GAO 

United States Government Accountability Office

Report to Congressional Committees

RYAN WHITE CARE

ACT 

Implementation of the 

New Minority AIDS 

Initiative Provisions 

March 2009 

GAO-09-315 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

March 2009

RYAN WHITE CARE ACT

Implementation of the New Minority AIDS Initiative 

Provisions 

Highlights of GAO-09-315, a report to 

congressional committees 

The Ryan White Comprehensive 

AIDS Resources Emergency Act of

1990 (CARE Act) makes federal 

funds available to assist individuals 

affected by HIV/AIDS. The

Department of Health and Human

Services’ (HHS) Health Resources

and Services Administration

(HRSA) awards CARE Act funding 

to grantees that include states, 

territories, and metropolitan areas.

Because minorities have been

disproportionately affected by

HIV/AIDS, the CARE Act’s Minority

AIDS Initiative (MAI) provides

funding through five parts (A, B, C,

D, and F) of the act with the goal of

reducing HIV-related health care

disparities among minorities. 

The reauthorization of CARE Act 

programs changed the process by

which HRSA awards MAI grants 

under Part A (funding for 

metropolitan areas) and Part B (for

states and territories) from a 

formula based solely on

demographics of the metropolitan 

area, state, or territory to a 

competitive process. The CARE 

Act requires GAO to report on MAI

and related issues. This report

provides information on (1) the

effect on grantees and service 

providers of the new competitive 

process for awarding Part A and B 

MAI funds, (2) the types of services 

grantees funded under MAI, and 

(3) barriers to minorities obtaining

services from HIV/AIDS programs 

that were identified by grantees. 

GAO surveyed CARE Act grantees

and interviewed selected grantee

and HRSA officials. GAO also 

reviewed Part A and B MAI 

applications. 

The new competitive process for Parts A and B altered MAI funding amounts 

from what they would have been under the old formula-based process, 

increased administrative requirements for grantees, and resulted in continued 

funding for existing initiatives to reduce health disparities for minorities. In 

determining the award amounts under the new process, HRSA considered the 

number of minorities with HIV/AIDS living in the grantee metropolitan area,

state, or territory, along with the MAI applications grantees were required to 

file. The quality of the grant applications sometimes resulted in considerable

differences in grantees’ share of MAI funds from what they would have 

received under the old process. Part A and B grantees that received MAI 

funding told us that the administrative requirements increased significantly 

because of the new process. All Part A and B grantees that applied for MAI 

funding received it, but some Part B grantees decided that the administrative 

requirements, including a separate application for MAI funds, were not worth 

the amount of funds that they expected to receive and therefore chose not to 

apply. Grantees generally funded the same service providers and initiatives to 

reduce minority health disparities as they had in prior years. 

After the reauthorization of CARE Act programs, MAI grantees continued to 

fund a range of core medical services, which include essential medical care 

services, and support services, which are services needed for individuals with 

HIV/AIDS to achieve their medical outcomes. Consistent with HRSA guidance, 

the types of services funded under MAI generally did not differ from services 

provided with other CARE Act funds. The five services Part A grantees funded 

most frequently were medical case management, outpatient and ambulatory 

health services, outreach services, substance abuse outpatient care, and 

mental health services—outreach services being the only support service 

among these. Part B grantees used MAI funds for efforts associated with the 

CARE Act-funded HIV/AIDS drug program, Part C and D grantees funded a 

range of core medical and support services with MAI funds, and Part F 

grantees used MAI funds for education efforts targeting health care 

professionals who are from, or primarily serve, minority communities. 

Grantees identified many barriers that make it more difficult for minorities to 

obtain services from HIV/AIDS programs, including those funded by the CARE 

Act. Barriers to HIV/AIDS care can delay or prevent individuals’ timely 

entrance into, or continuation of, core medical or support services, thus 

reducing the likely success of care. The barriers grantees identified included 

the presence of other diseases that impact immune systems, housing issues, 

and poverty. 

In commenting on this report, HHS suggested that we identify the law 

authorizing Ryan White programs as either Title XXVI of the Public Health 

Service Act (PHSA) or the Ryan White HIV/AIDS program. We continue to 

refer to the law authorizing Ryan White programs as the CARE Act, but have 

clarified that it refers to Title XXVI of PHSA. 

View GAO-09-315 or key components.

