we included. There would also have been at most a 

15 percent shift in HOPWA funding if HIV cases were used to allocate 

funding, although there would have been larger changes for some 

Page 49 GAO-06-332 HIV/AIDS Funding
grantees.76 CARE Act and HOPWA funding changes could have resulted 

from the number of people living with HIV/AIDS in each jurisdiction or 

differences in HIV case-reporting systems. 

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

addition to AIDS cases77 in funding formulas for CARE Act Title I and 

Title II base grants, ADAP base grants, and HOPWA base funding in the 

states and Puerto Rico. Under the first approach, we used HIV and AIDS 

case counts for the 35 grantees from which CDC accepted HIV data.78

Because CDC did not receive HIV case counts from the other 17 grantees, 

we used only the AIDS case counts received by CDC for these grantees. 

Consequently, for some grantees we used HIV and AIDS case counts, but 

Methodological Approaches 

Used 

 

76Unlike the CARE Act, there is currently no law requiring the use of HIV cases in 

determining HOPWA funding. In our analysis of HOPWA, we used living AIDS cases instead 

of cumulative AIDS cases, which is the measure currently required by law to be used to 

determine HOPWA base funding. As we reported in 1995, we believe that cumulative AIDS 

cases is an inappropriate measure for allocating funds (GAO/HEHS-96-26, 6). Consequently, 

our analyses of HOPWA funding reflect the effect of using HIV and living AIDS cases 

instead of cumulative AIDS cases. This measure of living AIDS cases is used for illustrative 

purposes only. 

77We used ELCs in our analyses of CARE Act programs, which is the measure of AIDS cases 

used by HRSA in determining funding for the grants we examined: Title I, Title II, and 

ADAP base grants. HUD does not have a measure of living AIDS cases that it uses to 

determine HOPWA funding. Because ELCs are specific to the CARE Act and because of 

shortcomings in this measure discussed earlier, we calculated an alternative measure of 

living AIDS cases in our examination of HOPWA funding. For the HOPWA analyses, the 

living AIDS case counts were calculated by subtracting the number of reported deaths 

among AIDS cases from the number of reported AIDS cases. 

78Because HIV-reporting systems in some jurisdictions are changing to name-based 

systems, CDC now accepts HIV case counts from some jurisdictions from which it did not 

accept HIV case counts earlier. For our analyses, we classified Connecticut, Kentucky, and 

New Hampshire as having HIV case counts that are not accepted by CDC. Our analyses 

were conducted using fiscal year 2004 allocations, which were based on case reports as of 

June 30, 2003, for the CARE Act and as of March 31, 2003, for HOPWA. At those times, 

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. A fourth state, Georgia, had not established any HIV case reporting as of 

June 30, 2003, but did so in 2004. Consequently, the HIV case count for Georgia is zero in 

our analyses. Pennsylvania is classified as having its HIV case counts accepted by CDC. 

However, these counts do not include any cases from Philadelphia, which established its 

code-based system in 2004. Philadelphia established a name-base HIV-reporting system in 

October 2005 and is in the process of having its HIV surveillance data certified by CDC; 

once certified, its data will be accepted by CDC. Illinois and Maine established name-based 

HIV-reporting systems in January 2006 and are also in the process of having their HIV data 

certified by CDC; once certified, their data will be accepted by CDC. 

Page 50 GAO-06-332 HIV/AIDS Funding
for others we used only AIDS case counts. This approach reflects the data 

that would have been used if funding allocations were based on the HIV 

and AIDS case counts received by CDC in time for determining fiscal year 

2004 formula grants. Under the second approach, we used the same HIV 

and AIDS case counts as our first approach, but supplemented these data 

with the code-based HIV case counts collected by the grantees from which 

CDC did not receive HIV data.79 We obtained these HIV case counts 

directly from these jurisdictions.80

For both approaches, we calculated the grantee’s percentage of the total 

number of HIV/AIDS cases in each jurisdiction81 and estimated the fiscal 

year 2004 formula grants that each would have received. Under each 

approach, CARE Act formula grants were calculated both with certain 

hold-harmless and minimum-grant provisions and again without those 

provisions.82 Eliminating hold-harmless and minimum-grant provisions 

 

79CDC receives, reviews, and processes name-based HIV case reports on individual cases. 

Potential duplicate reports across jurisdictions are reviewed through a CDC-coordinated 

process to remove duplicate reports from the national database. Code-based reports 

cannot be included in this de-duplication process because name-based and code-based 

systems do not have comparable patient identifiers. Because the name- and code-based 

case counts are not comparable, in its comments on a draft of this report HHS stated that it 

would not be appropriate to use the code-based case counts in monitoring HIV/AIDS 

nationally. Our purpose in using both the name- and code-based case counts was to provide 

a general indication of how funding would be affected by using HIV and AIDS cases to 

distribute CARE Act and HOPWA funds in light of the statutory requirement that HIV cases 

be used in CARE Act funding formulas not later than fiscal year 2007. Our use of the codebased case counts should not be taken as endorsement for their use in monitoring 

HIV/AIDS or distributing funds. An assessment of the feasibility of using code-based case 

counts was beyond the scope of our report. 

80HIV case counts for three states—Georgia, Kentucky, and the District of Columbia—were 

unavailable. Consequently, their HIV case counts are zero under both approaches. HIV case 

counts were also unavailable for Philadelphia, and as a consequence HIV counts were 

incomplete for Pennsylvania. 

81For example, for CARE Act Title I base funding, we calculated the EMA’s percentage of 

the total number of HIV/AIDS cases in all EMAs. 

82Under the CARE Act, there is a minimum-grant provision for Title II base grants, but not 

for Title I and ADAP base funding. However, there are hold-harmless provisions for Title I, 

Title II, and ADAP base funding. There is no comparable hold-harmless provision in 

HOPWA and minimum-grant requirements have been effectively waived in recent years. 

Consequently, the analyses in which the hold-harmless and minimum-grant provisions are 

maintained are limited to the CARE Act. For purposes of this analysis, we considered the 

Title I hold-harmless provision and the Title II hold-harmless provision that is funded by 

proportional reductions in Title II base grants and ADAP base grants. We did not include 

the Title II hold-harmless provision funded by amounts otherwise available for Severe Need 

grants. The effect on HOPWA allocations are discussed later. 

Page 51 GAO-06-332 HIV/AIDS Funding
was done to reveal the full effect of distributing fiscal year 2004 funding 

solely according to HIV/AIDS data available at that time. We also estimated 

the effect of using HIV cases and living AIDS cases for HOPWA base 

funding. Although there are limitations associated with the underlying 

data, the results of our analyses indicate the general effect of using HIV 

and AIDS cases to distribute CARE Act and HOPWA formula funding. (See 

app. I for a discussion of the limitations in the data.) 

Our analyses indicate that for fiscal year 2004 as much as 13 percent of 

Title I, Title II, and ADAP base grants would have shifted, with southern 

and midwestern grantees being the primary beneficiaries, if hold-harmless 

and minimum-grant provisions were maintained. However, there would 

have been grantees that would have received increased funding and 

grantees that would have received decreased funding in every region of 

the country. Changes in funding could have resulted from the actual 

number of HIV/AIDS cases living in each jurisdiction or from differences 

across jurisdictions in HIV case-reporting systems. The funding changes 

under each of our approaches would have been larger if we had not 

applied the hold-harmless and minimum-grant provisions. 

Changes in CARE Act Funding 

Using HIV Cases and Holdharmless and Minimum-grant 

Provisions 

Title I Base Funding 

Title I base grant funding would have shifted among grantees under both 

our approaches, but because the funds necessary to meet the holdharmless provision are taken from funds that would otherwise be used for 

supplemental grants, the overall effect on Title I EMAs is unclear.83 The 

Title I base grant includes (1) funding amounts determined by the number 

of ELCs and (2) the hold-harmless amounts, if applicable. In fiscal year 

2004, a total of about $8.0 million was needed to fund the hold-harmless 

payments for EMAs. The amount of Title I hold-harmless funding for all 

EMAs would have increased from $8.0 million to $43.3 million under our 

first approach in which we used only HIV data received by CDC and ELCs. 

It would have increased to $29.4 million under our second approach in 

which we used the HIV case counts collected by CDC, the code-based HIV 

counts we collected from the grantees, and ELCs. In order to meet the 

hold-harmless levels, funds would have to be deducted from the amounts 

otherwise available for Title I supplemental grants. Supplemental grants 

are divided among all EMAs using a competitive application process based 

on the demonstration of severe need and other criteria. Because these 

 

83There is no minimum funding provision for Title I base grants. 

Page 52 GAO-06-332 HIV/AIDS Funding
awards are made competitively, it is unclear how the reduction in funding 

for supplemental grants would have affected individual EMAs and, 

therefore, what the overall effect on funding for each EMA would have 

been under our two approaches. 

Under the first approach—using ELCs and HIV cases when accepted by 

CDC and only ELCs elsewhere—13 EMAs would have received a total of 

$2.8 million less in fiscal year 2004 Title I base grants, about 1 percent of 

the total Title I base grants. Twenty-nine grantees would have received 

$38.1 million in additional Title I base grant funding, about 13 percent of 

total Title I base grants, if HIV cases and ELCs had been used to allocate 

funding instead of just ELCs. The other 9 EMAs would have had no change 

in their funding. The effect on certain EMAs would have been large, with 

the Denver EMA more than doubling its Title I base funding and 16 others 

receiving at least a 25 percent increase in funding. Of the 29 that would 

have received more funding, 13 are in the South. In addition, 5 of the 

6 EMAs in the Midwest and 8 of 12 EMAs in the Northeast would have 

received increased funding. However, only 3 of 14 EMAs in the West 

would have received increased funding.84

Under the second approach—using the HIV case counts collected by CDC, 

the code-based HIV counts we collected from the grantees, and ELCs— 

15 EMAs would have received a total of $1.9 million less in fiscal year 2004 

Title I base grants, about 1 percent of the total Title I base grants. Twentyeight grantees would have received $23.3 million more in fiscal year 2004 

Title I base grants, about 8 percent of total Title I base grants. Eight EMAs 

would have had no change in their funding. Some EMAs would have 

received large increases in funding, with the Denver EMA more than 

doubling its Title I base grant funding and 9 others receiving at least a 

25 percent increase in funding. Of the 28 EMAs that would have received 

additional funding, 10 are in the South. All 6 midwestern EMAs would have 

received additional funding. Seven of 12 EMAs in the Northeast and 5 of 

14 EMAs in the West would have received increased funding. 

Appendix VIII shows the results of the analyses for each EMA under each 

approach. 

 

84See app. I for a listing of the four U.S. Census Bureau regions and the jurisdictions that 

constitute each region. 

Page 53 GAO-06-332 HIV/AIDS Funding
Title II Base Funding 

There would be some shifting of funds if HIV cases and ELCs had been 

used to allocate CARE Act Title II base grants while maintaining the holdharmless and minimum-grant provisions.85 Most southern and midwestern 

grantees would receive increased funding under either approach we used 

for analysis. Under the first approach—using ELCs and HIV cases when 

accepted by CDC and only ELCs elsewhere—about 5 percent or 

$14.3 million of Title II base grants would have shifted among grantees. 

Unlike funding for the Title I hold-harmless provision, the amounts 

necessary to fund the Title II base grant hold-harmless and minimum-grant 

provisions are subtracted from the base grants of those states that did not 

qualify for funding under these provisions. Consequently, the total amount 

of funding increases received by some Title II grantees would have to be 

equal to the total decreases received by other grantees. Twenty-one 

grantees would have received additional funding in their Title II base 

grants, and 22 would have received less. Nine grantees would have had no 

change in their funding. Of the 21 that would have received more funding, 

9 are in the South and 7 in the Midwest. Of the 22 that would have received 

less funding, 6 are in the Northeast and 5 are in the West. Changes in 

funding for individual grantees would have ranged from a 150 percent 

increase in North Dakota and Wyoming to a 22 percent decrease in 

Delaware and the District of Columbia. 

The second approach—using the HIV case counts accepted by CDC, the 

code-based HIV counts we collected from the grantees, and ELCs—would 

yield a smaller shift in funding. Under this approach, approximately 

4 percent or $12.6 million of fiscal year 2004 Title II base grants would 

have shifted. Of the 22 grantees that would have received additional 

funding, 10 are in the South and 7 in the Midwest. Among those that would 

have received less funding, 4 are in the Northeast and 4 are in the West. 

Twenty grantees would have received less funding and 10 would have 

received the same amount. Funding changes for individual grantees would 

have ranged from a 150 percent increase in North Dakota and Wyoming to 

a 22 percent decrease in Delaware and the District of Columbia. 

 

85We assume that the case threshold for determining the size of minimum grants would 

remain at 90 even if HIV cases were included in the case counts. Currently, states with 

fewer than 90 ELCs are guaranteed a minimum Title II base grant of $200,000 while states 

with 90 or more cases are guaranteed at least $500,000. Our analyses assume that the 

threshold would be a total of 90 HIV cases and ELCs. 

Page 54 GAO-06-332 HIV/AIDS Funding
Appendix IX shows the results of these analyses for each grantee under 

each approach. 

While a majority of southern grantees would have received increased 

funding under both approaches, the amount of the increase would have 

been relatively small. Southern grantees would have received a total of 

about $430,000 more funding under our first approach and about $640,000 

under the second approach. This relatively small shift can be attributed to 

the fact that southern states generally would not benefit from the 

minimum-grant and hold-harmless provisions. For example, many 

southern states would have their grants reduced in order to fund the holdharmless provision. Midwestern grantees would have received larger 

dollar and percent increases in funding than the southern grantees under 

both approaches. 

ADAP Base Funding 

Our analyses indicate that there would have been some shifting of funding 

for ADAP base grants if HIV and AIDS case counts had been used to 

determine allocations while maintaining the hold-harmless provision,86

with southern and midwestern grantees generally being among the areas 

that would have received increased funding.87 Under the first approach—

using ELCs and HIV cases when accepted by CDC and only ELCs 

elsewhere—about 12 percent or $85.2 million of fiscal year 2004 ADAP 

base grants would have shifted among grantees. The amounts necessary to 

fund the ADAP base grant hold-harmless provision are subtracted from the 

ADAP base grants of those states that did not qualify for hold-harmless 

funding. Consequently, the total amount of funding increases received by 

some Title II grantees must be equal to the total decreases received by 

other grantees. Thirty-one of the 52 grantees would have received 

additional funding in their ADAP base grants if HIV cases and ELCs had 

been used to allocate funding instead of just ELCs. Of the 31 that would 

have received more funding, 12 are in the South and 11 in the Midwest. 

The funding changes for some grantees would have been large. For 

 

86There is no minimum funding provision for ADAP base grants. 

87The ADAP base grant funding reported to us included any hold-harmless funding taken 

from funds otherwise set aside for the ADAP Severe Need grants. This hold-harmless 

funding results from a different Title II hold-harmless provision than that which requires 

HRSA to consider separately Title II base grants and ADAP base grants. In our analyses, we 

excluded hold-harmless funding taken from the ADAP Severe Need grants when we 

estimated the dollar and percent changes in the ADAP base grants. 

Page 55 GAO-06-332 HIV/AIDS Funding
example, Colorado’s allocation would have doubled and South Dakota’s 

would have increased by 84 percent while funding would be reduced by 

38 percent in Delaware, the District of Columbia, Illinois, Kentucky, and 

Maryland. 

The second approach—using the HIV case counts accepted by CDC, the 

code-based HIV counts we collected from the grantees, and ELCs—yields 

a smaller shift in funding. Under this approach, approximately 9 percent or 

$65.2 million of fiscal year 2004 ADAP base grants would have shifted. Of 

the 35 grantees that would have received additional funding, 12 are in the 

South and 10 are in the Midwest. Funding changes for some grantees 

would have been large. For example, the allocation for Montana would 

have increased 93 percent and the allocation for Colorado 84 percent, 

while funding would have declined by 40 percent in the District of 

Columbia and by 38 percent in Kentucky. Appendix X shows the results of 

these analyses for each grantee under both approaches. 

Changes in CARE Act 

Formula Funding Would 

Be Larger If Hold-harmless 

and Minimum-grant 

Provisions Were Not in 

Effect 

Hold-harmless provisions limit how much funding can decline from one 

grant period to the next. However, while these provisions limit changes in 

funding they also reduce a program’s ability to respond to changing need. 

Minimum-grant provisions guarantee that no grantee will receive less than 

a specified funding amount. These provisions also limit how funding can 

be distributed.88

Changes in CARE Act funding levels for Title I base grants, Title II base 

grants, and ADAP base grants caused by shifting to HIV cases and AIDS 

cases would be larger—up to 24 percent—if the current hold-harmless or 

minimum-grant amounts were not in effect than if they were in effect.89

Consider the hypothetical situation in which an EMA or Title II grantee 

received a $2 million base grant award according to its number of ELCs. 

Assume that in the following year, the formula is changed so that HIV 

cases and ELCs are used to determine funding allocations, and the grantee 

is then only entitled to $1 million. However, there is a hold-harmless 

 

88For a description of features in funding formulas, see National Research Council, 

Statistical Issues in Allocating Funds by Formula: Panel on Formula Allocations 

(Washington, D.C.: The National Academies Press, 2003). 

89In these analyses we considered the Title I hold-harmless provision and the Title II holdharmless provisions that are funded by proportional reductions in Title II base grants and 

ADAP base grants. We did not include the Title II hold-harmless provision funded by 

amounts otherwise available for Severe Need grants. 

Page 56 GAO-06-332 HIV/AIDS Funding
provision that guarantees the grantee 98 percent of what it received the 

previous year. The grantee 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 cases and ELCs. The change in funding with the holdharmless provision would be a decrease of $40,000, but the loss would 

grow to $1,000,000 without the hold-harmless provision. If a grantee 

qualified for $100,000 in formula funding using HIV case counts and ELCs, 

but the minimum award was $500,000, the grantee would receive $500,000 

because of the minimum-grant provision, thereby offsetting the changes 

due to using HIV cases and ELCs. 

Title I Base Funding 

Under both our methodological approaches, Title I funding would have 

been affected by eliminating the Title I base grant hold-harmless 

provision.90 If the hold-harmless provision had been eliminated, the 

number of EMAs that would have received less Title I base grant funding 

would have increased from 13 to 23 under our first approach—using ELCs 

and HIV cases when accepted by CDC and only ELCs elsewhere—and 

from 15 to 24 under our second approach—using the HIV case counts 

collected by CDC, the code-based HIV counts we collected from the 

grantees, and ELCs.91 The effect of the hold-harmless provision on an 

individual grantee can be illustrated with the New Haven EMA. New 

Haven, which would have had no change in base grant funding if the holdharmless provision was maintained would have had Title I base grant 

funding reductions of 31 and 35 percent under the first and second 

approaches, respectively, without the hold-harmless provision. Overall, 

southern and midwestern EMAs would gain funding under both 

approaches whether or not the hold-harmless provision was maintained 

while northeastern EMAs would lose funding only under our second 

approach and only if the hold-harmless provision was not maintained.92

However, in all four regions of the country, there would have been EMAs 

that would have received increased funding and EMAs that would have 

 

90There is no minimum funding provision for Title I base funding. 

91The amount of base grant funding would have been about $8 million less without the holdharmless provision. This money would have been distributed to EMAs in supplemental 

grants. 

92EMAs in the West would gain funding under both approaches if the hold-harmless was 

maintained but would receive less funding under both approaches if it was not maintained. 

Page 57 GAO-06-332 HIV/AIDS Funding
received decreased funding. Appendix XI shows the results of our analyses 

for Title I base grants if the hold-harmless provision was not maintained. 

Title II Base Funding 

The hold-harmless and minimum-grant provisions have a large effect on 

funding shifts in Title II base grants. Under our first approach—using ELCs 

and HIV cases when accepted by CDC and only ELCs elsewhere— 

14 percent of Title II base grants would have shifted among grantees if the 

hold-harmless and minimum-grant provisions had been eliminated, while 

5 percent would have shifted if they had been maintained. Under our 

second approach—using the HIV case counts collected by CDC, the codebased HIV counts we collected from the grantees, and ELCs—10 percent 

would have shifted if the provisions were eliminated and 4 percent if they 

had been maintained. The importance of these provisions can be 

illustrated by examining individual grantees. For example, Vermont, which 

received a minimum grant of $500,000 in fiscal year 2004, would have had 

a decrease of 74 percent under approach one and 52 percent under 

approach two if the hold-harmless and minimum-grant provisions had not 

been maintained. However, it would have had no change in funding if 

these provisions had been maintained. California would have received 

decreases of $11.8 million under our first approach and $5.0 million under 

our second approach if the provisions had been eliminated, but the state 

would have had no change in funding if the provisions had been 

maintained. Conversely, North Carolina would have received $5.0 million 

in additional funding under our first approach and $4.0 million under our 

second approach if the hold-harmless and minimum-grant provisions had 

not been maintained. It would have received $2.4 million and $2.1 million 

additional under each approach respectively if the provision had been 

maintained. Southern and midwestern grantees would gain funding under 

both approaches whether or not the hold-harmless and minimum-grant 

provisions had been maintained, while northeastern grantees would lose 

funding.93 However, in all four regions of the country, there would have 

been grantees that would have received increased funding and grantees 

that would have received decreased funding. Appendix XII shows the 

results of our analyses for Title II base grants if the hold-harmless and 

minimum-grant provisions were not maintained. 

 

93Grantees in the West would gain funding under both approaches if the hold-harmless and 

minimum-grant provisions were maintained but would receive less funding under both 

approaches if they were not maintained. 

Page 58 GAO-06-332 HIV/AIDS Funding
ADAP Base Funding 

The overall effect of the hold-harmless provision is smaller on funding 

shifts for the ADAP base grants.94 Under our first approach—using ELCs 

and HIV cases when accepted by CDC and only ELCs elsewhere— 

14 percent instead of 12 percent of ADAP base funding would have shifted 

among grantees if the hold-harmless provision was eliminated. Ten 

percent instead of 9 percent of the funding would have shifted under our 

second approach—using the HIV case counts collected by CDC, the codebased HIV counts we collected from the grantees, and ELCs. The reason 

for the smaller effect on the ADAP base grants than on the Title I and Title 

II base grants is the increase in ADAP base funding since fiscal year 2000. 

In fiscal year 2000, $528 million was distributed to grantees while 

$728 million was distributed in fiscal year 2004. Because of these 

increases, the hold-harmless provision had less effect in our analyses. 

However, under all our scenarios grantees in the Northeast and West 

would have received less total funding while grantees in the Midwest and 

South would have received more. In all four regions of the country, there 

would have been grantees that would have received increased funding and 

grantees that would have received decreased funding. For example, in the 

Northeast, New Jersey would have gained funding and New York would 

have lost funding under both our approaches. In the South, Alabama 

would gain funding and Georgia would lose funding under both our 

approaches. Appendix XIII shows the results of our analyses for ADAP 

base grants if the hold-harmless provision had not been in effect. 

HOPWA Base Funding 

Would Generally Shift If 

HIV Cases Were Used in 

Formula Allocations 

There would have been some shifting of funds if HIV and living AIDS case 

counts95 had been used to allocate HOPWA base grants instead of 

cumulative AIDS cases under either of our methodological approaches—

with or without the code-based HIV case counts—with southern and 

midwestern grantees generally being among the jurisdictions that would 

have received increased funding.96 Under the first approach—using living 

 

94There is no minimum funding provision for ADAP base funding. 

95For the HOPWA analyses, the living AIDS case counts were calculated by subtracting the 

number of reported deaths among AIDS cases from the number of reported AIDS cases. 

96This analysis indicates how HOPWA base funding would have changed if living AIDS 

cases and HIV cases had been used to distribute funding rather than cumulative case 

counts. The effect of using living AIDS cases but not HIV cases on HOPWA base funding is 

shown in app. V. 

Page 59 GAO-06-332 HIV/AIDS Funding
AIDS cases and HIV cases when accepted by CDC and only living AIDS 

cases elsewhere—about 15 percent or $30.0 million of fiscal year 2004 

HOPWA base grants would have shifted among grantees. Seventy of 117 

grantees would have received additional funding in their HOPWA base 

grants if living HIV and AIDS cases had been used to allocate funding. Six 

grantees would have more than doubled their funding.97 Thirty-five of 47 

southern grantees98 and 18 of the 20 midwestern grantees would have 

received more funding. Southern grantees would have received an 

additional $15.8 million (22 percent) in funding while those in the Midwest 

would have received an additional $3.3 million (17 percent). Seventeen of 

the 24 northeastern grantees and 14 of the 24 western grantees would have 

received less funding. The northeastern and western grantees would have 

received $6.3 million (10 percent) and $9.7 million (24 percent) less in 

funding respectively. 

The second approach—using the HIV case counts accepted by CDC, the 

code-based HIV counts we collected from the grantees, and living AIDS 

cases—yields an overall smaller shift in funding although changes would 

have been larger in the Midwest and Northeast. Under this approach, 

approximately 13 percent or $25.6 million of fiscal year 2004 HOPWA base 

grants would have shifted, with Maryland and Charlotte, North Carolina, 

more than doubling their funding. Of the 82 grantees that would have 

received additional funding, 39 are in the South, 19 in the Midwest, 14 in 

the West, and 10 in the Northeast. Overall, the South would have received 

$13.7 million (19 percent) in additional funding and the Midwest would 

have received an additional $4.0 million (21 percent). The Northeast would 

have received $8.5 million (14 percent) less in funding and the West 

$5.8 million (15 percent) less. Appendix XIV shows the results of these 

analyses for each jurisdiction under both approaches. 

One explanation for the changes in funding allocations when HIV cases 

and either ELCs or living AIDS cases are used—whether or not the codebased HIV case counts are included—instead of only AIDS cases99 is the 

Differences in Case-reporting 

Systems Would Affect 

Allocations 

 

97These six grantees are the state of Alabama; Birmingham, Alabama; Charlotte, North 

Carolina; Memphis, Tennessee; the state of North Carolina; and Wake County, North 

Carolina. 

98In those cases in which an EMSA included both southern and nonsouthern jurisdictions, 

we classified the EMSA as not being in the South. 

99In this instance, AIDS cases refers to ELCs for the CARE Act and cumulative AIDS cases 

for HOPWA. 

Page 60 GAO-06-332 HIV/AIDS Funding
maturity of HIV case-reporting systems. We found that those grantees that 

would receive increased funding from the use of HIV cases tend to be 

those with the oldest HIV case-reporting systems. Those grantees with the 

oldest reporting systems include 11 southern and 8 midwestern states 

whose HIV-reporting systems were implemented prior to 1995. As shown 

in table 10, jurisdictions with long histories of counting HIV cases tend to 

have many more reported HIV cases compared with their number of ELCs 

than do jurisdictions with less-mature reporting systems. This difference is 

likely because jurisdictions with newer systems do not have reports on 

many cases of HIV that were diagnosed before their reporting systems 

were established.100 This divergence can be illustrated by comparing 

Wisconsin and Delaware, two states with similar numbers of AIDS cases. 

Wisconsin began reporting HIV cases in 1985 while Delaware began in 

2001. In Wisconsin, as of June 2003, there were about 50 percent more 

reported HIV cases than AIDS cases, or 2,287 HIV cases and 1,507 AIDS 

cases. As of June 2003, the 909 reported HIV cases in Delaware were about 

40 percent less than the 1,518 ELCs. This variability could be reduced as 

Delaware identifies more preexisting HIV cases. However, the variability 

between HIV cases and ELCs would remain if there was a difference in the 

actual number of HIV cases. 

Table 10: Reported HIV Cases and ELCs as of June 2003 

HIV case-reporting 

system start date Number of jurisdictionsa

Ratio of HIV cases to ELCs

1985–1991 21 1.42

1992–1998 11 1.01

1999–2002 17 0.68

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

a

Georgia, Kentucky, and Puerto Rico are not included in this table because they established their 

HIV-reporting systems after 2002. Connecticut and New Hampshire established their name-based 

HIV-reporting system in 2005. However, 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. 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. 

 

100Other factors may also affect the ratio of HIV to AIDS cases in a reporting system. For 

example, some jurisdictions with newer HIV-reporting systems were among the first to be 

affected by the HIV epidemic. This factor could mean that in those jurisdictions there are 

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

jurisdictions more recently experiencing an HIV epidemic. 

Page 61 GAO-06-332 HIV/AIDS Funding
Under either approach, grantees might receive increased funding because 

other grantees did not yet have an accurate measure of HIV case counts. 

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.101

The maturity of the HIV-reporting systems can be linked to whether a 

jurisdiction has a name- or code-based system. As discussed earlier, CDC 

does not currently accept HIV case reports from code-based systems. 

However, even if code-based data were incorporated into the CDC case 

counts, the age of the code-based systems could still be a factor since the 

code-based systems tend to be newer than the name-based systems. As of 

December 2005, twelve of the 13 code-based systems were implemented in 

1999 or later, compared with 10 of the 39 name-based systems. The effect 

of the maturity of the code-based systems could be increased if, as CDC 

believes, name-based systems can be executed with more complete 

coverage of cases in much less time than code-based systems. As a result, 

jurisdictions with code-based systems could find themselves with 

undercounts of HIV cases for longer periods of time than jurisdictions with 

name-based systems. 

The use of HIV cases in CARE Act funding formulas could result in 

fluctuations in funding over time because of newly identified preexisting 

HIV cases. Grantees with more mature HIV-reporting systems have 

generally identified more of their HIV cases. Therefore, if HIV cases were 

used to distribute funding, these grantees would tend to receive more 

funds. As grantees with newer systems identify and report a higher 

percentage of their HIV cases, their proportion of the total number of 

ELCs and HIV cases in the country would increase and funding that had 

shifted away from states with newer HIV-reporting systems would shift 

back, creating potentially significant additional shifts in program funding. 

Without corresponding increases in CARE Act funding, this increase in 

identified HIV cases could cause grantees with more mature systems to 

experience funding decreases. Hold-harmless provisions would protect 

grantees with older reporting systems from funding losses. However, 

grantees with newer systems could receive less funding per case because 

funds would be needed to cover hold-harmless provisions. 

 

101Institute of Medicine, Measuring What Matters, 92. 

Page 62 GAO-06-332 HIV/AIDS Funding
The funding provided under the CARE Act and HOPWA has filled 

important gaps in communities throughout the country, but as Congress 

reviews these programs, it is important to understand how much funding 

can vary across communities with comparable numbers of persons living 

with AIDS. While provisions in the formulas have served specific 

purposes, such as maintaining consistent funding from year to year, it is 

clear that the level of funding available per AIDS case is quite variable 

because of these provisions: 

Conclusions 

• The use of ELCs—AIDS cases reported over the past 10 years weighted by 

survival rates—and the use of 2- and 5-year cumulative reported AIDS 

cases for CARE Act funding results in AIDS case counts that do not reflect 

the number of persons who could be served by the program because many 

persons with AIDS live longer than 10 years after their disease is reported, 

deceased cases are included in the case counts, and cases diagnosed prior 

to the reporting period are not included. 

• Considerably more CARE Act funding has gone to some grantees than 

others even though they have similar numbers of cases because of the 

counting of ELCs in EMAs for both Title I base funding and Title II base 

funding, hold-harmless provisions that protect Title I, Title II, and ADAP 

base grant funding levels, the grandfathering of EMAs so that metropolitan 

areas designated as EMAs for fiscal year 1996 continue to be eligible for 

Title I funding, and the division of Emerging Communities into two tiers 

with equal funding of each tier without regard to the number of 

communities or the number of reported AIDS cases in each tier. 

• The use of cumulative AIDS cases to determine eligibility for HOPWA 

formula grants, including for bonus grants, and the amount of HOPWA 

base grants has led to disproportionate funding per living AIDS case 

because the formula counts deceased cases in addition to living cases, 

thereby resulting in increased funding for areas with early outbreaks. 

The CARE Act Title II hold-harmless provision that is funded from 

amounts that would otherwise be available for ADAP Severe Need grants 

has had little effect so far as the amounts needed to fund this provision 

have been comparatively small. However, reducing funds to be made 

available for qualifying states could adversely affect the states with severe 

need in the future if the amounts needed to fund the hold-harmless 

provision increase. 

Congress recognized in the 2000 CARE Act amendments that the CARE 

Act benefits many people whose HIV infection has not progressed to AIDS 

when it required that HIV case counts be used in the distribution of funds. 

The inclusion of HIV cases in the CARE Act funding formulas by fiscal 

Page 63 GAO-06-332 HIV/AIDS Funding
year 2007 could eventually improve the targeting of funding to needy 

individuals with HIV disease. However, it could result in significant shifts 

in program funding that may not be related to the geographic distribution 

of HIV/AIDS cases because of differences in the type and maturity of the 

reporting system used in each state. 

While only AIDS case counts are currently used for determining CARE Act 

formula funding, Congress has required that HIV case counts be 

incorporated into the funding formulas not later than fiscal year 2007. 

Regardless of when HIV case counts are incorporated, issues will still exist 

regarding how AIDS cases are used in the formulas and the effect various 

provisions have on funding. If Congress wishes CARE Act funding to more 

closely reflect the distribution of persons living with AIDS, and to more 

closely reflect the distribution of persons living with HIV/AIDS when HIV 

cases are incorporated into the funding formulas, it should take the 

following five actions: 

Matters for 

Congressional 

Consideration 

• revising the funding formulas used to determine grantee eligibility and 

grant amounts using a measure of living AIDS cases that does not include 

deceased cases and reflects the longer lives of persons living with AIDS, 

• eliminating the counting of cases in EMAs for Title I base grants and again 

for Title II base grants, 

• modifying the hold-harmless provisions for Title I, Title II, and ADAP base 

grants to reduce the extent to which they prevent funding from shifting to 

areas where the epidemic has been increasing, 

• modifying the Title I grandfather clause, which protects the eligibility of 

metropolitan areas that no longer meet the eligibility criteria, and 

• eliminating the two-tiered structure of the Emerging Communities 

program. 

If Congress wishes to preserve funding for the ADAP Severe Need grants, 

it should revise the Title II hold-harmless provision that is funded with 

amounts set aside for ADAP Severe Need Grants. 

If Congress wishes HOPWA funding to more closely reflect the distribution 

of persons living with AIDS, it should change the program so that HOPWA 

formula grant eligibility, including for bonus grants, and base grant 

funding allocations are based on a measure of living AIDS cases. 

Page 64 GAO-06-332 HIV/AIDS Funding
HHS and HUD provided written comments on a draft of this report. HHS 

and HUD generally agreed with our identification of issues in the funding 

formulas. Their comments are reprinted in appendixes XV and XVI. HHS 

commended us for its comprehensive approach and ambitious analysis 

that pulled together data from many disparate sources. HUD noted that it 

appreciated that the report seeks to improve the targeting of federal 

resources to better assist those with HIV/AIDS. 

Agency Comments 

and Our Evaluation 

HHS noted that we identified various deficiencies in the current HIV data. 

However, HHS suggested that we did not examine the distribution 

differences that would result from incorporating HIV cases into the CARE 

Act funding formulas. HHS noted that we did not assess the potential 

usefulness of HIV data in funding formulas if all jurisdictions participated 

in the national reporting system coordinated by CDC using standardized 

methods of reporting. Such a determination was beyond the scope of our 

work. However, as noted in the draft report, we present analyses showing 

the impact of using HIV cases on fiscal year 2004 funding for Title I, 

Title II, and ADAP base grants, which comprise the bulk of CARE Act 

funding. 

While HHS generally agreed with our matters for congressional 

consideration, HHS made several comments on the issues these matters 

address. HHS noted that our matters for congressional consideration focus 

only on potential changes to the use of AIDS cases in formulas but not to 

the use of HIV cases. The matters for consideration are based on current 

funding formula provisions that require the use of AIDS cases. Our 

discussion should not be interpreted as endorsing the superiority of using 

living AIDS cases instead of HIV/AIDS cases. 

Regardless of whether HIV case counts are used, the funding formula 

provisions we identified will continue to affect proportional funding per 

case if they are maintained. We believe that the use of AIDS case counts 

that include deceased cases and do not reflect the current life spans of 

persons living with AIDS will continue to be of concern. Also, various 

provisions, such as allocating funding for Emerging Communities by tier 

and hold-harmless provisions, will affect the distribution of funding 

regardless of whether HIV cases are used in the formulas. 

HHS pointed out that our assessment of the impact of hold-harmless 

provisions on CARE Act formula funding appears accurate. HHS noted 

disparities in funding per AIDS case that can result from counting cases in 

EMAs once for Title I funding, and once again for Title II funding. HHS 

also agreed with our analysis of the Emerging Communities provision; we 

Page 65 GAO-06-332 HIV/AIDS Funding
deleted our reference to a population threshold as an eligibility 

requirement for Emerging Communities in response to its comment on this 

issue. HHS concurred with our suggestion that the Title II hold-harmless 

provision should be revised to preserve funding for ADAP Severe Need 

grants. 

HHS raised concerns that our discussion of the Title I grandfather clause 

in the CARE Act could be interpreted as suggesting EMAs that continue to 

receive grants because of this provision need not be funded. HHS noted 

that a cessation of funding could lead to a decline in these areas’ systems 

of care and, by extension, a decline in the progress made in fighting the 

epidemic. However, we note that these areas could receive funding 

through their respective states or territories, which receive funds under 

Title II. In addition, much of the improvement in care for those with 

HIV/AIDS is due to the improvement in drugs, which, as indicated in 

Appendix III, are primarily provided through Title II ADAP grants. HHS 

noted that without Title II minimum grant amounts for states and 

territories, the number of reported AIDS cases in low prevalence areas 

would not be sufficient to sustain state-of-the-art HIV/AIDS care and 

treatment services. 

HHS also noted that we do not have a specific matter for congressional 

consideration regarding the use of OMB’s revised definitions of 

metropolitan boundaries for determining Title I EMAs. HHS stated that the 

report suggests that the revised definitions be accepted for determining 

such boundaries. In the report, we discuss the methods used in our 

analysis and the results of this analysis, but take no position on whether 

the new definitions should be used in determining the EMA boundaries. 

HHS commented that the draft report lacked specificity regarding the 

process by which CDC receives HIV case counts from the states. We have 

modified our report to include a discussion of this process. HHS also 

stated in its comments that it would not be appropriate to use the codebased case counts in monitoring HIV/AIDS nationally. An assessment of 

whether code-based data should be used for monitoring HIV/AIDS is 

beyond the scope of our work. Our purpose was to provide Congress with 

an indication of the impact of using HIV cases in the CARE Act and 

HOPWA funding formulas in light of the statutory requirement that HIV 

cases be used in CARE Act funding formulas not later than fiscal year 

2007. We have added text to the report discussing HHS’s concerns about 

code-based data. 

Page 66 GAO-06-332 HIV/AIDS Funding
HUD concurred with our matter for congressional consideration that 

cumulative AIDS cases no longer be used in the HOPWA formula. HUD 

pointed out that incorporation of a more current estimate of persons living 

with HIV/AIDS would be more effective in targeting these HOPWA funds 

to grantees. HUD stated in its comments that we did not take into account 

differing housing costs across jurisdictions in the draft report. In response 

to this comment, we revised the report to note that housing costs are not 

currently part of the HOPWA funding formula, and consideration of 

housing costs was not within the scope of our work. However, we have 

clarified the draft report to note that if housing costs were included in the 

funding formulas, they could justify deviations from proportional funding 

per case. 

HUD suggested that we not use the terms base grant and bonus grant. We 

have added a note to our report to reflect that our terminology differs from 

HUD’s, but retained the use of bonus and base grants in order to 

differentiate between the two formula funding components. 