For more information, contact Marcia Crosse 

at (202) 512-7114 or crossem@gao.gov. 
Contents 

Letter 1

Background 6

The New Competitive Process for Parts A and B Altered MAI 

Funding Amounts, Increased Administrative Requirements for 

Grantees, and Generally Funded the Same Initiatives 13 

Grantees Fund a Range of Core Medical and Support Services 

under MAI 21 

MAI Grantees Identified Multiple Barriers to Minorities’ Access to 

the Services Provided by HIV/AIDS Programs 25 

Agency Comments and Our Evaluation 26 

Appendix I Grantees Reported Few Challenges to Program 

Integration 28 

Appendix II Objectives, Scope, and Methodology 30 

Appendix III Ryan White CARE Act Title I and II Funding for 

Fiscal Year 2006 and Part A and B Funding for 

Fiscal Year 2007 33 

Appendix IV Explanation of Barriers to Minorities Obtaining 

HIV/AIDS Services 43 

Appendix V Comments from the Department of Health and 

Human Services 48 

Appendix VI GAO Contact and Staff Acknowledgments 51 

Tables 

Table 1: Core Medical and Support Services Categories 7 

Page i GAO-09-315 Minority AIDS Initiative
Table 2: Ryan White CARE Act Part A MAI Grant Awards for Fiscal 

Year 2007: Award Amounts Received under the New 

Competitive Process Compared to Estimates of What 

Award Amounts Would Have Been under the Old FormulaBased Process 15 

Table 3: Ryan White CARE Act Part B MAI Grant Awards for Fiscal 

Year 2007: Award Amounts Received under the New 

Competitive Process Compared to Estimates of What 

Award Amounts Would Have Been under the Old FormulaBased Process 17 

Table 4: Core Medical and Support Services Funded by Ryan White 

CARE Act Part A Grantees in Fiscal Year 2007 under the 

Minority AIDS Initiative 23 

Table 5: Ten Barriers to Minorities in Obtaining HIV/AIDS Services 

Most Frequently Identified by Ryan White CARE Act 

Part A and B Minority AIDS Initiative Grantees 26 

Table 6: Ryan White CARE Act Title I Grant Awards and Minority 

AIDS Initiative (MAI) Grant Awards, Fiscal Year 2006 33 

Table 7: Ryan White CARE Act Part A Grant Awards and Minority 

AIDS Initiative (MAI) Grant Awards for Fiscal Year 2007, 

Including Percentage Change from Fiscal Year 2006 36 

Table 8: Ryan White CARE Act Title II Grant Awards and Minority 

AIDS Initiative (MAI) Grant Awards, Fiscal Year 2006 38 

Table 9: Ryan White CARE Act Part B Grant Awards and Minority 

AIDS Initiative (MAI) Grant Awards for Fiscal Year 2007, 

Including Percentage Change from Fiscal Year 2006 41 

Table 10: Barriers to Minorities in Obtaining HIV/AIDS Services 

Identified by Ryan White CARE Act Part A and B Minority 

AIDS Initiative (MAI) Grantees 43 

Figure 

Figure 1: Administration and Oversight of Ryan White CARE Act 

Minority AIDS Initiative (MAI) Funds 9 

Page ii GAO-09-315 Minority AIDS Initiative
Abbreviations 

ADAP AIDS Drug Assistance Program 

AETC AIDS education and training center 

AIDS acquired immunodeficiency syndrome 

CARE Act Ryan White Comprehensive AIDS Resources Emergency 

 Act of 1990 

CBO community-based organizations 

CDC Centers for Disease Control and Prevention 

EMA eligible metropolitan area 

HHS Department of Health and Human Services 

HIV human immunodeficiency virus 

HRSA Health Resources and Services Administration 

MAI Minority AIDS Initiative 

PHSA Public Health Service Act 

RFP request for proposal 

RWTMA Ryan White HIV/AIDS Treatment Modernization Act of 2006

SAMHSA Substance Abuse and Mental Health Services 

 Administration 

TGA transitional grant area 

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. The published product may be reproduced and distributed in its entirety 

without further permission from GAO. However, because this work may contain 

copyrighted images or other material, permission from the copyright holder may be 

necessary if you wish to reproduce this material separately. 