HUD expressed concern that the full effect of incorporating HIV case 

counts may not be apparent by only stating the amount of funding that 

would shift among grantees. We have added text to note that the changes 

could result in some grantees more than doubling their funding. HUD 

suggested that these analyses could be done based solely on data from 

jurisdictions with CDC-accepted HIV case counts, or those jurisdictions 

with mature HIV-reporting systems. However, as noted in the draft report, 

we present analyses showing the impact of using only CDC-accepted HIV 

data on fiscal year 2004 HOPWA base grants. We do not include an 

analysis using only jurisdictions with mature HIV-reporting systems 

because it would exclude many jurisdictions and we determined that such 

an analysis would not be appropriate. HUD also pointed out that the draft 

report did not describe the incremental effect on HOPWA allocations of 

using HIV cases with living AIDS cases rather than living AIDS cases only. 

The draft report provided information on this in appendix V, and we have 

added text to the report to refer the reader to this appendix. HUD 

suggested that we expand a footnote to further describe our analysis of 

HIV cases in funding formulas. However, this information is already 

presented in detail in appendix I and is also described in the text of the 

report. 

In its comments HUD noted bonus funding can provide a significant 

amount of resources to those eligible and that this funding can have a 

large effect on formula funding per AIDS case. As noted in the draft report, 

we show the amount of base funding and bonus funding that each grantee 

Page 67 GAO-06-332 HIV/AIDS Funding
received in fiscal year 2004 and state that funding differences per case are 

due in part to the bonus grants. HUD suggested that we revise our 

conclusion to reflect the importance of the bonus grants. However, our 

conclusion focuses on the base grants because of the use of cumulative 

AIDS cases in determining these grants. HUD also noted that not all 

grantees that receive bonus grants sustain the funding from year to year. 

We have added text to note the instability of the bonus funding and that, 

with respect to fiscal year 2006 funding, HUD’s appropriation act included 

a provision to mitigate the variability of incidence data by using data 

reported over a 3-year period. 

HUD also suggested that we use different terms to categorize how HOPWA 

funding was allocated by grantees and provided us with updated 

information on how grantees allocated fiscal year 2003 HOPWA grants. We 

have revised the report based on this information. 

HHS and HUD also provided technical comments, which we have 

incorporated where appropriate. 

We are sending copies of this report to the Secretary of Health and Human 

Services, the Secretary of Housing and Urban Development, the Director 

of the Centers for Disease Control and Prevention, the Administrator of 

the Health Resources and Services Administration, and to interested 

congressional committees. We will also make copies available to others 

upon request. In addition, the report will be available on GAO’s Web site at 

http://www.gao.gov. 

If you or your staff have any questions about this report, please contact me 

at (202) 512-7119 or crossem@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. GAO staff who made major contributions to this report are 

listed in appendix XVII. 

Marcia Crosse 

Director, Health Care 

Page 68 GAO-06-332 HIV/AIDS Funding
Appendix I: Objectives, Scope, and Appendix I: Objectives, Scope, and Methodology 

Methodology 

HIV/AIDS Funding

We assessed the distribution of funding for human immunodeficiency 

virus (HIV) and acquired immunodeficiency syndrome (AIDS) under the 

Ryan White Comprehensive AIDS Resources Emergency Act of 1990 

(CARE Act) and the AIDS Housing Opportunity Act’s Housing 

Opportunities for Persons with AIDS program (HOPWA). Specifically, we 

are reporting on (1) how CARE Act and HOPWA funds are allocated by 

grantees among the types of services each program supports; (2) the 

extent of funding distribution differences among CARE Act and HOPWA 

grantees, and how CARE Act and HOPWA funding-formula provisions 

contribute to these difference; and (3) what distribution differences would 

result from using HIV cases in CARE Act and HOPWA funding formulas. 

Objectives 

Scope and 

Methodology 

To report on these three objectives, we reviewed the CARE Act of 1990, as 

well as the 1996 and 2000 CARE Act amendments, the AIDS Housing 

Opportunity Act, Health Resources and Services Administration (HRSA) 

and Department of Housing and Urban Development (HUD) documents on 

CARE Act and HOPWA funding, HUD memoranda, Institute of Medicine 

reports on the CARE Act, and other related reports. We interviewed 

officials from HRSA, the Centers for Disease Control and Prevention 

(CDC), HUD, and the National Alliance of State and Territorial AIDS 

Directors. We received information from state government officials 

regarding their HIV case-reporting systems. Details on the scope of our 

work and the methods to address each objective follow. 

To determine how grantees allocate CARE Act and HOPWA funds by types 

of service, we obtained information on the allocation of these funds from 

HRSA and HUD.1

 HRSA provided information on grantees’ allocation of 

CARE Act Titles I and II funds for fiscal year 2003, and Title III allocations 

for fiscal year 2002. HRSA also provided funding amounts for its HIV/AIDS 

Dental Reimbursement Program, Community-Based Dental Partnership 

grants, Special Projects of National Significance, and AIDS Education and 

Training Centers program for fiscal year 2003. HUD provided HOPWA 

allocation data for fiscal year 2003, these being the most recently available 

data. We analyzed these data and, where available, calculated the 

percentage of the total amount each service category represented. To 

assess the reliability of HRSA and HUD data on the allocations of CARE 

Allocation of CARE Act 

and HOPWA Funds among 

Service Categories 

 

1

Grantees are those entities that receive CARE and HOPWA funding. Grantees vary by 

program and can include states, territories, metropolitan areas, and primary-care providers. 

Page 69 GAO-06-332 
Appendix I: Objectives, Scope, and 

Methodology 

Act and HOPWA grant funds, we interviewed agency officials about the 

data and reviewed relevant documentation. We determined that the data 

were sufficiently reliable for the purposes of our report. 

Funding-formula 

Provisions 

We examined the effect of specific funding-formula provisions on CARE 

Act and HOPWA grants. We first assessed the use of 2- and 5-year 

cumulative counts of AIDS cases and the use of estimated living AIDS 

cases (ELC) in CARE Act programs by comparing these measures with 

living AIDS case counts received from CDC.2

 We then examined the 

following CARE Act formula provisions: the counting of ELCs in eligible 

metropolitan areas (EMA) for both Title I and Title II funding, the tiered 

allocation of Emerging Communities funding, the Title I hold-harmless 

provision, the Title I grandfathering clause, and the Title II hold-harmless 

provision funded from amounts available for Severe Need grants.3

 To 

examine the effect of each provision on the CARE Act and HOPWA grant 

amounts, we measured differences on a per case basis, by the amount of 

funding received, or both. We calculated each grantee’s percentage of the 

total number of AIDS cases in all relevant jurisdictions, and we used these 

percentages to determine the funding each grantee would have received. 

We then compared these amounts with what was actually received to 

show the effect of a provision in the formula. In addition, we examined the 

effect of using living AIDS cases instead of cumulative cases in making 

HOPWA base grant distributions by comparing the actual funding 

distributions with simulated distributions using living AIDS cases. We also 

assessed the effect of HOPWA bonus grants on funding for eligible 

metropolitan statistical areas (EMSA) by examining the size of these 

grants and which EMSAs received them. 

To conduct our analyses of the effect of funding-formula provisions on 

CARE Act and HOPWA funding and programs in the states, including the 

District of Columbia, Puerto Rico, and metropolitan areas, we obtained 

 

2

HRSA calculates a jurisdiction’s ELCs by using data from CDC on the reported AIDS case 

counts for the last 10 years and weighting those numbers to account for the likelihood of 

death. 

3

Title II also contains a hold-harmless provision that requires HRSA to consider separately 

Title II base grants and ADAP base grants. For the Title II base grants, this hold-harmless 

provision is funded by proportionately reducing the size of the Title II base grants made to 

other jurisdictions that did not qualify for this hold-harmless funding or receive a minimum 

grant. The ADAP portion would be funded by reducing the size of the ADAP base grants 

made to those grantees that did not qualify for ADAP base grant hold-harmless funding. 

Page 70 GAO-06-332 HIV/AIDS Funding
Appendix I: Objectives, Scope, and 

Methodology 

fiscal year 2004 funding data and AIDS case counts from HRSA and HUD, 

and supplemented this information with additional AIDS case-count data 

from CDC. Fiscal year 2004 data were the latest data available at the time 

of our review. We limited our CARE Act analyses to Titles I and II because 

grants under other parts of the Act are not formula-driven. Similarly, our 

HOPWA analyses are also limited to the parts of the program that are 

formula-based, namely, the base and bonus grants. 

Our analyses of funding provisions take into consideration that CARE Act 

and HOPWA formula grants use different measures of the number of AIDS 

cases to determine grant amounts. There are three measures used for 

CARE Act grants—reported AIDS cases over 2 years, reported AIDS cases 

over 5 years, and ELCs. HRSA calculates a jurisdiction’s ELCs by using 

data from CDC on the reported AIDS case counts for the last 10 years and 

weighting those numbers to account for the likelihood of deaths. HOPWA 

uses two measures—total AIDS cases reported in the jurisdiction since the 

beginning of the epidemic in 1981 and AIDS incidence rates. 

In our analyses of the funding formulas, we used the measure of AIDS 

cases that is used to determine funding in a particular grant program in 

order to show the effect of different formula provisions on fund 

distribution. We also compared the AIDS data used for funding formulas 

with data on living AIDS cases to assess the effect of not using living AIDS 

cases on funding allocations. For the CARE Act, we used the measure of 

living AIDS cases that is required by law to be used by the program when 

distributing Title I, Title II, and ADAP base grants, that is, the number of 

ELCs based on 10 years of reported cases and survival rates. In the 

absence of a measure of living AIDS cases for HOPWA funding, we used a 

measure of living AIDS cases calculated by subtracting the number of 

reported deaths among AIDS cases in a jurisdiction from the number of 

reported cases. This measure of living AIDS cases is used for illustrative 

purposes only. 

In our analysis of counting ELCs in EMAs for both Title I and Title II CARE 

Act funding, we aggregated Title I and Title II funding received by each of 

the states and Puerto Rico. Because some EMAs cross state boundaries, 

we apportioned Title I funding among states according to the 

proportionate share of an EMA’s ELCs in each state. For example, 

approximately 96 percent of the ELCs 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. We then compared the combined total Title I 

and Title II funding received by all Title II grantees. 

Page 71 GAO-06-332 HIV/AIDS Funding
Appendix I: Objectives, Scope, and 

Methodology 

To examine the effect of using living AIDS case counts on funding for 

HOPWA base grants, we estimated the amount of funding grantees would 

have received by determining the number of living AIDS cases in each 

jurisdiction. CDC provided us with living AIDS cases counts for states, 

Puerto Rico, and EMSAs. To determine each grantee’s number of living 

AIDS cases, we subtracted the number of living AIDS cases in EMSAs in a 

state from the total number of living AIDS cases in the state.4

 When an 

EMSA crossed state boundaries, we used information from CDC to 

determine the number of living AIDS cases in each state within the EMSA. 

For example, the Memphis EMSA covers parts of Arkansas, Mississippi, 

and Tennessee. We obtained the living AIDS case counts for each of the 

states in the Memphis EMSA. We then subtracted the number of living 

AIDS cases from Arkansas in the Memphis EMSA from the Arkansas state 

total, and did comparable calculations for the cases from the other two 

states. After doing similar calculations for all EMSAs that crossed state 

boundaries, we had living AIDS case counts for all HOPWA grantees. We 

then calculated each grantee’s percentage of the total number of living 

AIDS cases in all jurisdictions and simulated the HOPWA base grant 

funding allocations according to this percentage. We then compared the 

base funding received using cumulative AIDS case counts with the 

simulated funding allocations using living AIDS cases. 

The dates of the AIDS case counts used in our analyses varied by program. 

Depending on the grant, formula allocations under the CARE Act are 

based on the number of ELCs in a jurisdiction as of June 30 preceding the 

start of the fiscal year for which the award is to be made or on the number 

of reported AIDS cases in either the most recent 2 or 5 calendar years. 

HOPWA eligibility is based on the number of cumulative AIDS cases as of 

March 31 preceding the start of the fiscal year. Where appropriate, we 

used ELCs as of June 30, 2003, to estimate the effect of formula provisions 

on CARE Act funding for fiscal year 2004, which began on October 1, 2003. 

For other CARE Act grants, we used reported cases for the appropriate 

calendar-year period. We used AIDS case counts as of March 31, 2003, to 

 

4

Unlike the CARE Act in which ELCs in EMAs are counted once for determining Title I 

funding and a second time for determining Title II funding, under HOPWA AIDS cases in 

EMSAs are counted only for determining funding for EMSAs. These cases are not counted a 

second time for determining HOPWA base funding allocations for states and territories. 

Funding for states and territories is based on the number of cumulative AIDS cases outside 

of EMSAs. For example, HOPWA base funding for Colorado is based on the number of 

cumulative AIDS cases in the state minus the number of cumulative cases in the Denver 

EMSA. 

Page 72 GAO-06-332 HIV/AIDS Funding
Appendix I: Objectives, Scope, and 

Methodology 

estimate the effect of formula provisions on HOPWA funding for fiscal 

year 2004. 

We used funding per AIDS case5

 to illustrate the effect of certain fundingformula provisions on the distribution of CARE Act and HOPWA funds. 

There are other considerations that could be included in funding formulas. 

For example, differing health care and housing costs across regions and 

differences in grantees’ capacities to fund services from local resources 

could be used as bases for distributing program funds and to justify 

deviations from proportional funding per case.6

 Without such 

considerations, regions with the same funding and the same number of 

AIDS cases could not treat the same number of patients. Currently, these 

considerations are not taken into account when awarding formula grants 

under either the CARE Act or HOPWA. 

To analyze the effect of retaining the current EMA boundaries, we 

reviewed documents pertaining to the Office of Management and Budget’s 

(OMB) 2004 metropolitan boundary definitions. In particular, we relied on 

information generated in our June 2004 report on metropolitan statistical 

areas (MSA) that reported on the process used to develop the 2000 

standards and how the 2000 standards differ from the 1990 standards.7

Before each decennial census, OMB reviews the standards used in defining 

the boundaries of these statistical areas to ensure their continued 

usefulness and relevance and, if warranted, revises them. OMB had 

determined that a more fundamental examination of the standards was 

required for 2000, and advisory groups were formed to look at the 

standards. These groups suggested OMB consider defining less-populated 

areas, which had been statistically unrecognized. The 2000 standards differ 

from the 1990 standards in many ways, and the Census Bureau and OMB 

have stated that the new standards are simpler and more transparent. 

 

5

The AIDS case count used in the analyses varied by program (e.g., ELCs and cumulative 

AIDS cases). 

6

In our November 1995 report, we showed under the CARE Act that differences in funding 

per living AIDS case were not related to cost differences. For a discussion of this issue as 

well as criteria for distributing funding per case, see GAO, Ryan White CARE Act of 1990: 

Opportunities to Enhance Funding Equity, GAO/HEHS-96-26 (Washington, D.C.: Nov. 13, 

1995). 

7

GAO, Metropolitan Statistical Areas: New Standards and Their Impact on Selected 

Federal Programs, GAO-04-758 (Washington, D.C.: June 14, 2004). 

Page 73 GAO-06-332 HIV/AIDS Funding
Appendix I: Objectives, Scope, and 

Methodology 

To demonstrate the effect on the current boundaries of the 51 CARE Act 

Title I EMAs if OMB’s 2004 definitions of MSAs were used to establish 

EMA boundaries, we compared the boundaries of existing EMAs with the 

new MSA boundaries that could be created using the new definitions. 

Because most EMA boundaries include portions of more than one new 

metropolitan area, for our analysis we chose two decision rules to serve as 

a basis for selecting new metropolitan areas to be compared with the 

existing EMAs.8

 First, we assumed there would be no change in eligibility 

of the current 51 Title I EMAs. Second, since the number of ELCs within 

an EMA would change if its boundaries were revised, we chose whatever 

combination of the newly defined metropolitan areas9

 would result in the 

least change to the numbers of ELCs within the EMA’s boundaries. The 

results of our method are shown in appendix VII, which lists each of the 

existing EMAs together with the corresponding new areas, the number of 

counties constituting the metropolitan areas, and the number of ELCs 

contained within those areas. 

To assess the reliability of the data on HRSA’s and HUD’s distribution of 

CARE Act and HOPWA funds, we asked agency officials about how the 

data were developed and reported. We also reviewed relevant 

documentation. We determined the data were sufficiently reliable for the 

purposes of our report. 

Use of HIV Cases in 

Formulas 

We examined how CARE Act and HOPWA fiscal year 2004 allocations 

would have been affected by using HIV cases in addition to living AIDS 

cases to determine funding. We undertook our analyses in light of the 

statutory requirement that HIV cases be used in CARE Act funding 

formulas not later than fiscal year 2007.10 We examined the effect of using 

 

8

There is no straightforward way to equate EMAs based on OMB’s 1993 metropolitan areas 

with OMB’s 2004 metropolitan areas. In developing its 2000 metropolitan area standards 

and its 2004 metropolitan area boundary definitions, OMB did not seek to make them 

conform to past standards and definitions. Moreover, even where OMB employed the same 

terminology (e.g., the term “metropolitan statistical area” was retained), the terms were 

given new meanings. 

9

These include combinations of adjoining MSAs or adjoining MSAs and metropolitan 

divisions. We exclude the use of the smaller micropolitan statistical areas (a new OMB 

designation for less-populated areas) and also exclude combined statistical areas (a new 

OMB designation for groupings of adjacent metropolitan and micropolitan areas). 

10Unlike the CARE Act, there are no requirements regarding the use of HIV cases in 

determining HOPWA funding. 

Page 74 GAO-06-332 HIV/AIDS Funding
Appendix I: Objectives, Scope, and 

Methodology 

HIV cases in addition to living AIDS cases on formula funding for CARE 

Act Title I, Title II, and ADAP base grants, and HOPWA base grants in the 

states, Puerto Rico, and metropolitan areas.11 We limited our analyses to 

these grants because they constitute the majority of the CARE Act and 

HOPWA formula funding. For the CARE Act, we used the measure of 

living AIDS cases that is required by law to be used by the program when 

distributing Title I, Title II, and ADAP base grants, that is, the number of 

ELCs based on 10 years of reported cases and survival rates. In the 

absence of a measure of living AIDS cases for HOPWA funding, we used a 

measure of living AIDS cases calculated by subtracting the number of 

reported deaths among AIDS cases in a jurisdiction from the number of 

reported cases. This measure of living AIDS cases is used for illustrative 

purposes only. We used fiscal year 2004 allocations, which were based on 

case counts reported as of June 30, 2003, for the CARE Act and as of 

March 31, 2003, for HOPWA. As of these dates there were 35 jurisdictions12

from which CDC accepted HIV data and 17 without CDC-approved HIV 

data. CDC will only accept name-based case counts as no code-based 

system has yet met CDC’s quality criteria.13

Because CDC did not accept HIV case counts from 17 jurisdictions, we 

conducted our analysis using two approaches to measure total HIV/AIDS 

cases for purposes of formula calculations. Under the first approach, we 

used HIV and live AIDS case counts for the 35 jurisdictions from which 

 

11In our analysis of HOPWA, we used living AIDS cases instead of cumulative AIDS cases, 

which is the measure currently required by law to be used to determine HOPWA base grant 

funding. Therefore, our analyses reflect the effect of using HIV cases and living AIDS cases 

instead of cumulative AIDS case counts on fiscal year 2004 HOPWA base grant funding. 

12These 35 include 34 states and Puerto Rico. 

13Some HIV case-reporting systems are name-based while others are code-based. Currently, 

CDC will only accept name-based case counts as no code-based system has yet met CDC’s 

quality criteria. CDC 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 must result in accurate case counts (less 

than or equal to 5 percent of reported cases are duplicates). CDC has determined that the 

only systems that have been evaluated that meet these standards use confidential, namebased reporting. Some jurisdictions use codes instead of names to secure the privacy of the 

individuals being counted. In July 2005, CDC began recommending that all states and 

territories adopt confidential, name-based surveillance systems to report HIV infections. 

Page 75 GAO-06-332 HIV/AIDS Funding
Appendix I: Objectives, Scope, and 

Methodology 

CDC accepted HIV data.14 Because CDC did not accept the HIV case 

counts from the other 17 jurisdictions, we used only the live AIDS case 

counts received by CDC for these grantees. Consequently, for some 

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

AIDS case counts. This approach reflects the data that would have been 

used if funding allocations were based on the HIV and AIDS case counts 

received by CDC in time for determining fiscal year 2004 allocations. 