Page iii GAO-09-315 Minority AIDS Initiative
United States Government Accountability Office

Washington, DC 20548 

 

March 27, 2009 

The Honorable Edward M. Kennedy 

Chairman 

The Honorable Michael B. Enzi 

Ranking Member 

Committee on Health, Education, Labor, and Pensions 

United States Senate 

The Honorable Henry A. Waxman 

Chairman 

The Honorable Joe Barton 

Ranking Member 

Committee on Energy and Commerce 

House of Representatives 

Racial and ethnic minorities in the United States have been 

disproportionately affected by acquired immunodeficiency syndrome 

(AIDS) and human immunodeficiency virus (HIV) since the beginning of

the HIV/AIDS epidemic.1

 According to the most recent Centers for Disease 

Control and Prevention (CDC) data, 60 percent of all estimated AIDS cases 

since the beginning of the HIV/AIDS epidemic have been among racial and 

ethnic minorities and in 2006 racial and ethnic minorities represented 69

percent of AIDS cases and 67 percent of estimated new HIV infections. 

Since the first U.S. cases of what would become known as AIDS were 

reported in June 1981, over 1 million people in the United States have been 

infected with HIV, including almost 550,000 who have already died and 

over 1 million living with HIV/AIDS today. The Ryan White Comprehensive 

AIDS Resources Emergency Act of 1990 (CARE Act), administered by the 

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

Services Administration (HRSA), was enacted to address the needs of 

jurisdictions, health care providers, and people with HIV/AIDS and their 

family members.2 Total CARE Act grant funding was approximately 

 1

HIV is the virus that causes AIDS. In 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. 

2

Pub. L. No. 101-381, 104 Stat. 576 (codified as amended at 42 U.S.C. §§ 300ff through 300ff121). 

Page 1 GAO-09-315 Minority AIDS Initiative
 

$2.1 billion in fiscal year 2007.

3

 The Minority AIDS Initiative (MAI), first 

known as the Congressional Black Caucus Initiative, originated in fiscal 

year 1999 and it included the provision of funds to CARE Act grantees to 

reduce HIV-related disparities in access to health care and to improve 

health-related outcomes among racial and ethnic minority populations. 

Total MAI grant funding in fiscal year 2007 was approximately 

$131.2 million, representing 6 percent of overall CARE Act grant funding. 

Organizations that provide care to minorities living with HIV/AIDS have 

suggested that barriers exist for minorities in accessing HIV/AIDS services, 

which often make it more difficult for minorities living with HIV/AIDS to 

receive treatment and other HIV/AIDS services. Barriers to HIV/AIDS care 

can delay or prevent minorities’ timely entrance into, or continuation of, 

HIV/AIDS services, thus reducing the likely success of those services.4

The Ryan White HIV/AIDS Treatment Modernization Act of 2006 (RWTMA) 

reauthorized CARE Act programs for fiscal year 2007 through fiscal year 

2009 and included new provisions on MAI.5

 There are five primary sections 

of the CARE Act under which HRSA awards grants—Parts A, B, C, D, and 

F.6

 Together, grants made under these provisions annually fund services 

for approximately 500,000 people living with or affected by HIV/AIDS. 

CARE Act Part A provides for grants to selected metropolitan areas—

known as eligible metropolitan areas (EMA) and transitional grant areas 

(TGA)—that have been disproportionately affected by the HIV/AIDS 

 3

Unless otherwise indicated, references to the CARE Act are to Public Health Service Act

Title XXVI. 

4

We focus our discussion on how barriers to access to HIV/AIDS services affect minorities. 

However, research shows that many of the same barriers apply more generally to all 

individuals with HIV/AIDS. See, for example, Institute of Medicine, Public Financing and

Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White (Washington, D.C., 2005). 

Under the CARE Act, as amended, racial and ethnic minority populations include African

Americans, Alaska Natives, Latinos, American Indians, Asian Americans, Native Hawaiians, 

and Pacific Islanders. 

5

Pub. L. No. 109-415, § 603, 120 Stat. 2767, 2818. There was no specific statutory provision 

regarding the distribution of MAI funds prior to RWTMA. CARE Act programs were 

previously reauthorized by the Ryan White CARE Act Amendments of 1996 (Pub. L. 

No. 104-146, 110 Stat. 1346) and the Ryan White CARE Act Amendments of 2000 (Pub. L. 

No. 106-345, 114 Stat. 1319). 

6

The 1990 CARE Act added Title XXVI to the Public Health Service Act. Title XXVI, as 

enacted, contained several parts, which authorized various HIV/AIDS-related grants. Prior 

to the enactment of RWTMA, Parts A, B, C, D, and F of the CARE Act were referred to as 

Titles I, II, III, IV, and the AIDS Education and Training Centers, respectively. 

Page 2 GAO-09-315 Minority AIDS Initiative
 

epidemic.7 Part B provides for grants to states and territories to improve 

quality, availability, and organization of HIV/AIDS services. Part C provides 

for grants to public and private nonprofit entities to provide early 

intervention services, such as HIV testing and ambulatory care. Part D 

provides for grants to programs for family-centered comprehensive care to

children, youth, and women and their families. Part F provides for grants 

for demonstration and evaluation of innovative models of HIV/AIDS care 

delivery for hard-to-reach populations and training of health care 

providers. Part E does not provide for funding for HIV/AIDS services but

rather includes provisions to address various administrative functions. To

be eligible for MAI funds, grantees must also have received CARE Act 

Part A, B, C, D, or F funds. 

Grantees can arrange with service providers to offer essential medical 

care, referred to as core medical services, as well as support services 

needed to achieve positive medical outcomes. Grantees may also provide 

these services themselves. Grantees and service providers can include 

states, territories and associated jurisdictions, metropolitan areas, 

community-based organizations, and academic medical centers.8

Prior to the enactment of RWTMA, HRSA awarded Part A and B MAI funds 

to Part A and B grantees according to a formula that was solely based on

the demographic characteristics of the grantees’ jurisdictions out of funds 

otherwise available for Parts A and B;9

 those that received other Part A 

and Part B funds received MAI funds without having to file separate 

applications.

10 The CARE Act now requires HRSA to award MAI funds 

under Parts A and B according to a competitive process. Under this new 

 7

EMAs are areas that have a population of 50,000 persons or more and had a cumulative 

total of more than 2,000 new AIDS cases during the most recent 5-year period. TGAs are

areas that have a population of 50,000 persons or more and had a cumulative total of 1,000 

to 1,999 new AIDS cases during the most recent 5-year period. 

8

In this report, “grantees” refers to organizations or entities that receive funding directly 

from HRSA for CARE Act services, and “service providers” refers to organizations awarded 

contracts or subgrants from grantees to provide services or arrange for another 

organization to provide services. Grantees may also provide services to minorities living 

with HIV/AIDS themselves. Therefore, when we use “services,” we are referring to services 

provided by both grantees and their service providers. 

9

In this report, “formula-based process” refers to the process prior to the enactment of

RWTMA when the distribution of MAI funds was based solely on the number of minority

individuals with AIDS within the jurisdiction. 

10Prior to RWTMA, U.S. territories and associated jurisdictions did not receive MAI funding. 

Page 3 GAO-09-315 Minority AIDS Initiative
 

process, HRSA evaluates grantee applications for MAI funds in addition to

the demographic characteristics of the jurisdictions.11

The CARE Act requires us to report on MAI and related issues. In this 

report, we provide information on (1) the effect on grantees and service 

providers of the new competitive process for awarding Part A and B MAI 

funds, (2) the types of services grantees funded under MAI, and 

(3) barriers to minorities obtaining services from HIV/AIDS programs that 

were identified by grantees. The CARE Act also requires us to report on 

the challenges of integrating CARE Act–funded programs with HIV/AIDS 

programs funded from other sources, such as Medicaid, Medicare, CDC, 

and the Substance Abuse and Mental Health Services Administration. (See 

app. I for information on the challenges of HIV/AIDS program integration 

experienced by CARE Act grantees.) 

To determine the effect on grantees and service providers of the new 

competitive process for awarding Part A and B MAI funds, we conducted a 

Web-based survey of CARE Act fiscal year 2007 Part A and B grantees to 

learn how the grantees applied for funds, distributed funds to service 

providers, and provided oversight, and what services they provided prior

to and after the enactment of RWTMA.12 The survey response rates were 

about 77 percent (43 of 56) for Part A and about 81 percent (48 of 59) for 

Part B. Also, we created estimated funding amounts for Part A and B 

grantees based on the old formula-based process and analyzed the 

difference between these amounts and the actual funding for fiscal year 

2007. To create these estimated funding amounts, we reviewed CARE Act 

MAI funding data for fiscal years 2006 and 2007, case counts of minorities 

living with AIDS for fiscal year 2006, and case counts of minorities living 

with HIV/AIDS for fiscal year 2007, all of which were provided by HRSA. 