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

as our first approach, but supplemented these data with the code-based 

HIV case counts collected by the grantees from which CDC did not receive 

HIV data.15 We obtained these HIV case counts directly from these 

 

14Because HIV-reporting systems in some jurisdictions are changing to name-based 

systems, CDC now accepts HIV case counts from some jurisdictions from which it did not 

accept HIV case counts earlier. For our analyses, we classified Connecticut, Kentucky, and 

New Hampshire as having HIV case counts that are not accepted by CDC. Our analyses 

were conducted using fiscal year 2004 allocations, which were based on case reports as of 

June 30, 2003, for the CARE Act and as of March 31, 2003, for HOPWA. At those times, 

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. A fourth state, Georgia, had not established any HIV case reporting as of 

June 30, 2003, but did so in 2004. Consequently, the HIV case count for Georgia is zero in 

our analyses. Pennsylvania is classified as having its HIV case counts accepted by CDC. 

However, these counts do not include any cases from Philadelphia, which established its 

code-based system in 2004. Philadelphia establsihed a name-based system in October 2005. 

Philadelphia is in the process of having its HIV surveillance data certified by CDC; once 

certified, its data will be accepted by CDC. Illinois and Maine established name-based HIVreporting systems in January 2006 and are also in the process of having their HIV data 

certified by CDC; once certified, their data will be accepted by CDC. 

15HIV case counts for three of these jurisdictions, Georgia, Kentucky, and the District of 

Columbia, were unavailable. Consequently, their HIV case counts are zero under both 

approaches. HIV case counts were also unavailable for Philadelphia, and as a consequence 

HIV counts were incomplete for Pennsylvania. 

Page 76 GAO-06-332 HIV/AIDS Funding
Appendix I: Objectives, Scope, and 

Methodology 

jurisdictions.16 These case counts were collected and reported to us by 

public health authorities. We also received information from them 

regarding their HIV case-reporting systems. 

For both approaches, we calculated the grantee’s percentage of the total 

number of HIV/AIDS cases relative to all grantees for that program and 

estimated the fiscal year 2004 grants that each would have received.17

CARE Act formula allocations were calculated both with certain holdharmless and minimum-grant provisions and again without those 

provisions.18 Eliminating hold-harmless and minimum-grant provisions 

was done to show the full effect of distributing fiscal year 2004 funding 

solely according to HIV/AIDS data available at that time. We also estimated 

the effect of using HIV cases and living AIDS cases for HOPWA base 

funding. 

In our analyses of how the use of HIV cases would affect funding by 

region, we use U.S. Census Bureau definitions to define regions of the 

country. The Census Bureau divides the country into four regions: 

Northeast, Midwest, South, and West.19 Table 11 lists the four regions and 

the jurisdictions that constitute them. 

 

16CDC receives, reviews, and processes name-based HIV case reports on individual cases. 

Potential duplicate reports across jurisdictions are reviewed through a CDC-coordinated 

process to remove duplicate reports from the national database. Code-based reports 

cannot be included in this de-duplication process because name-based and code-based 

systems do not have comparable patient identifiers. Because the name- and code-based 

case counts are not comparable, in its comments on a draft of this report HHS stated that it 

would not be appropriate to use the code-based case counts in monitoring HIV/AIDS 

nationally. Our purpose in using both the name- and code-based case counts was to provide 

a general indication of how funding would be affected by using HIV and AIDS cases to 

distribute CARE Act and HOPWA funds. Our use of the code-based case counts should not 

be taken as endorsement for their use in monitoring HIV/AIDS or distributing funds. An 

assessment of the feasibility of using code-based case counts was beyond the scope of our 

report. 

17For example, for CARE Act Title I base funding, we calculated the EMA’s percentage of 

the total number of HIV cases and ELCs across all EMAs. 

18Under the CARE Act, there is a minimum-grant provision for Title II base grants, but not 

for Title I and ADAP base grants. However, there are hold-harmless provisions for Title I, 

Title II, and ADAP base grants. There are no comparable hold-harmless provisions in 

HOPWA and minimum-grant requirements have been effectively waived in recent years. 

Consequently, the analyses in which the hold-harmless and minimum-grant provisions are 

maintained are limited to the CARE Act. 

19Puerto Rico is not included in any of these regions and is, therefore, excluded from these 

analyses. 

Page 77 GAO-06-332 HIV/AIDS Funding
Appendix I: Objectives, Scope, and 

Methodology 

Table 11: U.S. Census Bureau Regions 

Northeast 

Connecticut New York 

Maine Pennsylvania 

Massachusetts Rhode Island 

New Hampshire Vermont 

New Jersey 

Midwest 

Illinois Missouri 

Indiana Nebraska 

Iowa North Dakota 

Kansas Ohio 

Michigan South Dakota 

Minnesota Wisconsin 

South 

Alabama Mississippi 

Arkansas North Carolina 

Delaware Oklahoma 

District of Columbia South Carolina 

Florida Tennessee 

Georgia Texas 

Kentucky Virginia 

Louisiana West Virginia 

Maryland

West 

Alaska Nevada 

Arizona New Mexico 

California Oregon 

Colorado Utah 

Hawaii Washington 

Idaho Wyoming 

Montana 

Source: U.S. Census Bureau. 

Our analyses of the effect of using HIV case counts for determining CARE 

Act and HOPWA funding rely on data whose reliability has been 

questioned. In June 2004, the Secretary of Health and Human Services 

determined that because of the problems associated with these data, they 

Page 78 GAO-06-332 HIV/AIDS Funding
Appendix I: Objectives, Scope, and 

Methodology 

should not currently be used in determining CARE Act funding. We used 

these data in our analyses to give a general indication of the effect of using 

HIV cases in future formula allocations as required by the CARE Act. By 

using HIV/AIDS counts in determining CARE Act and HOPWA funding, the 

number of persons on which funding is based would increase. The effect 

on individual grantees would depend on the number of reported HIV cases 

in the jurisdiction compared with the number reported in other 

jurisdictions. The extent to which the use of HIV cases could affect 

formula allocations cannot be determined by these analyses because 

jurisdictions use different methods to identify HIV cases, and it is unclear 

to what degree the resulting case counts are comparable. However, we 

think our approaches in these analyses are informative in light of the 

statutory requirement that HIV cases be used in CARE Act funding 

formulas not later than fiscal year 2007. 

To assess the reliability of the HIV and AIDS case-count data, we asked 

HRSA, HUD, CDC, state, and local officials a series of questions about how 

the data were collected and the methods used to ensure their accuracy. 

We asked state and local officials about their HIV data only when they 

were not accepted by CDC. On the basis of the information provided 

regarding the verification of the reliability of these data, we determined 

these data to be sufficiently reliable for the purposes of our analyses. 

Our analyses do not include the different costs of treating patients with 

HIV and AIDS. The cost of serving persons who have HIV and AIDS can 

vary substantially, depending on the stage of the disease. Patients whose 

disease has progressed to AIDS often require more expensive drug 

therapies and more intensive care than those whose disease has not 

progressed to AIDS. One study found that the average annual cost of 

treating an HIV patient was about $18,000 per year. However, the cost 

ranged from about $14,000 per year for well patients with HIV to $34,000 

per year for patients with advanced-stage AIDS.20

We performed our work from July 2004 through February 2006, in 

accordance with generally accepted government auditing standards. 

 

20Michael Saag (paper presented at the XIV International AIDS Conference: Plenary 

Session, HIV/AIDS Treatment and Care in the New Century, Barcelona, July 2002); “UAB 

Announces Results of First HIV Patient Care Cost Analysis,” UAB Media Relations 

(Birmingham, Ala.: University of Alabama at Birmingham, July 2002), 

http://main.uab.edu/show.asp?durki=51750 (downloaded March 30, 2005). 

Page 79 GAO-06-332 HIV/AIDS Funding
Appendix II: CARE Act Title I Awards, Fiscal 

Year 2004 

Page 80 GAO-06-332 HIV/AIDS Funding

Eligible metropolitan area Base award

Supplemental 

award

Minority AIDS 

Initiative award Total Title I award

Total Title I 

award per 

ELCa

Atlanta, Ga. $9,268,937 $7,518,391 $1,552,404 $18,339,732 $2,417

Austin, Tex. 2,016,473 1,559,617 224,430 3,800,520 2,302

Baltimore, Md. 10,195,952 7,615,994 1,898,933 19,710,879 2,361

Bergen-Passaic, N.J.b2,605,497 2,002,220 206,987 4,814,704 2,306

Boston, Mass.b, c 7,434,884 6,630,052 783,761 14,848,697 2,459

Caguas, P.R. 935,565 735,726 145,356 1,816,647 2,372

Chicago, Ill. 12,801,123 10,363,895 2,261,742 25,426,760 2,426

Cleveland, Ohiob1,850,098 1,379,848 256,990 3,486,936 2,308

Dallas, Tex 6,425,600 5,378,653 1,016,330 12,820,583 2,437

Denver, Colo.b2,440,655 1,843,081 245,361 4,529,097 2,273

Detroit, Mich. 4,382,256 3,427,753 780,272 8,590,281 2,394

District of Columbiac 14,431,645 9,840,164 2,679,205 26,951,014 2,281

Dutchess County, N.Y. 639,995 512,173 79,074 1,231,242 2,350

Fort Lauderdale, Fla. 7,330,631 6,349,097 1,069,822 14,749,550 2,457

Fort Worth, Tex. 1,805,177 1,386,868 181,405 3,373,450 2,282

Hartford, Conn. 2,386,547 1,899,397 266,293 4,552,237 2,330

Houston, Tex. 9,416,722 8,472,252 1,239,598 19,128,572 2,481

Jacksonville, Fla.b2,517,844 1,873,132 472,117 4,863,093 2,371

Jersey City, N.J.b3,022,562 2,548,825 312,807 5,884,194 2,424

Kansas City, Mo.b, c 1,716,152 1,358,374 166,287 3,240,813 2,503

Las Vegas, Nev.c2,375,554 1,832,717 265,130 4,473,401 2,300

Los Angeles, Calif. 18,540,316 16,153,706 1,950,099 36,644,121 2,414

Miami, Fla. 12,806,009 10,268,761 2,465,241 25,540,011 2,436

Middlesex-Somerset-Hunterdon, N.J.b1,520,364 988,206 215,127 2,723,697 2,200

Minneapolis–St. Paul, Minn.b, c 1,587,346 1,328,653 177,916 3,093,915 2,432

Nassau-Suffolk, N.Y.b3,182,104 2,402,225 367,460 5,951,789 2,300

New Haven, Conn.b3,639,492 3,012,393 417,463 7,069,348 2,400

New Orleans, La. 3,852,184 2,239,460 695,384 6,787,028 2,152

New York, N.Y. 60,276,790 52,106,068 9,720,259 122,103,117 2,474

Newark, N.J.b8,151,371 6,076,957 1,083,776 15,312,104 2,297

Norfolk, Va.c2,732,193 1,639,148 448,860 4,820,201 2,155

Oakland, Calif.b3,534,076 2,614,717 462,814 6,611,607 2,318

Orange County, Calif. 2,666,239 2,282,192 284,898 5,233,329 2,397

Orlando, Fla. 4,021,954 3,028,863 770,969 7,821,786 2,375

Appendix II: CARE Act Title I Awards, Fiscal 

Year 2004 
Appendix II: CARE Act Title I Awards, Fiscal 

Year 2004 

Eligible metropolitan area Base award

Supplemental 

award

Minority AIDS 

Initiative award Total Title I award

Total Title I 

award per 

ELCa

Philadelphia, Pa.c12,038,992 10,407,066 2,002,427 24,448,485 2,480

Phoenix, Ariz. 3,480,889 2,975,380 358,158 6,814,427 2,391

Ponce, P.R. 1,414,340 1,002,813 301,178 2,718,331 2,347

Portland, Oreg.c1,889,451 1,572,205 105,819 3,567,475 2,306

Riverside–San Bernardino, Calif. 3,913,252 2,613,404 296,527 6,823,183 2,130

Sacramento, Calif.b1,558,276 1,328,376 81,399 2,968,051 2,382

St. Louis, Mo.c2,412,195 1,646,152 312,807 4,371,154 2,213

San Antonio, Tex. 2,097,083 1,400,297 336,063 3,833,443 2,233

San Diego, Calif. 5,201,792 4,554,583 531,422 10,287,797 2,416

San Francisco, Calif.b16,171,607 13,199,079 479,094 29,849,780 4,137

San Jose, Calif.b1,411,781 1,069,179 175,590 2,656,550 2,318

San Juan, P.R.b8,139,880 5,255,408 1,337,277 14,732,565 2,222

Santa Rosa, Calif.b611,312 469,370 26,746 1,107,428 2,298

Seattle, Wash.b3,024,172 2,605,642 212,801 5,842,615 2,367

Tampa–St. Petersburg, Fla.b4,777,696 3,348,920 593,053 8,719,669 2,250

Vineland-Millville-Bridgeton, N.J. 473,889 297,261 76,748 847,898 2,185

West Palm Beach, Fla.b4,577,648 3,964,724 866,323 9,408,695 2,515

Totald$305,704,561 $246,379,437 $43,258,002 $595,342,000

Source: GAO analysis of HRSA data. 

Notes: HRSA has awarded Minority AIDS Initiative grants to EMAs. HRSA characterizes Minority 

AIDS Initiative grants to EMAs as Title I grants. 

a

HRSA calculates a jurisdiction’s ELCs by using data from CDC on the reported AIDS case counts for 

the last 10 years and weighting those numbers to account for the likelihood of death. The average 

total Title I award per ELC was $2,380. 

b

EMA received hold-harmless funding that is included in base award. 

c

EMA boundaries include jurisdictions in more than one state. 

d

Individual entries may not sum to totals because of rounding. 

Page 81 GAO-06-332 HIV/AIDS Funding
Appendix III: CARE Act Title II Awards, 

Fiscal Year 2004 

Page 82 GAO-06-332 HIV/AIDS Funding

Grantee 

Base grant 

award 

ADAP 

base grant 

award

Minority 

AIDS 

Initiative 

award

Emerging 

Communities 

award

ADAP Severe 

Need award 

Total Title II 

award

Total Title II 

award per 

ELCa

Alabama $4,042,811 $7,004,635 $77,828 $192,260 $824,913 $12,142,447 $3,657

Alaskab500,000 472,602 2,103 974,705 4,351

Arizona 3,201,547 8,392,903 54,164 11,648,614 2,928

Arkansas 1,785,169 3,116,716 31,946 4,933,831 3,366

California 31,236,233 89,623,465 565,829 121,425,527 2,858

Colorado 2,117,525 5,607,928 34,181 660,427 8,420,061 3,168

Connecticut 3,779,591 11,315,018 81,114 15,175,723 2,830

Delaware 1,848,490 3,202,722 39,177 250,406 5,340,795 3,518

District of Columbia 4,305,124 13,842,594 175,770 18,323,488 2,793

Florida 29,860,865 80,386,630 893,442 528,011 111,668,948 2,931

Georgia 9,408,492 23,684,951 260,828 2,789,298 36,143,569 3,220

Hawaii 1,203,101 2,084,512 10,517 3,298,130 3,338

Idahob500,000 464,163 526 54,663 1,019,352 4,633

Illinois 8,837,193 25,746,254 287,121 34,870,568 2,858

Indiana 3,768,825 6,529,924 47,196 1,057,005 11,402,950 3,684

Iowa 753,765 1,305,985 7,625 2,067,375 3,340

Kansas 1,007,120 2,045,495 8,545 3,061,160 3,192

Kentucky 2,358,712 4,086,741 22,875 220,395 481,282 7,170,005 3,702

Louisiana 6,211,002 13,829,935 192,072 1,091,712 1,628,705 22,953,426 3,502

Maineb500,000 833,383 526 36,525 1,370,434 3,469

Maryland 8,446,358 25,746,254 317,359 34,509,971 2,828

Massachusetts 5,223,382 14,684,416 99,257 183,819 20,190,874 2,901

Michigan 4,335,555 11,002,763 117,531 15,455,849 2,964

Minnesota 1,026,762 3,010,727 22,218 4,059,707 2,845

Mississippi 3,345,060 5,795,703 88,477 225,710 9,454,950 3,442

Missouri 2,783,489 7,409,723 56,925 10,250,137 2,919

Montanab500,000 310,145 526 810,671 5,515

Nebraska 639,300 1,107,661 10,254 130,445 1,887,660 3,596

Nevada 1,684,896 4,738,678 32,735 6,456,309 2,875

New Hampshireb500,000 755,319 1,709 1,257,028 3,511

New Jersey 12,302,631 34,877,598 279,365 181,943 47,641,537 2,882

New Mexico 1,195,795 2,127,024 15,644 3,338,463 3,400

New York 42,659,431 124,956,784 1,252,475 394,523 169,263,213 2,858

Appendix III: CARE Act Title II Awards, 

Fiscal Year 2004 
Appendix III: CARE Act Title II Awards, 

Fiscal Year 2004 

Grantee 

Base grant 

award 

ADAP 

base grant 

award

Minority 

AIDS 

Initiative 

award

Emerging 

Communities 

award

ADAP Severe 

Need award 

Total Title II 

award

Total Title II 

award per 

ELCa

North Carolina 7,403,985 12,834,095 197,593 708,703 1,511,429 22,655,805 3,724

North Dakotac200,000 92,543 0 292,543 6,803

Ohio 5,448,305 10,909,930 67,968 336,063 16,762,266 3,242

Oklahoma 2,054,284 3,655,707 23,795 190,071 419,165 6,343,022 3,760

Oregon 1,664,149 4,225,989 12,489 5,902,627 2,947

Pennsylvania 10,779,206 27,090,216 258,856 188,196 38,316,474 2,984

Puerto Rico 8,238,917 22,598,388 260,697 2,661,337 33,759,339 3,152

Rhode Island 1,103,249 1,911,506 14,461 160,060 3,189,276 3,520

South Carolina 6,774,143 11,736,984 164,858 647,118 1,382,225 20,705,328 3,722

South Dakotab500,000 204,654 1,052 705,706 7,275

Tennessee 6,185,987 12,018,438 122,526 2,851,283 21,178,234 4,169

Texas 19,125,106 50,471,351 469,070 5,943,843 76,009,370 3,177

Utah 1,074,024 1,980,565 7,099 173,503 3,235,191 3,668

Vermontb500,000 382,007 1,052 883,059 4,879

Virginia 5,929,341 14,498,751 145,007 244,779 1,707,470 22,525,348 3,278

Washington 3,118,978 7,966,718 35,890 11,121,586 2,945

West Virginia 713,239 1,303,875 4,733 153,553 2,175,400 3,520

Wisconsin 1,831,726 3,179,514 28,791 174,440 374,441 5,588,912 3,709

Wyomingc200,000 160,347 0 360,347 4,741

Total $284,712,863 $727,320,929 $6,903,797 $10,000,000 $20,759,721 $1,049,697,310

Source: GAO analysis of HRSA data. 

Notes: HRSA has awarded grants for Minority AIDS Initiative grants to states and territories. HRSA 

characterizes Minority AIDS Initiative grants to states and territories as Title II grants. 

In addition to the grantees listed, American Samoa, the Federated States of Micronesia, Guam, the 

Republic of the Marshall Islands, the Commonwealth of the Northern Mariana Islands, the Republic of 

Palau, and the Virgin Islands also received Title II funding ranging from a total of $50,000 to 

$1,048,657. 

a

HRSA calculates a jurisdiction’s ELCs by using data from CDC on the reported AIDS case counts for 

the last 10 years and weighting those numbers to account for the likelihood of death. The average 

total Title II award per ELC was $3,559. 

b

State received a Title II base award of $500,000, the minimum it could receive based on the number 

of ELCs in the state. 

c

State received a Title II base award of $200,000, the minimum it could receive based on the number 

of ELCs in the state. 

Page 83 GAO-06-332 HIV/AIDS Funding
Appendix IV: HOPWA Formula Grantees and 

Award Amounts, Fiscal Year 2004 

Page 84 GAO-06-332 HIV/AIDS Funding

Grantee Base funding Bonus fundingaTotal formula funding 

Total formula 

funding per 

cumulative 

AIDS caseb

Total formula 

funding per living 

AIDS casec

Alabama $1,139,000 $1,139,000 $230 $444

Albany, N.Y. 429,000 429,000 230 497

Arizona 164,000 164,000 230 474

Arkansas 752,000 752,000 230 418

Atlanta, Ga. 4,262,000 $637,000 4,899,000 264 573

Augusta, Ga. 373,000 373,000 230 455

Austin, Tex. 988,000 988,000 230 520

Baltimore, Md. 3,940,000 3,996,000 7,936,000 463 1,039

Baton Rouge, La. 666,000 1,147,000 1,813,000 626 1,290

Birmingham, Ala. 520,000 520,000 230 461

Boston, Mass. 1,829,000 1,829,000 230 563

Bridgeport, Conn. 752,000 27,000 779,000 238 476

Buffalo, N.Y. 472,000 472,000 230 523

California 3,042,000 3,042,000 230 518

Cambridge, Mass. 659,000 659,000 230 518

Camden, N.J. 657,000 657,000 230 567

Charleston, S.C. 411,000 7,000 418,000 234 480

Charlotte, N.C. 571,000 571,000 230 450

Chicago, Ill. 5,622,000 2,716,000 8,338,000 341 805

Cincinnati, Ohio 550,000 550,000 230 523

Cleveland, Ohio 854,000 854,000 230 479

Colorado 366,000 366,000 230 462

Columbia, S.C. 626,000 644,000 1,270,000 466 824

Columbus, Ohio 584,000 584,000 230 619

Connecticut 251,000 251,000 230 479

Dallas, Tex. 3,192,000 3,192,000 230 496

Delaware 164,000 164,000 230 463

Denver, Colo. 1,424,000 1,424,000 230 547

Detroit, Mich. 1,624,000 355,000 1,979,000 280 749

District of Columbia 5,626,000 6,176,000 11,802,000 482 939

Florida 4,063,000 4,063,000 230 489

Fort Lauderdale, Fla. 3,337,000 2,903,000 6,240,000 430 954

Fort Worth, Tex. 835,000 835,000 230 500

Appendix IV: HOPWA Formula Grantees and 

Award Amounts, Fiscal Year 2004 
Appendix IV: HOPWA Formula Grantees and 

Award Amounts, Fiscal Year 2004 

Grantee Base funding Bonus fundingaTotal formula funding 

Total formula 

funding per 

cumulative 

AIDS caseb

Total formula 

funding per living 

AIDS casec

Gaithersburg, Md. 535,000 535,000 230 467

Georgia 1,515,000 1,515,000 230 469

Hartford, Conn. 1,023,000 1,023,000 230 460

Hawaii 181,000 181,000 230 439

Honolulu, Hawaii 452,000 452,000 230 571

Houston, Tex. 5,068,000 5,068,000 230 591

Illinois 864,000 864,000 230 466

Indiana 836,000 836,000 230 500

Indianapolis, Ind. 759,000 759,000 230 476

Iowa 347,000 347,000 230 511

Islip, N.Y. 1,660,000 1,660,000 230 577

Jackson, Miss. 449,000 275,000 724,000 371 728

Jacksonville, Fla. 1,195,000 369,000 1,564,000 301 623

Kansas 363,000 363,000 230 562

Kansas City, Mo. 978,000 978,000 230 506

Kentucky 423,000 423,000 230 418

Las Vegas, Nev. 916,000 916,000 230 455

Los Angeles, Calif. 10,476,000 10,476,000 230 622

Louisiana 940,000 940,000 230 488

Louisville, Ky. 462,000 462,000 230 443

Maryland 345,000 345,000 230 453

Massachusetts 525,000 525,000 230 521

Memphis, Tenn. 920,000 1,214,000 2,134,000 533 1,000

Miami, Fla. 6,149,000 4,566,000 10,715,000 400 934

Michigan 911,000 911,000 230 546

Milwaukee, Wis. 512,000 512,000 230 511

Minneapolis, Minn. 839,000 839,000 230 508

Minnesota 110,000 110,000 230 529

Mississippi 756,000 756,000 230 484

Missouri 496,000 496,000 230 471

Nashville, Tenn. 737,000 737,000 230 387

Nevada 238,000 238,000 230 499

New Haven, Conn. 937,000 295,000 1,232,000 302 605

New Jersey 1,106,000 1,106,000 230 593

New Mexico 533,000 533,000 230 501

Page 85 GAO-06-332 HIV/AIDS Funding
Appendix IV: HOPWA Formula Grantees and 

Award Amounts, Fiscal Year 2004 

Grantee Base funding Bonus fundingaTotal formula funding 

Total formula 

funding per 

cumulative 

AIDS caseb

Total formula 

funding per living 

AIDS casec

New Orleans, La. 1,785,000 1,207,000 2,992,000 385 887

New York 1,776,000 1,776,000 230 500

New York, N.Y. 33,487,000 26,868,000 60,355,000 414 1,099

Newark, N.J. 4,297,000 885,000 5,182,000 277 828

North Carolina 2,082,000 2,082,000 230 437

Oakland, Calif. 2,006,000 2,006,000 230 595

Ohio 1,041,000 1,041,000 230 524

Oklahoma 518,000 518,000 230 521

Oklahoma City, Okla. 466,000 466,000 230 509

Orlando, Fla. 1,660,000 1,529,000 3,189,000 441 913

Pennsylvania 1,540,000 1,540,000 230 445

Philadelphia, Pa. 4,340,000 3,292,000 7,632,000 404 799

Phoenix, Ariz. 1,434,000 1,434,000 230 490

Pittsburgh, Pa. 626,000 626,000 230 568

Portland, Oreg. 1,006,000 1,006,000 230 523

Poughkeepsie, N.Y. 604,000 604,000 230 556

Providence, R.I. 807,000 807,000 230 498

Puerto Rico 1,748,000 1,748,000 230 584

Richmond, Va. 692,000 692,000 230 527

Riverside, Calif. 1,772,000 1,772,000 230 462

Rochester, N.Y. 597,000 597,000 230 460

Sacramento, Calif. 844,000 844,000 230 574

St. Louis, Mo. 1,217,000 1,217,000 230 491

Salt Lake City, Utah 386,000 386,000 230 455

San Antonio, Tex. 1,027,000 1,027,000 230 480

San Diego, Calif. 2,683,000 2,683,000 230 522

San Francisco, Calif. 6,698,000 1,864,000 8,562,000 294 1,130

San Jose, Calif. 792,000 792,000 230 538

San Juan, P.R. 4,585,000 2,555,000 7,140,000 358 1,000

Santa Ana, Calif. 1,436,000 1,436,000 230 489

Sarasota, Fla. 397,000 397,000 230 501

Seattle, Wash. 1,688,000 1,688,000 230 524

South Carolina 1,387,000 1,387,000 230 446

Springfield, Mass. 461,000 461,000 230 535

Tampa, Fla. 2,221,000 168,000 2,389,000 247 569

Page 86 GAO-06-332 HIV/AIDS Funding
Appendix IV: HOPWA Formula Grantees and 

Award Amounts, Fiscal Year 2004 

Grantee Base funding Bonus fundingaTotal formula funding 

Total formula 

funding per 

cumulative 

AIDS caseb

Total formula 

funding per living 

AIDS casec

Tennessee 739,000 739,000 230 438

Texas 2,736,000 2,736,000 230 454

Tucson, Ariz. 402,000 402,000 230 515

Utah 120,000 120,000 230 467

Virginia 640,000 640,000 230 499

Virginia Beach, Va. 1,022,000 1,022,000 230 505

Wake County, N.C. 345,000 7,000 352,000 234 408

Warren, Mich. 405,000 405,000 230 571

Washington 652,000 652,000 230 480

West Palm Beach, Fla. 2,019,000 1,817,000 3,836,000 436 933

Wilmington, Del. 566,000 232,000 798,000 325 624

Wisconsin 405,000 405,000 230 509

Woodbridge, N.J. 1,462,000 1,462,000 230 627

Worcester, Mass. 369,000 369,000 230 480

Total $197,288,000 $65,751,000 $263,039,000

Sources: GAO analysis of CDC and HUD data. 

a

Bonus grants were awarded to EMSAs that have a higher-than-average per capita incidence of AIDS 

over the previous year. 

b

The average formula funding per cumulative AIDS case was $260. 

c

The number of living AIDS cases was calculated by subtracting the number of reported deaths 

among AIDS cases in a jurisdiction from the number of reported cases. The average formula funding 

per living AIDS case was $573. 

Page 87 GAO-06-332 HIV/AIDS Funding
Appendix V: HOPWA Base Funding 

Allocations Using Cumulative and Living AIDS 

Cases, Fiscal Year 2004 

Page 88 GAO-06-332 HIV/AIDS Funding

Grantee Base funding 

Cumulative 

AIDS cases

Percent of 

cumulative 

AIDS cases

Living 

AIDS 

casesa

Percent of 

living 

AIDS 

cases

Funding if 

allocated using 

living AIDS cases

Difference in 

fundingb

Alabama $1,139,000 4,969 0.58% 2,568 0.70% $1,378,278 -$239,278

Albany, N.Y. 429,000 1,867 0.22 864 0.24 463,720 -34,720

Arizona 164,000 712 0.08 346 0.09 185,703 -21,703

Arkansas 752,000 3,274 0.38 1,799 0.49 965,546 -213,546

Atlanta, Ga. 4,262,000 18,554 2.16 8,557 2.33 4,592,649 -330,649

Augusta, Ga. 373,000 1,623 0.19 819 0.22 439,568 -66,568

Austin, Tex. 988,000 4,302 0.50 1,899 0.52 1,019,217 -31,217

Baltimore, Md. 3,940,000 17,150 2.00 7,641 2.08 4,101,020 -161,020

Baton Rouge, La. 666,000 2,898 0.34 1,405 0.38 754,081 -88,081

Birmingham, Ala. 520,000 2,265 0.26 1,127 0.31 604,875 -84,875

Boston, Mass. 1,829,000 7,960 0.93 3,248 0.88 1,743,242 85,758

Bridgeport, Conn. 752,000 3,275 0.38 1,637 0.45 878,598 -126,598

Buffalo, N.Y. 472,000 2,053 0.24 902 0.25 484,115 -12,115

California 3,042,000 13,240 1.54 5,870 1.60 3,150,502 -108,502

Cambridge, Mass. 659,000 2,868 0.33 1,271 0.35 682,162 -23,162

Camden, N.J. 657,000 2,861 0.33 1,159 0.32 622,050 34,950

Charleston, S.C. 411,000 1,788 0.21 870 0.24 466,940 -55,940

Charlotte, N.C. 571,000 2,486 0.29 1,269 0.35 681,088 -110,088

Chicago, Ill. 5,622,000 24,471 2.85 10,362 2.82 5,561,415 60,585

Cincinnati, Ohio 550,000 2,394 0.28 1,051 0.29 564,085 -14,085

Cleveland, Ohio 854,000 3,718 0.43 1,784 0.49 957,495 -103,495

Colorado 366,000 1,595 0.19 792 0.22 425,076 -59,076

Columbia, S.C. 626,000 2,727 0.32 1,541 0.42 827,074 -201,074

Columbus, Ohio 584,000 2,542 0.30 944 0.26 506,657 77,343

Connecticut 251,000 1,092 0.13 524 0.14 281,237 -30,237

Dallas, Tex. 3,192,000 13,895 1.62 6,436 1.75 3,454,282 -262,282

Delaware 164,000 716 0.08 354 0.10 189,996 -25,996

Denver, Colo. 1,424,000 6,200 0.72 2,602 0.71 1,396,526 27,474

Detroit, Mich. 1,624,000 7,068 0.82 2,641 0.72 1,417,458 206,542

District of Columbia 5,626,000 24,490 2.85 12,570 3.42 6,746,476 -1,120,476

Florida 4,063,000 17,686 2.06 8,306 2.26 4,457,934 -394,934

Fort Lauderdale, 

Fla. 3,337,000 14,527 1.69 6,541 1.78 3,510,636 -173,636

Appendix V: HOPWA Base Funding 

Allocations Using Cumulative and Living 

AIDS Cases, Fiscal Year 2004 
Appendix V: HOPWA Base Funding 

Allocations Using Cumulative and Living AIDS 

Cases, Fiscal Year 2004 

Grantee Base funding 

Cumulative 

AIDS cases

Percent of 

cumulative 

AIDS cases

Living 

AIDS 

casesa

Percent of 

living 

AIDS 

cases

Funding if 

allocated using 

living AIDS cases

Difference in 

fundingb

Fort Worth, Tex. 835,000 3,635 0.42 1,670 0.45 896,310 -61,310

Gaithersburg, Md. 535,000 2,328 0.27 1,146 0.31 615,073 -80,073

Georgia 1,515,000 6,593 0.77 3,233 0.88 1,735,192 -220,192

Hartford, Conn. 1,023,000 4,455 0.52 2,222 0.60 1,192,575 -169,575

Hawaii 181,000 786 0.09 412 0.11 221,126 -40,126

Honolulu, Hawaii 452,000 1,966 0.23 791 0.22 424,540 27,460

Houston, Tex. 5,068,000 22,063 2.57 8,579 2.33 4,604,457 463,543

Illinois 864,000 3,761 0.44 1,855 0.50 995,602 -131,602

Indiana 836,000 3,638 0.42 1,673 0.46 897,920 -61,920

Indianapolis, Ind. 759,000 3,302 0.38 1,595 0.43 856,056 -97,056

Iowa 347,000 1,509 0.18 679 0.18 364,428 -17,428

Islip, N.Y. 1,660,000 7,226 0.84 2,877 0.78 1,544,122 115,878

Jackson, Miss. 449,000 1,953 0.23 994 0.27 533,492 -84,492

Jacksonville, Fla. 1,195,000 5,202 0.61 2,509 0.68 1,346,612 -151,612

Kansas 363,000 1,582 0.18 646 0.18 346,716 16,284

Kansas City, Mo. 978,000 4,256 0.50 1,933 0.53 1,037,465 -59,465

Kentucky 423,000 1,841 0.21 1,011 0.28 542,616 -119,616

Las Vegas, Nev. 916,000 3,986 0.46 2,014 0.55 1,080,939 -164,939

Los Angeles, Calif. 10,476,000 45,601 5.31 16,834 4.58 9,035,018 1,440,982

Louisiana 940,000 4,091 0.48 1,926 0.52 1,033,708 -93,708

Louisville, Ky. 462,000 2,011 0.23 1,044 0.28 560,328 -98,328

Maryland 345,000 1,501 0.17 762 0.21 408,975 -63,975

Massachusetts 525,000 2,287 0.27 1,007 0.27 540,469 -15,469

Memphis, Tenn. 920,000 4,006 0.47 2,133 0.58 1,144,808 -224,808

Miami, Fla. 6,149,000 26,766 3.12 11,477 3.12 6,159,849 -10,849

Michigan 911,000 3,966 0.46 1,669 0.45 895,773 15,227

Milwaukee, Wis. 512,000 2,228 0.26 1,001 0.27 537,249 -25,249

Minneapolis, Minn. 839,000 3,654 0.43 1,650 0.45 885,576 -46,576

Minnesota 110,000 480 0.06 208 0.06 111,636 -1,636

Mississippi 756,000 3,291 0.38 1,563 0.43 838,882 -82,882

Missouri 496,000 2,157 0.25 1,053 0.29 565,158 -69,158

Nashville, Tenn. 737,000 3,208 0.37 1,902 0.52 1,020,827 -283,827

Nevada 238,000 1,034 0.12 477 0.13 256,012 -18,012

New Haven, Conn. 937,000 4,077 0.47 2,036 0.55 1,092,747 -155,747

New Jersey 1,106,000 4,778 0.56 1,864 0.51 1,000,432 105,568

Page 89 GAO-06-332 HIV/AIDS Funding
Appendix V: HOPWA Base Funding 

Allocations Using Cumulative and Living AIDS 

Cases, Fiscal Year 2004 

Grantee Base funding 

Cumulative 

AIDS cases

Percent of 

cumulative 

AIDS cases

Living 

AIDS 

casesa

Percent of 

living 

AIDS 

cases

Funding if 

allocated using 

living AIDS cases

Difference in 

fundingb

New Mexico 533,000 2,319 0.27 1,064 0.29 571,062 -38,062

New Orleans, La. 1,785,000 7,769 0.90 3,374 0.92 1,810,868 -25,868

New York 1,776,000 7,730 0.90 3,553 0.97 1,906,940 -130,940

New York, N.Y. 33,487,000 145,769 16.97 54,900 14.94 29,465,516 4,021,484

Newark, N.J. 4,297,000 18,704 2.18 6,262 1.70 3,360,894 936,106

North Carolina 2,082,000 9,065 1.06 4,761 1.30 2,555,288 -473,288

Oakland, Calif. 2,006,000 8,731 1.02 3,374 0.92 1,810,868 195,132

Ohio 1,041,000 4,533 0.53 1,985 0.54 1,065,374 -24,374

Oklahoma 518,000 2,254 0.26 995 0.27 534,029 -16,029

Oklahoma City, 

Okla. 466,000 2,027 0.24 916 0.25 491,629 -25,629

Orlando, Fla. 1,660,000 7,228 0.84 3,494 0.95 1,875,273 -215,273

Pennsylvania 1,540,000 6,702 0.78 3,463 0.94 1,858,635 -318,635

Philadelphia, Pa. 4,340,000 18,890 2.20 9,546 2.60 5,123,457 -783,457

Phoenix, Ariz. 1,434,000 6,244 0.73 2,924 0.80 1,569,347 -135,347

Pittsburgh, Pa. 626,000 2,723 0.32 1,103 0.30 591,994 34,006

Portland, Oreg. 1,006,000 4,378 0.51 1,925 0.52 1,033,172 -27,172

Poughkeepsie, N.Y. 604,000 2,630 0.31 1,087 0.30 583,406 20,594

Providence, R.I. 807,000 3,514 0.41 1,622 0.44 870,548 -63,548

Puerto Rico 1,748,000 7,608 0.89 2,995 0.81 1,607,454 140,546

Richmond, Va. 692,000 3,012 0.35 1,312 0.36 704,167 -12,167

Riverside, Calif. 1,772,000 7,714 0.90 3,834 1.04 2,057,756 -285,756

Rochester, N.Y. 597,000 2,599 0.30 1,297 0.35 696,116 -99,116

Sacramento, Calif. 844,000 3,676 0.43 1,470 0.40 788,967 55,033

St. Louis, Mo. 1,217,000 5,297 0.62 2,481 0.67 1,331,584 -114,584

Salt Lake City, Utah 386,000 1,680 0.20 849 0.23 455,669 -69,669

San Antonio, Tex. 1,027,000 4,469 0.52 2,138 0.58 1,147,491 -120,491

San Diego, Calif. 2,683,000 11,677 1.36 5,136 1.40 2,756,555 -73,555

San Francisco, Calif. 6,698,000 29,156 3.40 7,577 2.06 4,066,671 2,631,329

San Jose, Calif. 792,000 3,446 0.40 1,472 0.40 790,041 1,959

San Juan, P.R. 4,585,000 19,960 2.32 7,141 1.94 3,832,664 752,336

Santa Ana, Calif. 1,436,000 6,250 0.73 2,939 0.80 1,577,398 -141,398

Sarasota, Fla. 397,000 1,730 0.20 792 0.22 425,076 -28,076

Seattle, Wash. 1,688,000 7,347 0.86 3,221 0.88 1,728,751 -40,751

South Carolina 1,387,000 6,039 0.70 3,108 0.85 1,668,102 -281,102

Page 90 GAO-06-332 HIV/AIDS Funding
Appendix V: HOPWA Base Funding 

Allocations Using Cumulative and Living AIDS 

Cases, Fiscal Year 2004 

Grantee Base funding 

Cumulative 

AIDS cases

Percent of 

cumulative 

AIDS cases

Living 

AIDS 

casesa

Percent of 

living 

AIDS 

cases

Funding if 

allocated using 

living AIDS cases

Difference in 

fundingb

Springfield, Mass. 461,000 2,005 0.23 861 0.23 462,109 -1,109

Tampa, Fla. 2,221,000 9,670 1.13 4,201 1.14 2,254,729 -33,729

Tennessee 739,000 3,218 0.37 1,689 0.46 906,507 -167,507

Texas 2,736,000 11,911 1.39 6,024 1.64 3,233,156 -497,156

Tucson, Ariz. 402,000 1,749 0.20 780 0.21 418,636 -16,636

Utah 120,000 524 0.06 257 0.07 137,935 -17,935

Virginia 640,000 2,788 0.32 1,282 0.35 688,065 -48,065

Virginia Beach, Va. 1,022,000 4,450 0.52 2,024 0.55 1,086,306 -64,306

Wake County, N.C. 345,000 1,502 0.17 863 0.23 463,183 -118,183

Warren, Mich. 405,000 1,763 0.21 709 0.19 380,529 24,471

Washington 652,000 2,839 0.33 1,357 0.37 728,319 -76,319

West Palm Beach, 

Fla. 2,019,000 8,789 1.02 4,112 1.12 2,206,962 -187,962

Wilmington, Del. 566,000 2,459 0.29 1,278 0.35 685,919 -119,919

Wisconsin 405,000 1,761 0.21 795 0.22 426,686 -21,686

Woodbridge, N.J. 1,462,000 6,363 0.74 2,332 0.63 1,251,614 210,386

Worcester, Mass. 369,000 1,607 0.19 768 0.21 412,195 -43,195

Total $197,288,000 858,752 367,586 $197,288,000

Sources: GAO analysis of CDC and HUD data. 