We used this information to assess the effect of the new competitive 

process on MAI funding. (See app. II for more information on the survey 

and how estimated funding amounts were determined.) To assess the 

validity of the funding amounts, we compared data we received from 

 11The way HRSA awards MAI funds under Parts C, D, and F remains unchanged. The Part 

C, D, and F MAI funds are awarded through a competitive process as a component of the

competitive grant award for the base parts C, D, and F.

12Fiscal year 2007 funds were the only fiscal year funds awarded under the new competitive 

application process when we began our work in January 2008. Each part of the Care Act

has its own defined fiscal year; for example, the fiscal year for Part A funding is March 1 to

February 28, and the fiscal year for Part B funding is April 1 to March 31, but the Part A and

Part B MAI fiscal year is August 1 to July 31. 

Page 4 GAO-09-315 Minority AIDS Initiative
 

HRSA to previously published funding amounts. We provided HRSA 

officials with a copy of our tables, and they agreed with our methodology. 

We determined that the funding data and case count data were sufficiently 

reliable for the purposes of this report. 

Additionally, we reviewed HRSA’s policies and reporting requirements 

under MAI for Part A and B grantees. We interviewed HRSA officials and 

staff from selected grantees for Parts A and B to determine how funds 

were distributed and how grantees provided oversight. We selected 

grantees to interview based on the amount of MAI funding they received

and their location to ensure geographic diversity. We also interviewed staff 

from national organizations with HIV/AIDS expertise, including the 

National Minority AIDS Council, Kaiser Family Foundation, the National 

Alliance of State and Territorial AIDS Directors, and the Communities 

Advocating Emergency AIDS Relief Coalition. 

To identify the types of services funded under MAI, we conducted a Webbased survey of Part A grantees, as described above, and interviewed 

selected Part A, B, C, D, and F grantees about services they provided 

under MAI prior to and after the enactment of RWTMA. There was no 

change in the process for awarding MAI funds under Parts C, D, and F, but 

we interviewed these grantees to learn about the services they funded. We 

reviewed HRSA’s policies, reporting requirements, and guidance for 

Parts A, B, C, D, and F, and we interviewed HRSA officials about 

implementation of MAI. Additionally, we reviewed Part A and B MAI 

competitive grant applications for fiscal year 2007. 

To identify the barriers to minorities obtaining services from HIV/AIDS 

programs that were identified by grantees, we reviewed Part A MAI and 

Part B MAI competitive grant applications for fiscal year 2007, which 

included grantees’ responses regarding barriers minorities face in 

accessing HIV/AIDS services. We interviewed staff from selected Part A, B,

C, D, and F grantees to better understand the barriers. We also interviewed 

staff from the organizations listed above. 

We conducted our work from January 2008 to February 2009 in 

accordance with all sections of GAO’s Quality Assurance Framework that

are relevant to our objectives. The framework requires that we plan and 

perform the engagement to obtain sufficient and appropriate evidence to 

meet our stated objectives and to discuss any limitations in our work. We 

believe that the information and data obtained, and the analysis 

conducted, provide a reasonable basis for any findings and conclusions. 

Page 5 GAO-09-315 Minority AIDS Initiative
 

MAI, a component of the CARE Act, provides for funds to eligible grantees 

with the goal of reducing HIV-related health disparities among minority 

populations. HRSA awards MAI grants to Part A, B, C, D, and F grantees 

through a competitive process. HRSA provides oversight of these grantees, 

while the grantees provide oversight of their service providers. 

HRSA primarily awards CARE Act funds to grantees for core medical 

services, support services, and education through five primary sections of 

the legislation—Parts A, B, C, D, and F. In fiscal year 2007, 22 EMAs and 34 

TGAs received grants under Part A; all 50 states, the District of Columbia, 

Puerto Rico, and 7 U.S. territories received grants under Part B;13 354 

public and private organizations that provide services directly to 

individuals with HIV received grants under Part C; and 90 public and 

private organizations that provide services to families in which at least one 

member is HIV positive received grants under Part D. For Parts A, B, C, 

and D, programs funded by the CARE Act are the payers of last resort for 

care.14 In addition, some Part B funds are used to provide medication for 

HIV/AIDS treatment through the AIDS Drug Assistance Program (ADAP) 

when annual appropriation laws provide funds exclusively for this 

purpose.15 Fifteen AIDS education and training centers (AETC), which 

provide HIV/AIDS education to health professionals such as nurses and 

physicians, received funding under Part F.16 For all parts of the CARE Act, 

grantees may use CARE Act funds to engage service providers that provide 

HIV/AIDS services to individuals. 