Notes: By law HOPWA base grants are distributed according to cumulative AIDS case counts. 

a

The number of living AIDS cases was calculated by subtracting the number of reported deaths 

among AIDS cases in a jurisdiction from the number of reported cases. 

b

This was calculated by subtracting the amount that would have been received if living AIDS cases 

had been used from the amount that was received using cumulative AIDS cases. A positive value 

indicates that the jurisdiction received more funding using cumulative AIDS cases than it would have 

received if living AIDS cases had been used. A negative value indicates that the jurisdiction would 

have received more funding if living AIDS cases had been used. 

Page 91 GAO-06-332 HIV/AIDS Funding
Appendix VI: Total CARE Act Title I and Title 

II Funding by State and Territory, Fiscal Year 

2004 

Page 92 GAO-06-332 HIV/AIDS Funding

State/territory 

Total Title I and 

Title II awards ELCsa

Percent of ELCs 

in EMAs 

Total Title I and Title II 

awards per ELC

Alabama $12,142,447 3,320 0% $3,657

Alaskab974,705 224 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

Idahob1,019,352 220 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

Maineb1,333,909 395 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

Montanab847,196 147 0 5,763

Nebraska 1,887,660 525 0 3,596

Nevada 10,757,214 2,246 83.3 4,789

New Hampshireb1,864,452 358 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 Dakotac292,543 43 0 6,803

Appendix VI: Total CARE Act Title I and Title 

II Funding by State and Territory, Fiscal Year 

2004 
Appendix VI: Total CARE Act Title I and Title 

II Funding by State and Territory, Fiscal Year 

2004 

Total Title I and 

Title II awards ELCsa

Percent of ELCs 

in EMAs 

Total Title I and Title II 

State/territory awards per ELC

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 Dakotab705,706 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

Vermontb883,059 181 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

Wyomingc360,347 76 0 4,741

Source: GAO analysis of HRSA data. 

Notes: Our analysis is limited to the states and Puerto Rico. 

a

HRSA calculates a jurisdiction’s ELCs by using data from CDC on the reported AIDS case counts for 

the last 10 years and weighting those numbers to account for the likelihood of death. 

b

State received a Title II base award of $500,000, the minimum it could receive based on the number 

of ELCs in the state. 

c

State received a Title II base award of $200,000, the minimum it could receive based on the number 

of ELCs in the state. 

Page 93 GAO-06-332 HIV/AIDS Funding
Appendix VII: HRSA’s Title I EMAs, GAOIdentified Set of Comparable 2004 OMBDefined Metropolitan Areas, and Changes 

Table 12: EMAs with Service Area Changes 

HRSA 2004 EMA 

GAO-identified comparable OMB newly defined 

2004 MSA(s) or MDIV(s)a

Changes 

OMB’s 1993 full title 

of metropolitan area 

Number 

of 

counties 

in EMA 

ELCs in 

EMAs 

OMB’s 2004 full title of 

metropolitan area(s) 

Number of 

counties in 

EMA 

ELCs in 

EMAs 

Decrease 

in 

counties 

Increase 

in 

counties

Change in 

ELCs 

(percent)

Atlanta, Ga. MSA 20 7,589 Atlanta–Sandy Springs–

Ga. Marietta, Ga. MSA 

28 7,663 0 8 1%

Boston-WorcesterLawrence-LowellBrockton, Mass.-N.H. 

NECMA 

10 6,038 Boston-CambridgeQuincy, Mass-N.H. MSA; 

Worcester, Mass. MSA; 

and Manchester-Nashua, 

N.H. MSA 

9 5,484 1 0 -9

Chicago, Ill. PMSA 9 10,481 Chicago-Naperville-Joliet, 

Ill. MDIV; and Lake 

County–Kenosha County, 

Ill.-Wis. MDIV 

10 10,534 0 1 1

Cleveland-LorainElyria, Ohio PMSA 6 1,511 Cleveland-Elyria-Mentor, 

Ohio MSA 

5 1,484 1 0 -2

Dallas, Tex. PMSA 8 5,261 Dallas-Plano-Irving, Tex. 

MDIV 

8 5,229 1 1 -1

Denver, Colo. PMSA 5 1,993 Denver-Aurora, Colo./ 

MSA 

10 2,017 0 5 1

Detroit, Mich. PMSA 6 3,588 Detroit-Warren-Livonia, 

Mich. MSA and Monroe, 

Mich. MSA 

7 3,601 0 1 0b

Dutchess County, 

N.Y. PMSA 

1 524 Poughkeepsie-NewburghMiddletown, N.Y. MSA 2 1,010 0 1 93

Fort Worth–Arlington, 

Tex. PMSA 

4 1,478 Fort Worth–Arlington, 

Tex. MDIV 

4 1,475 1 1 0b

Houston, Tex. PMSA 6 7,710 Houston–Sugar Land–

Baytown, Tex. MSA 

10 8,106 0 4 5

Jacksonville, Fla. 

MSA 

4 2,051 Jacksonville, Fla. MSA 5 2,080 0 1 1

Kansas City, Mo.-

Kans. MSA 

11 1,295 Kansas City, Mo.-Kans. 

MSA 

15 1,305 0 4 1

Las Vegas, Nev.-Ariz. 

MSA 

3 1,945 Las Vegas–Paradise, 

Nev. MSA 

1 1,857 2 0 -5

Middlesex-SomersetHunterdon, N.J. 

PMSA 

3 1,238 Edison, N.J. MDIV 4 2,217 1 2 79

New Orleans, La. 

MSA 

8 3,154 New Orleans–Metairie–

Kenner, La. MSA 

7 3,130 1 0 -1

Newark, N.J. PMSA 5 6,665 Newark-Union, N.J.-Pa. 

MDIV 

6 6,735 1 2 1

Appendix VII: HRSA’s Title I EMAs, GAOIdentified Set of Comparable 2004 OMBDefined Metropolitan Areas, and Changes 

Page 94 GAO-06-332 HIV/AIDS Funding
Appendix VII: HRSA’s Title I EMAs, GAOIdentified Set of Comparable 2004 OMBDefined Metropolitan Areas, and Changes 

HRSA 2004 EMA 

GAO-identified comparable OMB newly defined 

2004 MSA(s) or MDIV(s)a

Changes 

OMB’s 1993 full title 

of metropolitan area 

Number 

of 

counties 

in EMA 

ELCs in 

EMAs 

OMB’s 2004 full title of 

metropolitan area(s) 

Number of 

counties in 

EMA 

ELCs in 

EMAs 

Decrease 

in 

counties 

Increase 

in 

counties

Change in 

ELCs 

(percent)

Norfolk–Virginia 

Beach–Newport 

News, VA-N.C. MSA 

15 2,237 Virginia Beach–Norfolk–

Newport News, Va.-N.C. 

MSA 

16 2,240 0 1 0b

Philadelphia, Pa.-N.J. 

PMSA 

9 9,857 Philadelphia, Pa. MDIV 

and Camden, N.J. MDIV 

8 9,782 1 0 -1

Ponce, P.R. MSA 6 1,158 Ponce, P.R. MSA and 

Yauco, P.R. MSA 

7 1,202 0 1 4

Portland-Vancouver, 

Oreg.-Wash. PMSA 

6 1,547 Portland-VancouverBeaverton, Oreg.-Wash. 

MSA 

7 1,548 0 1 0b

Sacramento, Calif. 

PMSA 

3 1,246 Sacramento-ArdenArcade-Roseville, Calif. 

MSA 

4 1,321 0 1 6

St. Louis, Mo.-Ill. 

MSA 

12 1,975 St. Louis, Mo.-Ill. MSA 16 1,993 0 4 1

San Antonio, Tex. 

MSA 

4 1,717 San Antonio, Tex. MSA 8 1,750 0 4 2

San Jose, Calif. 

PMSA 

1 1,146 San Jose–Sunnyvale–

Santa Clara, Calif. MSA 

2 1,163 0 1 1

Seattle-BellevueEverett, Wash. PMSA 3 2,468 Seattle-Bellevue-Everett, 

Wash. MDIV 

2 2,445 1 0 -1

Washington, D.C.-

Md.-Va-W.Va. PMSA 

25 11,816 Washington-ArlingtonAlexandria, D.C.-Va.-Md. 

MSA 

22 11,732 3 0 -1

Bergen-Passaic, N.J. 

PMSA 

2 2,088 

Jersey City, N.J. 

PMSA 

1 2,427 

New York City, N.Y. 

PMSA 

8 

New York–White Plains–

Wayne, N.Y.-N.J. MDIV 11 53,867 0 0 0

49,352 

Caguas, P.R. PMSA 5 766 

San Juan–Bayamon, 

P.R. PMSA 

30 6,631 San Juan–Caguas–

Guaynabo, P.R. MSA 41 7,724 3 9 4

Subtotal of changed 239 158,952 Not applicable 275 160,694 17 

areas 

53 1

Subtotal of 

unchanged areas 

(see table 13) 

57 84,768 Not applicable 57 84,768 0 0 0

Total 

HIV/AIDS Funding

296 243,720 Not applicable 332 245,462 17 53 1

Sources: GAO analysis of CDC, HRSA, and OMB data. 

Page 95 GAO-06-332 
Appendix VII: HRSA’s Title I EMAs, GAOIdentified Set of Comparable 2004 OMBDefined Metropolitan Areas, and Changes 

HIV/AIDS Funding

Notes: HRSA’s Title I EMAs are based on OMB’s 1993 metropolitan area definitions.This table uses 

OMB’s terminology for classifying types of metropolitan areas. Specifically, it includes metropolitan 

statistical area (MSA), primary metropolitan statistical area (PMSA), New England county 

metropolitan area (NECMA), and metropolitan division (MDIV). The terms used and meaning of those 

terms differ between1993 and 2004 because of OMB’s fundamental revisions of metropolitan 

concepts. For further explanation, see GAO-04-758. 

a

We chose whatever combination of the newly defined metropolitan areas that would result in the 

least change to the numbers of ELCs within the EMA’s boundaries. 

b

Percent change that rounds to zero, but does not equal zero percent. 

Page 96 GAO-06-332 
Appendix VII: HRSA’s Title I EMAs, GAOIdentified Set of Comparable 2004 OMBDefined Metropolitan Areas, and Changes 

Table 13: EMAs with No Service Area Changes 

HRSA 2004 EMA 

GAO-identified comparable OMB newly defined 

2004 MSA(s) or MDIV(s)a

Changes 

OMB’s 1993 full 

title of 

metropolitan 

area 

Number 

of 

counties 

in EMA 

ELCs in 

EMAs 

OMB’s 2004 full title of 

metropolitan area(s) 

Number 

of 

counties 

in EMA 

ELCs in 

EMAs 

Decrease 

in 

counties 

Increase 

in 

counties

Change in 

ELCs 

(percent)

Austin–San 

Marcos, Tex. 

MSA 

5 1,651 Austin–Round Rock, 

Tex. MSA 

5 1,651 0 0 0%

Baltimore, Md. 

PMSA 

7 8,348 Baltimore-Towson, Md. 

MSA 

7 8,348 0 0 0

Fort Lauderdale, 

Fla. PMSA 

1 6,002 Fort Lauderdale–

Pompano Beach–

Deerfield Beach, Fla. 

MDIV 

1 6,002 0 0 0

Hartford, Conn. 

NECMA 

3 1,954 Hartford–West Hartford–

East Hartford, Conn. 

MSA 

3 1,954 0 0 0

Los Angeles–

Long Beach, 

Calif. PMSA 

1 15,180 Los Angeles–Long 

Beach–Glendale, Calif. 

MDIV 

1 15,180 0 0 0

Miami, Fla. 

PMSA 

1 10,485 Miami–Miami Beach–

Kendall, Fla. MDIV 

1 10,485 0 0 0

Minneapolis–St. 

Paul, Minn.–Wis. 

MSA 

13 1,272 Minneapolis–St. Paul–

Bloomington, Minn.–Wis. 

MSA 

13 1,272 0 0 0

Nassau-Suffolk, 

N.Y. PMSA 

2 2,588 Nassau-Suffolk, N.Y. 

MDIV 

2 2,588 0 0 0

New Haven–

Bridgeport–

Stamford–

Waterbury–

Danbury, Conn. 

NECMA 

2 2,945 Bridgeport-StamfordNorwalk, Conn. MSA 

and New Haven–Milford, 

Conn. MSA 

2 2,945 0 0 0

Oakland, Calif. 

PMSA 

2 2,852 Oakland-FremontHayward, Calif. MDIV 2 2,852 0 0 0

Orange County, 

Calif. PMSA 

1 2,183 Santa Ana–Anaheim–

Irvine, Calif. MDIV 

1 2,183 0 0 0

Orlando, Fla. 

MSA 

4 3,293 Orlando-Kissimmee, Fla. 

MSA 

4 3,293 0 0 0

Phoenix-Mesa, 

Ariz. MSA 

2 2,850 Phoenix-MesaScottsdale, Ariz. MSA 2 2,850 0 0 0

Riverside–San 

Bernardino, 

Calif. PMSA 

2 3,204 Riverside–San 

Bernardino–Ontario, 

Calif. MSA 

2 3,204 0 0 0

Page 97 GAO-06-332 HIV/AIDS Funding
Appendix VII: HRSA’s Title I EMAs, GAOIdentified Set of Comparable 2004 OMBDefined Metropolitan Areas, and Changes 

HRSA 2004 EMA 

GAO-identified comparable OMB newly defined 

2004 MSA(s) or MDIV(s)a

Changes 

OMB’s 1993 full 

title of 

metropolitan 

area 

Number 

of 

counties 

in EMA 

ELCs in 

EMAs 

OMB’s 2004 full title of 

metropolitan area(s) 

Number 

of 

counties 

in EMA 

ELCs in 

EMAs 

Decrease 

in 

counties 

Increase 

in 

counties

Change in 

ELCs 

(percent)

San Diego, Calif. 

MSA 

1 4,259 San Diego–Carlsbad 

San Marcos, CA MSA 

1 4,259 0 0 0

San Francisco, 

Calif. PMSA 

3 7,216 San Francisco–San 

Mateo–Redwood City, 

Calif. MDIV 

3 7,216 0 0 0

Santa Rosa, 

Calif. PMSA 

1 482 Santa Rosa–Petaluma, 

Calif. MSA 

1 482 0 0 0

Tampa–St. 

Petersburg–

Clearwater, Fla. 

MSA 

4 3,875 Tampa–St. Petersburg–

Clearwater, Fla. MSA 

4 3,875 0 0 0

VinelandMillvilleBridgeton, N.J. 

PMSA 

1 388 Vineland-MillvilleBridgeton, N.J. MSA 1 388 0 0 0

West Palm 

Beach–Boca 

Raton, Fla. MSA 

1 3,741 West Palm Beach–Boca 

Raton–Boynton Beach, 

Fla. MDIV 

1 3,741 0 0 0

Total 57 84,768 Not applicable 57 84,768 0 0 0

Sources: GAO analysis of CDC, HRSA, and OMB data. 

Notes: This table uses OMB’s terminology for classifying types of metropolitan areas. Specifically, it 

includes metropolitan statistical area (MSA), primary metropolitan statistical area (PMSA), New 

England county metropolitan area (NECMA), and metropolitan division (MDIV). The terms used and 

meaning of those terms differs between1993 and 2004 because of OMB’s fundamental revisions of 

metropolitan concepts. For further explanation, see GAO-04-758. 

a

We chose whatever combination of the newly defined metropolitan areas that would result in the 

least change to the numbers of ELCs within the EMA’s boundaries. 

Page 98 GAO-06-332 HIV/AIDS Funding
Appendix VIII: Estimated CARE Act Title I 

Funding Changes from Use of HIV Case 

Counts and ELCs with Hold-harmless 

Page 99 GAO-06-332 HIV/AIDS Funding

Change in Title I base funding if CDCaccepted HIV case counts and ELCs were 

used to distribute funding with holdharmless provision 

Change in Title I base funding if HIV case 

counts from all grantees and ELCs were 

used to distribute funding with holdharmless provisiona

Eligible metropolitan area Dollar changeb Percent change Dollar changeb Percent change

Atlanta, Ga. -$210,000 -2% -$210,000 -2%

Austin, Tex. 260,000 13 -10,000 0c

Baltimore, Md. -240,000 -2 3,210,000 32

Bergen-Passaic, N.J. 600,000 23 210,000 8

Boston, Mass. 0 0 1,180,000 16

Caguas, P.R. -50,000 -5 -50,000 -5

Chicago, Ill. -950,000 -7 510,000 4

Cleveland, Ohio 940,000 51 610,000 33

Dallas, Tex. 1,630,000 25 660,000 10

Denver, Colo. 3,210,000 132 2,530,000 104

Detroit, Mich. 1,520,000 35 810,000 19

District of Columbia -750,000 -5 -750,000 -5

Dutchess County, N.Y. 40,000 7 -30,000 -5

Fort Lauderdale, Fla. 2,060,000 28 940,000 13

Fort Worth, Tex. 350,000 19 90,000 5

Hartford, Conn. -80,000 -3 -80,000 -3

Houston, Tex. 1,130,000 12 -20,000 0c

Jacksonville, Fla. 570,000 23 200,000 8

Jersey City, N.J. 590,000 20 160,000 5

Kansas City, Mo. 870,000 51 560,000 32

Las Vegas, Nev. 1,460,000 61 1,000,000 42

Los Angeles, Calif. -10,000 0c -10,000 0c

Miami, Fla. 3,580,000 28 1,620,000 13

Middlesex-Somerset-Hunterdon, N.J. 400,000 26 170,000 11

Minneapolis–St. Paul, Minn. 1,130,000 71 810,000 51

Nassau-Suffolk, N.Y. 40,000 1 40,000 1

New Haven, Conn. 0 0 0 0

New Orleans, La. 1,950,000 51 1,250,000 33

New York, N.Y. 5,660,000 9 -310,000 -1

Newark, N.J. 2,360,000 29 1,100,000 14

Norfolk, Va. 1,560,000 57 1,040,000 38

Oakland, Calif. 0 0 0 0

Appendix VIII: Estimated CARE Act Title I 

Funding Changes from Use of HIV Case 

Counts and ELCs with Hold-harmless 
Appendix VIII: Estimated CARE Act Title I 

Funding Changes from Use of HIV Case 

Counts and ELCs with Hold-harmless 

Change in Title I base funding if CDCaccepted HIV case counts and ELCs were 

used to distribute funding with holdharmless provision 

Change in Title I base funding if HIV case 

counts from all grantees and ELCs were 

used to distribute funding with holdharmless provisiona

Eligible metropolitan area Dollar changebPercent change Dollar changebPercent change

Orange County, Calif. -30,000 -1 -30,000 -1

Orlando, Fla. 1,190,000 30 570,000 14

Philadelphia, Pa. -230,000 -2 -230,000 -2

Phoenix, Ariz. 2,020,000 58 1,360,000 39

Ponce, P.R. -30,000 -2 -30,000 -2

Portland, Oreg. -20,000 -1 -20,000 -1

Riverside–San Bernardino, Calif. -90,000 -2 -90,000 -2

Sacramento, Calif. 0 0 0 0

St. Louis, Mo. 1,120,000 47 830,000 34

San Antonio, Tex. 180,000 8 -20,000 -1

San Diego, Calif. -120,000 -2 800,000 15

San Francisco, Calif. 0 0 0 0

San Jose, Calif. 0 0 0 0

San Juan, P.R. 0 0 0 0

Santa Rosa, Calif. 0 0 0 0

Seattle, Wash. 0 0 640,000 21

Tampa–St. Petersburg, Fla. 1,000,000 21 310,000 7

Vineland-Millville-Bridgeton, N.J. 130,000 28 60,000 12

West Palm Beach, Fla. 530,000 12 0 0

Sources: GAO analysis of CDC, HRSA, state, and local data. 

Notes: The estimated dollar and percent changes are based on what the EMAs received in their base 

grants, including any hold-harmless funding, and what they would have received if HIV cases and 

ELCs had been used to allocate funding. In fiscal year 2004, the amount of hold-harmless funding 

was $8,033,563. Because the amounts needed to fund the Title I hold-harmless provision are taken 

from funds that would otherwise be available for supplemental grants, the total funding actually 

allocated as base grants and our estimated base grant funding differ by the amounts necessary to 

fund the hold-harmless provision. The hold-harmless funding was $43,300,968 when only CDCaccepted HIV case counts and ELCs were used and $29,413,708 when the HIV case counts from all 

grantees were used. 

HRSA calculates a jurisdiction’s ELCs by using data from CDC on the reported AIDS case counts for 

the last 10 years and weighting those numbers to account for the likelihood of death. 

a

In some jurisdictions, HIV cases are collected by name while in others HIV cases are collected using 

a coded identifier. We used both name- and code-based case counts for this estimate. CDC only 

accepts name-based case counts as no code-based system has yet met its quality criteria. 

b

Rounded to nearest $10,000. 

c

Percent change that rounds to zero, but does not equal zero percent. 

Page 100 GAO-06-332 HIV/AIDS Funding
Appendix IX: Estimated CARE Act Title II 

Base Funding Changes from Use of HIV Case 

Counts and ELCs with Hold-harmless 

Page 101 GAO-06-332 HIV/AIDS Funding

Change in Title II base funding if CDC-accepted 

HIV case counts and ELCs were used to distribute 

funding with hold-harmless and minimum-grant 

provisions 

Change in Title II base funding if HIV case 

counts from all grantees and ELCs were used to 

distribute funding with hold-harmless and 

minimum-grant provisionsa

Grantee Dollar changeb Percent change Dollar changeb Percent change

Alabama $1,170,000 29% $1,000,000 25%

Alaskac0 0 0 0

Arizona 620,000 19 410,000 13

Arkansas 320,000 18 250,000 14

California 0 0 0 0

Colorado 1,540,000 73 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 -1,330,000 -4 -2,910,000 -10

Georgia -1,350,000 -14 -1,350,000 -14

Hawaii -70,000 -6 -70,000 -6

Idahoc0 0 0 0

Illinois -1,780,000 -20 -780,000 -9

Indiana 180,000 5 50,000 1

Iowa -90,000 -11 -90,000 -11

Kansas 0 0 0 0

Kentucky -400,000 -17 -400,000 -17

Louisiana 700,000 11 390,000 6

Mainec0 0 0 0

Maryland -1,650,000 -20 2,060,000 24

Massachusetts -620,000 -12 20,000 0d

Michigan 370,000 9 130,000 3

Minnesota 460,000 45 370,000 36

Mississippi 590,000 18 460,000 14

Missouri 720,000 26 520,000 19

Montanac0 0 0 0

Nebraska -10,000 -2 -30,000 -5

Nevada 520,000 31 400,000 24

New Hampshirec0 0 0 0

New Jersey 370,000 3 0 0

New Mexico -70,000 -6 -70,000 -6

Appendix IX: Estimated CARE Act Title II 

Base Funding Changes from Use of HIV Case 

Counts and ELCs with Hold-harmless 
Appendix IX: Estimated CARE Act Title II 

Base Funding Changes from Use of HIV Case 

Counts and ELCs with Hold-harmless 

Change in Title II base funding if CDC-accepted 

HIV case counts and ELCs were used to distribute 

funding with hold-harmless and minimum-grant 

provisions 

Change in Title II base funding if HIV case 

counts from all grantees and ELCs were used to 

distribute funding with hold-harmless and 

minimum-grant provisionsa

Grantee Dollar changebPercent change Dollar changebPercent change

New York -1,730,000 -4 -1,730,000 -4

North Carolina 2,440,000 33 2,120,000 29

North Dakotae300,000 150 300,000 150

Ohio 940,000 17 690,000 13

Oklahoma 370,000 18 290,000 14

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 470,000 7 230,000 3

South Dakotac0 0 0 0

Tennessee 490,000 8 270,000 4

Texas -1,140,000 -6 -1,140,000 -6

Utah -60,000 -6 -60,000 -6

Vermontc0 0 0 0

Virginia 1,100,000 19 750,000 13

Washington -200,000 -7 -170,000 -5

West Virginia -20,000 -3 -50,000 -7

Wisconsin 360,000 20 290,000 16

Wyominge300,000 150 300,000 150

Sources: GAO analysis of CDC, HRSA, state, and local data. 

Notes: HRSA calculates a jurisdiction’s ELCs by using data from CDC on the reported AIDS case 

counts for the last 10 years and weighting those numbers to account for the likelihood of death. 

For purposes of this analysis, we considered the Title II hold-harmless provision that is funded by 

proportional reductions in Title II base grants. We did not include the Title II hold-harmless provision 

funded by amounts otherwise available for Severe Need grants. 

a

In some jurisdictions, HIV cases are collected by name while in others HIV cases are collected using 

a coded identifier. We used both name- and code-based case counts for this estimate. CDC only 

accepts name-based case counts as no code-based system has yet met its quality criteria. 

b

Rounded to nearest $10,000. 

c

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. 

d

Percent change that rounds to zero, but does not equal zero percent. 

e

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 102 GAO-06-332 HIV/AIDS Funding
Appendix X: Estimated CARE Act ADAP Base 

Funding Changes from Use of HIV Case 

Counts and ELCs with Hold-harmless 

Page 103 GAO-06-332 HIV/AIDS Funding

Change in ADAP base funding if CDC-accepted 

HIV case counts and ELCs were used to 

distribute funding with hold-harmless provision

Change in ADAP base funding if HIV case counts 

from all grantees and ELCs were used to 

distribute funding with hold-harmless provisiona

Grantee Dollar changebPercent change Dollar changebPercent change

Alabama $4,810,000 69% $3,860,000 55%

Alaska -60,000 -13 -90,000 -20

Arizona 3,180,000 38 2,260,000 27

Arkansas 1,670,000 54 1,290,000 42

California -18,530,000 -21 -13,400,000 -15

Colorado 5,610,000 100 4,710,000 84

Connecticut -2,970,000 -26 -2,970,000 -26

Delaware -1,210,000 -38 -280,000 -9

District of Columbia -5,240,000 -38 -5,490,000 -40

Florida 7,570,000 9 530,000 1

Georgia -8,120,000 -34 -8,120,000 -34

Hawaii -610,000 -30 -230,000 -11

Idaho 290,000 62 230,000 49

Illinois -9,750,000 -38 -520,000 -2

Indiana 2,400,000 37 1,690,000 26

Iowa 90,000 7 -20,000 -2

Kansas 570,000 28 360,000 18

Kentucky -1,550,000 -38 -1,550,000 -38

Louisiana 4,840,000 35 3,350,000 24

Maine -260,000 -32 150,000 18

Maryland -9,750,000 -38 7,340,000 29

Massachusetts -4,760,000 -32 1,360,000 9

Michigan 2,710,000 25 1,610,000 15

Minnesota 1,750,000 58 1,370,000 46

Mississippi 3,120,000 54 2,410,000 42

Missouri 3,260,000 44 2,400,000 32

Montana -80,000 -25 290,000 93

Nebraska 310,000 28 200,000 18

Nevada 2,180,000 46 1,630,000 34

New Hampshire -170,000 -22 200,000 26

New Jersey 5,210,000 15 2,000,000 6

New Mexico 170,000 8 -10,000 0c

New York -4,960,000 -4 -14,570,000 -12

Appendix X: Estimated CARE Act ADAP 

Base Funding Changes from Use of HIV Case 

Counts and ELCs with Hold-harmless 
Appendix X: Estimated CARE Act ADAP Base 

Funding Changes from Use of HIV Case 

Counts and ELCs with Hold-harmless 

Change in ADAP base funding if CDC-accepted 

HIV case counts and ELCs were used to 

distribute funding with hold-harmless provision

Change in ADAP base funding if HIV case counts 

from all grantees and ELCs were used to 

distribute funding with hold-harmless provisiona

Grantee Dollar changebPercent change Dollar changebPercent change

North Carolina 9,470,000 74 7,680,000 60

North Dakota 50,000 52 40,000 40

Ohio 5,010,000 46 3,730,000 34

Oklahoma 1,930,000 54 1,490,000 42

Oregon -1,230,000 -29 -640,000 -15

Pennsylvania -7,180,000 -27 -8,780,000 -32

Puerto Rico -5,900,000 -26 -5,900,000 -26

Rhode Island -520,000 -27 -230,000 -12

South Carolina 4,660,000 40 3,350,000 29

South Dakota 170,000 84 140,000 69

Tennessee 4,400,000 41 3,180,000 30

Texas 1,760,000 4 -2,430,000 -5

Utah 260,000 14 90,000 5

Vermont -130,000 -35 50,000 12

Virginia 5,610,000 39 4,000,000 28

Washington -2,220,000 -28 630,000 8

West Virginia 330,000 25 200,000 15

Wisconsin 1,790,000 56 1,400,000 44

Wyoming 30,000 20 20,000 11

Sources: GAO analysis of CDC, HRSA, state, and local data. 

Notes: The ADAP base grant funding levels reported to us included any hold-harmless funding that 

would otherwise be used for ADAP Severe Need grants. The estimated dollar and percent changes 

presented here are based on what grantees received in their ADAP base grants without this holdharmless funding. 

HRSA calculates a jurisdiction’s ELCs by using data from CDC on the reported AIDS case counts for 

the last 10 years and weighting those numbers to account for the likelihood of death. 

For purposes of this analysis, we considered the Title II hold-harmless provision that is funded by 

proportional reductions in ADAP base grants. We did not include the Title II hold-harmless provision 

funded by amounts otherwise available for Severe Need grants. 

a

In some jurisdictions, HIV cases are collected by name while in others HIV cases are collected using 

a coded identifier. We used both name- and code-based case counts for this estimate. CDC only 

accepts name-based case counts as no code-based system has yet met its quality criteria. 

b

Rounded to nearest $10,000. 

c

Percent change that rounds to zero, but does not equal zero percent. 

Page 104 GAO-06-332 HIV/AIDS Funding
Appendix XI: Estimated CARE Act Title I 

Base Funding Changes from Use of HIV Case 

Counts and ELCs without Hold-harmless 

Page 105 GAO-06-332 HIV/AIDS Funding

Change in Title I base funding if CDCaccepted HIV case counts and ELCs were 

used to distribute funding without holdharmless provision 

Change in Title I base funding if HIV case 

counts from all grantees and ELCs were 

used to distribute funding without holdharmless provisiona

Eligible metropolitan area Dollar changeb Percent change Dollar changeb Percent change

Atlanta, Ga. -$2,830,000 -31% -$3,600,000 -39%

Austin, Tex. 260,000 13 -10,000 0c

Baltimore, Md. -3,110,000 -31 3,210,000 32

Bergen-Passaic, N.J. 600,000 23 210,000 8

Boston, Mass. -2,310,000 -31 1,180,000 16

Caguas, P.R. -260,000 -28 -340,000 -37

Chicago, Ill. -3,900,000 -31 510,000 4

Cleveland, Ohio 940,000 51 610,000 33

Dallas, Tex. 1,630,000 25 660,000 10

Denver, Colo. 3,210,000 132 2,530,000 104

Detroit, Mich. 1,520,000 35 810,000 19

District of Columbia -2,330,000 -16 -1,390,000 -10

Dutchess County, N.Y. 40,000 7 -40,000 -6

Fort Lauderdale, Fla. 2,060,000 28 940,000 13

Fort Worth, Tex. 350,000 19 90,000 5

Hartford, Conn. -730,000 -31 -800,000 -34

Houston, Tex. 1,130,000 12 -140,000 -1

Jacksonville, Fla. 570,000 23 200,000 8

Jersey City, N.J. 590,000 20 160,000 5

Kansas City, Mo. 870,000 51 560,000 32

Las Vegas, Nev. 1,460,000 61 1,000,000 42

Los Angeles, Calif. -5,660,000 -31 -2,660,000 -14

Miami, Fla. 3,580,000 28 1,620,000 13

Middlesex–Somerset–Hunterdon, N.J. 400,000 26 170,000 11

Minneapolis–St. Paul, Minn. 1,130,000 71 810,000 51

Nassau-Suffolk, N.Y. -940,000 -29 -1,210,000 -38

New Haven, Conn. -1,140,000 -31 -1,270,000 -35

New Orleans, La. 1,950,000 51 1,250,000 33

New York, N.Y. 5,660,000 9 -2,240,000 -4

Newark, N.J. 2,360,000 29 1,100,000 14

Norfolk, Va. 1,560,000 57 1,040,000 38

Oakland, Calif. -1,100,000 -32 -680,000 -19

Appendix XI: Estimated CARE Act Title I 

Base Funding Changes from Use of HIV Case 

Counts and ELCs without Hold-harmless 
Appendix XI: Estimated CARE Act Title I 

Base Funding Changes from Use of HIV Case 

Counts and ELCs without Hold-harmless 

Change in Title I base funding if CDCaccepted HIV case counts and ELCs were 

used to distribute funding without holdharmless provision 

Change in Title I base funding if HIV case 

counts from all grantees and ELCs were 

used to distribute funding without holdharmless provisiona

Eligible metropolitan area Dollar changebPercent change Dollar changebPercent change

Orange County, Calif. -810,000 -31 -190,000 -7

Orlando, Fla. 1,190,000 30 570,000 14

Philadelphia, Pa. -2,620,000 -22 -3,750,000 -31

Phoenix, Ariz. 2,020,000 58 1,360,000 39

Ponce, P.R. -420,000 -29 -540,000 -38

Portland, Oreg. -580,000 -31 -90,000 -5

Riverside–San Bernardino, Calif. -1,190,000 -31 -170,000 -4

Sacramento, Calif. -500,000 -32 -330,000 -21

St. Louis, Mo. 1,120,000 47 830,000 34

San Antonio, Tex. 180,000 8 -100,000 -5

San Diego, Calif. -1,590,000 -31 800,000 15

San Francisco, Calif. -10,050,000 -62 -8,470,000 -52

San Jose, Calif. -440,000 -31 -30,000 -2

San Juan, P.R. -2,430,000 -30 -3,120,000 -38

Santa Rosa, Calif. -200,000 -33 -30,000 -5

Seattle, Wash. -930,000 -31 640,000 21

Tampa–St. Petersburg, Fla. 1,000,000 21 310,000 7

Vineland-Millville-Bridgeton, N.J. 130,000 28 60,000 12

West Palm Beach, Fla. 530,000 12 -80,000 -2

Sources: GAO analysis of CDC, HRSA, state, and local data. 

Notes: The estimated dollar and percent changes are based on what the EMAs actually received in 

their base grants, which includes hold-harmless funding, and what they would have received using 

HIV cases and ELCs if there had been no hold-harmless provision. Because hold-harmless funding is 

taken from amounts otherwise available for supplemental grants, the total funding actually allocated 

as base grants and our estimated funding differ by the amount of the hold-harmless funding 

($8,033,563). 

HRSA calculates a jurisdiction’s ELCs by using data from CDC on the reported AIDS case counts for 

the last 10 years and weighting those numbers to account for the likelihood of death. 

a

In some jurisdictions, HIV cases are collected by name while in others HIV cases are collected using 

a coded identifier. We used both name- and code-based case counts for this estimate. CDC only 

accepts name-based case counts as no code-based system has yet met its quality criteria. 

b

Rounded to nearest $10,000. 

c

Percent change that rounds to zero, but does not equal zero percent. 

Page 106 GAO-06-332 HIV/AIDS Funding
Appendix XII: Estimated CARE Act Title II 

Base Funding Changes from Use of HIV Case 

Counts and ELCs without Hold-harmless 

Change in Title II base funding if CDC-accepted 

HIV case counts and ELCs were used to 

distribute funding without hold-harmless and 

minimum-grant provisions 

Change in Title I base funding if HIV case 

counts from all grantees and ELCs were used to 

distribute funding without hold-harmless and 

minimum-grant provisionsa

Grantee Dollar changeb Percent change Dollar changeb Percent change

Alabama $2,550,000 63% $2,010,000 50%

Alaskac-270,000 -54 -290,000 -58

Arizona 1,220,000 38 810,000 25

Arkansas 870,000 49 650,000 37

California -11,750,000 -38 -4,980,000 -16

Colorado 2,100,000 99 1,700,000 81

Connecticut -1,360,000 -36 -1,410,000 -37

Delaware -740,000 -40 -220,000 -12

District of Columbia -1,520,000 -35 -1,800,000 -42

Florida 2,970,000 10 -110,000 0d

Georgia -3,530,000 -38 -4,060,000 -43

Hawaii -480,000 -40 -170,000 -14

Idahoc-80,000 -16 -110,000 -23

Illinois -3,200,000 -36 -60,000 -1

Indiana 1,210,000 32 810,000 21

Iowa 30,000 3 -40,000 -5

Kansas 210,000 21 110,000 11

Kentucky -940,000 -40 -1,060,000 -45

Louisiana 2,110,000 34 1,380,000 22

Mainec-210,000 -42 50,000 10

Maryland -3,020,000 -36 2,980,000 35

Massachusetts -1,910,000 -37 530,000 10

Michigan 1,180,000 27 680,000 16

Minnesota 650,000 64 490,000 48

Mississippi 1,630,000 49 1,220,000 37

Missouri 1,260,000 45 880,000 32

Montanac-390,000 -79 -170,000 -33

Nebraska 150,000 24 90,000 14

Nevada 840,000 50 600,000 36

New Hampshirec-310,000 -63 -120,000 -24

New Jersey 2,140,000 17 760,000 6

New Mexico 60,000 5 -50,000 -4

Appendix XII: Estimated CARE Act Title II 

Base Funding Changes from Use of HIV Case 

Counts and ELCs without Hold-harmless 

Page 107 GAO-06-332 HIV/AIDS Funding
Appendix XII: Estimated CARE Act Title II 

Base Funding Changes from Use of HIV Case 

Counts and ELCs without Hold-harmless 

Change in Title II base funding if CDC-accepted 

HIV case counts and ELCs were used to 

distribute funding without hold-harmless and 

minimum-grant provisions 

Change in Title I base funding if HIV case 

counts from all grantees and ELCs were used to 

distribute funding without hold-harmless and 

minimum-grant provisionsa

Grantee Dollar changebPercent change Dollar changebPercent change

New York -600,000 -1 -4,640,000 -11

North Carolina 5,030,000 68 4,020,000 54

North Dakotae-120,000 -62 -130,000 -65

Ohio 2,420,000 45 1,750,00 32

Oklahoma 1,010,000 49 760,000 37

Oregon -620,000 -37 -280,000 -17

Pennsylvania -2,320,000 -22 -3,080,000 -29

Puerto Rico -2,950,000 -36 -3,450,000 -42

Rhode Island -440,000 -40 -170,000 -15

South Carolina 2,370,000 35 1,620,000 24

South Dakotac-290,000 -58 -310,000 -62

Tennessee 2,250,000 36 1,550,000 25

Texas 870,000 5 -990,000 -5

Utah 110,000 10 10,000 1

Vermontc-370,000 -74 -260,000 -52

Virginia 2,370,000 40 1,620,000 27

Washington -1,170,000 -37 170,000 5

West Virginia 150,000 21 80,000 11

Wisconsin 940,000 51 710,000 39

Wyominge-90,000 -46 -100,000 -51

Sources: GAO analysis of CDC, HRSA, state, and local data. 