Background 

HRSA Administration of 

CARE Act Funding 

 13The seven U.S. territories and associated jurisdictions that received Part B funding in 

fiscal year 2007 were 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. 

14As the “payer of last resort,” the CARE Act pays for HIV/AIDS services that are not 

covered by other resources, such as Medicaid, Medicare, or private insurance. U.S.C. 

§§ 300ff-15(a)(6), 300ff-27(b)(7)(F), 300ff-64(f)(1). According to HRSA officials, Part D is a 

payer of last resort by operation of HRSA policy. 

1542 U.S.C. § 300ff-28(a)(2)(F). 

16There are 11 regional AETCs and 4 national AETCs, which are funded under Part F. One 

of the national centers is the National Minority AETC, which receives 100 percent of its

funding from MAI. 

Page 6 GAO-09-315 Minority AIDS Initiative
 

CARE Act funding for metropolitan areas, states, and territories is 

distributed in the form of base, supplemental, and MAI grants.17 CARE Act

grant funding totaled approximately $2.1 billion in fiscal year 2007; 

$131.2 million of that amount was MAI grants, representing 6 percent of 

overall CARE Act grants. Grantees under Parts A, B, and C must spend at 

least 75 percent of their grants for core medical services, while no more 

than 25 percent of these funds can be spent for support services.18 Table 1 

lists core medical service and support service categories. 

Table 1: Core Medical and Support Services Categories 

Core medical service categories Support service categories 

Outpatient and ambulatory health services Respite care for persons caring for 

persons living with HIV/AIDS 

ADAP treatments Outreach services 

AIDS pharmaceutical assistance Medical transportation

Oral health care Linguistics services 

Early intervention services Referrals for health care and 

supportive services 

Health insurance premium and cost-sharing 

assistance 

Home health care 

Medical nutrition therapy 

Hospice services 

Home and community-based health services

Mental health services 

Substance abuse outpatient care 

Medical case management 

Source: HRSA guidance.

Note: According to HRSA officials, HRSA guidance does not provide an exhaustive list of the core 

medical and support services that can be provided using CARE Act funds. 

 17Base funding, also known as formula funding, is awarded based on the number of people 

with HIV/AIDS living in the grantee’s jurisdiction, and supplemental funding is awarded on 

a competitive basis based on demonstrated need, including criteria such as HIV/AIDS 

prevalence. Base and supplemental funds are awarded separately from MAI funds. 

18According to HRSA application guidance for the Part A Minority AIDS Initiative Grant

Program (issued April 27, 2007), the 75 percent “core medical services” requirement applies

to MAI funds. However, an EMA/TGA could allocate and spend up to 100 percent of its MAI 

funds on support services so long as 75 percent of total Part A funding (base, supplemental, 

and MAI funding) is allocated and spent on core medical services. 

Page 7 GAO-09-315 Minority AIDS Initiative
 

In administering the CARE Act, HRSA issues guidance for applying for and 

spending MAI grants. HRSA requires MAI grantees to submit reports as a 

condition of their grant awards. The reports MAI grantees submit to HRSA 

summarize grantees’ MAI activities and include data on individuals served, 

services offered, budget allocations, and expenditures. For all parts of the 

CARE Act, HRSA provides oversight of grantees but expects grantees to 

provide oversight of service providers. (See fig. 1 for HRSA’s role in the 

administration and oversight of MAI funds.) 

Page 8 GAO-09-315 Minority AIDS Initiative
 

Figure 1: Administration and Oversight of Ryan White CARE Act Minority AIDS Initiative (MAI) Funds

Source: GAO analysis of HRSA guidance.

General area of HRSAd oversight 

$ MAI funds

States and 

territories

EMAs and

TGAsb

CARE Act 

Part

B

CARE Acta

Part

A

Outreach

providers

Core medical 

and support 

services

providers

MAI

grantees:

MAIfunded

service

providers:

c

Academic and

medical 

institutions

CARE Act

Part

F

Community

organizations

CARE Act 

Part

C

Community 

organizations

focused on women, 

children, and youth

CARE Act

Part

D

Core medical

and support

services

providers

Service providers 

can be funded through 

multiple CARE Act parts.

Sometimes MAI grantees also

function as service providers.