Notes: HRSA calculates a jurisdiction’s ELCs by using data from CDC on the reported AIDS case 

counts for the last 10 years and weighting those numbers to account for the likelihood of death. 

a

In some jurisdictions, HIV cases are collected by name while in others HIV cases are collected using 

a coded identifier. We used both name- and code-based case counts for this estimate. CDC only 

accepts name-based case counts as no code-based system has yet met its quality criteria. 

b

Rounded to nearest $10,000. 

c

State received a Title II base award of $500,000, the minimum it could receive based on the number 

of ELCs in the state. The estimated changes compare this amount with what the state would have 

received if HIV case counts and ELCs had been used to determine funding and if there had been no 

hold-harmless and minimum-grant provisions. 

d

Percent change that rounds to zero, but does not equal zero percent. 

e

State received a Title II base award of $200,000, the minimum it could receive based on the number 

of ELCs in the state. The estimated changes compare this amount with what the state would have 

received if HIV case counts and ELCs had been used to determine funding and if there had been no 

hold-harmless and minimum-grant provisions. 

Page 108 GAO-06-332 HIV/AIDS Funding
Appendix XIII: Estimated CARE Act ADAP 

Base Funding Changes from Use of HIV Case 

Counts and ELCs without Hold-harmless 

Page 109 GAO-06-332 HIV/AIDS Funding

Change in ADAP base funding if CDCaccepted HIV case counts and ELCs were 

used to distribute funding without holdharmless provision 

Change in ADAP base funding if HIV case 

counts from all grantees and ELCs were used 

to distribute funding without hold-harmless 

provisiona

Grantee Dollar changeb Percent change Dollar changeb Percent change

Alabama $5,190,000 74% $3,970,000 57%

Alaska -50,000 -10 -90,000 -19

Arizona 3,550,000 42 2,370,000 28

Arkansas 1,820,000 59 1,330,000 43

California -32,150,000 -36 -12,590,000 -14

Colorado 5,970,000 106 4,820,000 86

Connecticut -4,060,000 -36 -4,240,000 -38

Delaware -1,150,000 -36 -250,000 -8

District of Columbia -4,970,000 -36 -5,850,000 -42

Florida 10,400,000 13 1,390,000 2

Georgia -8,500,000 -36 -10,010,000 -42

Hawaii -750,000 -36 -210,000 -10

Idaho 310,000 68 240,000 51

Illinois -9,240,000 -36 -250,000 -1

Indiana 2,690,000 41 1,770,000 27

Iowa 140,000 10 -10,000 -1

Kansas 650,000 32 390,000 19

Kentucky -1,470,000 -36 -1,730,000 -42

Louisiana 5,440,000 39 3,530,000 26

Maine -300,000 -36 160,000 19

Maryland -9,240,000 -36 7,700,000 30

Massachusetts -5,270,000 -36 1,530,000 10

Michigan 3,150,000 29 1,740,000 16

Minnesota 1,910,000 63 1,420,000 47

Mississippi 3,410,000 60 2,490,000 43

Missouri 3,600,000 49 2,510,000 34

Montana -110,000 -36 300,000 95

Nebraska 360,000 32 210,000 19

Nevada 2,400,000 51 1,700,000 36

New Hampshire -270,000 -36 210,000 28

New Jersey 6,500,000 19 2,390,000 7

New Mexico 250,000 12 20,000 1

Appendix XIII: Estimated CARE Act ADAP 

Base Funding Changes from Use of HIV Case 

Counts and ELCs without Hold-harmless 
Appendix XIII: Estimated CARE Act ADAP 

Base Funding Changes from Use of HIV Case 

Counts and ELCs without Hold-harmless 

Change in ADAP base funding if CDCaccepted HIV case counts and ELCs were 

used to distribute funding without holdharmless provision 

Change in ADAP base funding if HIV case 

counts from all grantees and ELCs were used 

to distribute funding without hold-harmless 

provisiona

Grantee Dollar changebPercent change Dollar changebPercent change

New York -1,110,000 -1 -13,400,000 -11

North Carolina 10,190,000 79 7,900,000 62

North Dakota 50,000 57 40,000 41

Ohio 5,520,000 51 3,890,000 36

Oklahoma 2,100,000 59 1,540,000 43

Oregon -1,520,000 -36 -600,000 -14

Pennsylvania -6,540,000 -24 -8,540,000 -32

Puerto Rico -7,890,000 -35 -9,350,000 -41

Rhode Island -690,000 -36 -210,000 -11

South Carolina 5,190,000 44 3,510,000 30

South Dakota 180,000 90 150,000 71

Tennessee 4,880,000 46 3,330,000 31

Texas 3,440,000 7 -1,920,000 -4

Utah 330,000 18 110,000 6

Vermont -140,000 -36 50,000 14

Virginia 6,260,000 43 4,200,000 29

Washington -2,860,000 -36 720,000 9

West Virginia 380,000 29 210,000 16

Wisconsin 1,950,000 61 1,440,000 45

Wyoming 40,000 24 20,000 12

Sources: GAO analysis of CDC, HRSA, state, and local data. 

Notes: The ADAP base grant funding levels reported to us included any hold-harmless funding that 

would otherwise be used for ADAP Severe Need grants. The estimated dollar and percent changes 

presented here are based on what grantees received in their ADAP base grants without this holdharmless funding. 

HRSA calculates a jurisdiction’s ELCs by using data from CDC on the reported AIDS case counts for 

the last 10 years and weighting those numbers to account for the likelihood of death. 

a

In some jurisdictions, HIV cases are collected by name while in others HIV cases are collected using 

a coded identifier. We used both name- and code-based case counts for this estimate. CDC only 

accepts name-based case counts as no code-based system has yet met its quality criteria. 

b

Rounded to nearest $10,000. 

Page 110 GAO-06-332 HIV/AIDS Funding
Appendix XIV: Estimated HOPWA Base 

Funding Changes from Use of HIV and Living 

AIDS Case Counts, Fiscal Year 2004 

Change in HOPWA base funding if CDCaccepted HIV case counts and living AIDS 

case counts were used to distribute funding 

Change in HOPWA base funding if HIV case 

counts from all grantees and living AIDS case 

counts were used to distribute fundinga

Grantee Dollar changebPercent change Dollar changebPercent change

Alabama $1,150,000 101% $960,000 84%

Albany, N.Y. 80,000 18 30,000 8

Arizona 60,000 39 40,000 27

Arkansas 630,000 84 520,000 69

Atlanta, Ga. -1,160,000 -27 -1,420,000 -33

Augusta, Ga. 10,000 3 -20,000 -6

Austin, Tex. 70,000 7 -20,000 -2

Baltimore, Md. -1,170,000 -30 1,770,000 45

Baton Rouge, La. 470,000 71 370,000 56

Birmingham, Ala. 550,000 106 460,000 89

Boston, Mass. -650,000 -36 110,000 6

Bridgeport, Conn. -160,000 -21 -180,000 -24

Buffalo, N.Y. 30,000 6 -10,000 -3

California -1,150,000 -38 -600,000 -20

Cambridge, Mass. -200,000 -30 110,000 16

Camden, N.J. 180,000 27 110,000 16

Charleston, S.C. 290,000 72 230,000 57

Charlotte, N.C. 900,000 158 780,000 137

Chicago, Ill. -1,860,000 -33 -10,000 0c

Cincinnati, Ohio 200,000 36 130,000 24

Cleveland, Ohio 410,000 48 300,000 35

Colorado 350,000 97 290,000 80

Columbia, S.C. 600,000 96 490,000 80

Columbus, Ohio 360,000 61 280,000 48

Connecticut -60,000 -24 -70,000 -28

Dallas, Tex. 590,000 19 270,000 9

Delaware -40,000 -22 30,000 18

Denver, Colo. 1,210,000 85 990,000 69

Detroit, Mich. 270,000 17 110,000 7

District of Columbia -230,000 -4 20,000 0c

Florida -660,000 -16 -950,000 -23

Fort Lauderdale, Fla. 820,000 24 460,000 14

Fort Worth, Tex. 110,000 13 30,000 3

Appendix XIV: Estimated HOPWA Base 

Funding Changes from Use of HIV and Living 

AIDS Case Counts, Fiscal Year 2004 

Page 111 GAO-06-332 HIV/AIDS Funding
Appendix XIV: Estimated HOPWA Base 

Funding Changes from Use of HIV and Living 

AIDS Case Counts, Fiscal Year 2004 

Page 112 GAO-06-332 HIV/AIDS Funding

Change in HOPWA base funding if CDCaccepted HIV case counts and living AIDS 

case counts were used to distribute funding 

Change in HOPWA base funding if HIV case 

counts from all grantees and living AIDS case 

counts were used to distribute fundinga

Grantee Dollar changebPercent change Dollar changebPercent change

Gaithersburg, Md. -120,000 -22 190,000 35

Georgia -340,000 -23 -440,000 -29

Hartford, Conn. -220,000 -21 -230,000 -23

Hawaii -30,000 -17 10,000 5

Honolulu, Hawaii -160,000 -37 -70,000 -16

Houston, Tex. -260,000 -5 -660,000 -13

Illinois -190,000 -22 140,000 17

Indiana 470,000 56 360,000 43

Indianapolis, Ind. 420,000 56 320,000 42

Iowa 60,000 17 30,000 8

Islip, N.Y. -300,000 -18 -410,000 -25

Jackson, Miss. 450,000 99 370,000 82

Jacksonville, Fla. 290,000 24 160,000 14

Kansas 90,000 25 50,000 15

Kentucky -60,000 -13 -90,000 -21

Kansas City, Mo. 360,000 36 240,000 25

Las Vegas, Nev. 710,000 77 570,000 62

Los Angeles, Calif. -4,370,000 -42 -3,660,000 -35

Louisiana 580,000 62 460,000 49

Louisville, Ky. -40,000 -9 -80,000 -17

Maryland -70,000 -20 710,000 204

Massachusetts -160,000 -30 60,000 12

Memphis, Tenn. 940,000 102 780,000 85

Miami, Fla. 1,140,000 19 520,000 9

Michigan 370,000 41 270,000 29

Milwaukee, Wis. 340,000 66 260,000 52

Minneapolis, Minn. 350,000 42 250,000 30

Minnesota 60,000 56 50,000 43

Mississippi 630,000 84 520,000 68

Missouri 270,000 55 210,000 42

Nashville, Tenn. 680,000 93 560,000 77

Nevada 130,000 55 100,000 41

New Haven, Conn. -200,000 -21 -220,000 -24

New Jersey -770,000 -70 -800,000 -72

New Mexico 110,000 21 60,000 11
Appendix XIV: Estimated HOPWA Base 

Funding Changes from Use of HIV and Living 

AIDS Case Counts, Fiscal Year 2004 

Change in HOPWA base funding if CDCaccepted HIV case counts and living AIDS 

case counts were used to distribute funding 

Change in HOPWA base funding if HIV case 

counts from all grantees and living AIDS case 

counts were used to distribute fundinga

Grantee Dollar changebPercent change Dollar changebPercent change

New Orleans, La. 760,000 43 550,000 31

New York 300,000 17 130,000 7

New York, N.Y. -3,040,000 -9 -5,610,000 -17

Newark, N.J. 40,000 1 -330,000 -8

North Carolina 2,130,000 103 1,780,000 85

Oakland, Calif. -780,000 -39 -670,000 -33

Ohio 500,000 49 370,000 36

Oklahoma 430,000 83 350,000 67

Oklahoma City, Okla. 180,000 39 130,000 27

Orlando, Fla. 610,000 37 420,000 25

Pennsylvania -50,000 -4 -180,000 -12

Philadelphia, Pa. -730,000 -17 -1,040,000 -24

Phoenix, Ariz. 920,000 65 730,000 51

Pittsburgh, Pa. -120,000 -19 -160,000 -26

Portland, Oreg. -300,000 -30 -110,000 -11

Poughkeepsie, N.Y. -30,000 -5 -80,000 -13

Providence, R.I. -220,000 -27 40,000 5

Puerto Rico -1,080,000 -62 -1,130,000 -65

Richmond, Va. 490,000 71 390,000 57

Riverside, Calif. -380,000 -22 -90,000 -5

Rochester, N.Y. 170,000 29 110,000 18

Sacramento, Calif. -310,000 -37 -280,000 -33

St. Louis, Mo. 450,000 37 370,000 30

Salt Lake City, Utah 120,000 32 80,000 21

San Antonio, Tex. 100,000 10 0 d 1

San Diego, Calif. -820,000 -31 20,000 1

San Francisco, Calif. -3,950,000 -59 -3,420,000 -51

San Jose, Calif. -260,000 -33 -100,000 -13

San Juan, P.R. -1,990,000 -44 -2,210,000 -48

Santa Ana, Calif. -370,000 -26 -130,000 -9

Sarasota, Fla. 40,000 11 10,000 1

Seattle, Wash. -520,000 -31 170,000 10

South Carolina 1,040,000 75 840,000 61

Springfield, Mass. -150,000 -32 90,000 20

Tampa, Fla. 330,000 15 110,000 5

Page 113 GAO-06-332 HIV/AIDS Funding
Appendix XIV: Estimated HOPWA Base 

Funding Changes from Use of HIV and Living 

AIDS Case Counts, Fiscal Year 2004 

Change in HOPWA base funding if CDCaccepted HIV case counts and living AIDS 

case counts were used to distribute funding 

Change in HOPWA base funding if HIV case 

counts from all grantees and living AIDS case 

counts were used to distribute fundinga

Grantee Dollar changebPercent change Dollar changebPercent change

Tennessee 490,000 67 390,000 53

Texas 780,000 29 480,000 18

Tucson, Ariz. 210,000 53 160,000 40

Utah 30,000 26 20,000 15

Virginia 320,000 50 240,000 37

Virginia Beach, Va. 720,000 71 580,000 56

Wake County, N.C. 360,000 105 300,000 88

Warren, Mich. 120,000 31 80,000 20

Washington -160,000 -25 70,000 10

West Palm Beach, Fla. 270,000 14 80,000 4

Wilmington, Del. -70,000 -13 110,000 19

Wisconsin 220,000 54 170,000 41

Woodbridge, N.J. 50,000 4 -80,000 -5

Worcester, Mass. -90,000 -25 80,000 22

Sources: GAO analysis of CDC, HUD, state, and local data. 

Notes: The number of living AIDS cases was calculated by subtracting the number of reported deaths 

among AIDS cases in a jurisdiction from the number of reported cases. 

a

In some jurisdictions, HIV cases are collected by name while in others HIV cases are collected using 

a coded identifier. We used both name- and code-based case counts for this estimate. CDC only 

accepts name-based case counts as no code-based system has yet met its quality criteria. 

b

Rounded to nearest $10,000. 

c

Percent change that rounds to zero, but does not equal zero. 

d

Dollar change that rounds to zero, but does not equal zero. 

Page 114 GAO-06-332 HIV/AIDS Funding
Appendix XV: Comments from the Department Appendix XV: Comments from the of Health and Human Services 

Department of Health and Human Services 

Page 115 GAO-06-332 HIV/AIDS Funding
Appendix XV: Comments from the Department 

of Health and Human Services 

Page 116 GAO-06-332 HIV/AIDS Funding
Appendix XV: Comments from the Department 

of Health and Human Services 

Page 117 GAO-06-332 HIV/AIDS Funding
Appendix XV: Comments from the Department 

of Health and Human Services 

Page 118 GAO-06-332 HIV/AIDS Funding
Appendix XV: Comments from the Department 

of Health and Human Services 

Page 119 GAO-06-332 HIV/AIDS Funding
Appendix XVI: Comments from the 

Department of Housing and Urban Appendix XVI: Comments from the Development 

Department of Housing and Urban 

Development 

Page 120 GAO-06-332 HIV/AIDS Funding
Appendix XVI: Comments from the 

Department of Housing and Urban 

Development 

Page 121 GAO-06-332 HIV/AIDS Funding
Appendix XVI: Comments from the 

Department of Housing and Urban 

Development 

Page 122 GAO-06-332 HIV/AIDS Funding
Appendix XVI: Comments from the 

Department of Housing and Urban 

Development 

Page 123 GAO-06-332 HIV/AIDS Funding
Appendix XVI: Comments from the 

Department of Housing and Urban 

Development 

Page 124 GAO-06-332 HIV/AIDS Funding
Appendix XVI: Comments from the 

Department of Housing and Urban 

Development 

Page 125 GAO-06-332 HIV/AIDS Funding
Appendix XVI: Comments from the 

Department of Housing and Urban 

Development 

Page 126 GAO-06-332 HIV/AIDS Funding
Appendix XVII: GAO Contact and Staff Appendix XVII: GAO Contact and Staff Acknowledgments 

Acknowledgments 

HIV/AIDS Funding

Marcia Crosse, (202) 512-7119 or crossem@gao.gov GAO Contact 

In addition to the contact above, James McClyde, Assistant Director; 

Robert Copeland; Robert Dinkelmeyer; Louise Duhamel; Cathy Hamann; 

Opal Winebrenner; Craig Winslow; and Suzanne Worth made key 

contributions to this report. 

Acknowledgments 

Page 127 GAO-06-332 
Related GAO Products Related GAO Products 

Ryan White CARE Act: Factors that Impact HIV and AIDS Funding and 

Client Coverage. GAO-05-841T. Washington, D.C.: June 23, 2005. 

Ryan White CARE Act: Title I Funding for San Francisco. GAO/HEHS-00-

189R. Washington, D.C.: August 24, 2000. 

Ryan White CARE Act: Opportunities to Enhance Funding Equity. 

GAO/T-HEHS-00-150. Washington, D.C.: July 11, 2000. 

HIV/AIDS: Use of Ryan White CARE Act and Other Assistance Grant 

Funds. GAO/HEHS-00-54.Washington, D.C.: March 1, 2000. 

HIV/AIDS Drugs: Funding Implications of New Combination Therapies 

for Federal and State Programs. GAO/HEHS-99-2.Washington, D.C.: 

October 14, 1998. 

Revising Ryan White Funding Formulas. GAO/HEHS-96-116R. 

Washington, D.C.: March 26, 1996. 

Ryan White CARE Act of 1990: Opportunities to Enhance Funding 

Equity. GAO/HEHS-96-26. Washington, D.C.: November 13, 1995. 

Ryan White CARE Act: Access to Services by Minorities, Women, and 

Substance Abusers. GAO/T-HEHS-95-212. Washington, D.C.: July 17, 1995. 

Ryan White CARE Act of 1990: Opportunities Are Available to Improve 

Funding Equity. GAO/T-HEHS-95-126. Washington, D.C.: April 5, 1995. 

Follow-up on Ryan White Testimony. GAO/HEHS-95-119R. Washington, 

D.C.: March 31, 1995. 

Ryan White CARE Act of 1990: Opportunities Are Available to Improve 

Funding Equity. 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 to Services by Minorities, Women, and 

Substance Abusers. GAO/HEHS-95-49. Washington, D.C.: January 13, 1995. 

(290345) Page 128 GAO-06-332 HIV/AIDS Funding
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