Training and

education

providers

Core medical 

and support 

services

providers

$ $

$ $ $ $ $

$ $ $

a

Ryan White Comprehensive AIDS Resources Emergency Act of 1990, as amended. 

b

EMAs are eligible metropolitan areas, TGAs are transitional grant areas. 

c

Service providers are organizations with which grantees contract or award subgrants to provide 

services or arrange to have another organization to provide services. 

d

Health Resources and Services Administration. 

Page 9 GAO-09-315 Minority AIDS Initiative
 

Federal grantees are required to comply with certain audit requirements 

based upon their total expenditures of federal funding and to submit 

certain reports at a frequency determined by the agency awarding the 

grant. HRSA requires CARE Act grantees to submit the following reports: 

Reporting Requirements 

for CARE Act Grantees 

• quarterly payment management reports, which include grantee spending 

for the previous 3-month period, and

• a financial status report, which is required within 90 days of the end of 

each grant year and accounts for expenditures under the project that year. 

Additionally, HRSA has grant-specific reporting requirements. For 

example, Part A and B grantees are required to submit the annual Ryan 

White HIV/AIDS Program Data Report, which requires grantees and their 

service providers to provide information on 

• the number of clients who have received services and demographic 

information about these clients, 

• the services provided by the grantees’ service providers, 

• the number of clients who received HIV counseling and testing, and 

• medical information about the clients who received services.

There are also MAI-specific reporting requirements. Each MAI grantee is

required to submit the Minority AIDS Initiative Report, which includes 

• the final annual MAI plan due within 90 days of the budget start date each 

year and 

• the annual progress report. 

Grantees that receive Part A and B MAI grants have some additional 

reporting requirements since the enactment of RWTMA. Since the 

enactment of RWTMA, Part A and B MAI grantees have been required to 

submit separate sets of the payment management reports and financial

status reports for their base and supplemental funding. 

Page 10 GAO-09-315 Minority AIDS Initiative
 

MAI grants were first distributed in conjunction with CARE Act funding in 

fiscal year 1999. RWTMA added provisions on MAI funding to the CARE 

Act, authorizing specific amounts for the purpose of carrying out activities 

to evaluate and address the disproportionate impact of HIV/AIDS on, and 

the disparities in access, treatment, care, and outcomes for, racial and 

ethnic minorities. The amount of CARE Act funds used for MAI grants has 

increased from $24 million in fiscal year 1999 to $131 million in fiscal year 

2007. 

According to HRSA officials, Part A and B MAI funds are to be used to 

expand the core medical and support services to minorities that might not 

otherwise be provided through the base funding. Part C, D, and F MAI 

funds are to be used to expand the number of individuals receiving 

services as these individuals may not otherwise be served by non-MAI 

funding. 

Prior to the enactment of RWTMA, the MAI funds for Part A and B 

grantees were awarded according to a formula that solely reflected the 

number of living minority AIDS cases in the metropolitan area, state, or 

territory receiving funds. These data are referred to as case counts. 

RWTMA changed how case counts are defined for other CARE Act 

programs to include living HIV cases. For Part A and B MAI grants, HRSA 

changed the case counts from the number of living minority AIDS cases to 

the number of living minorities with HIV/AIDS for the most recent year 

available as reported to CDC. 

The CARE Act requires HRSA to award Part A and B MAI grants using a 

competitive process. The Part A and B MAI applications, which are 

separate from Part A and B base and supplemental applications, require 

grantees to describe their local needs and the services they would provide

using MAI funds. HRSA continues to use minority case counts in 

determining MAI grant awards, but now does so in combination with 

application scores. HRSA officials reported that the agency calculates 

Part A and B MAI grant awards based on both the grantee’s application 

scores and the minority case count in the metropolitan area, state, or 

territory. HRSA application guidance outlines the points awarded for each

MAI Changes Resulting 

from RWTMA 

Page 11 GAO-09-315 Minority AIDS Initiative
 

section of the application,19 and the impact of a grantee’s performance in 

its completion of the application is demonstrated in the MAI funding the 

grantee receives. The CARE Act does not specifically require Part C, D, 

and F MAI grants to be awarded on a competitive basis or to be awarded 

separately from base funds under those parts. HRSA awarded MAI grants 

under these parts competitively, as a component of the competitive grant 

award for the base Parts C, D, and F. HRSA did this prior to the enactment 

of RWTMA and continues to do so. 

Barriers to HIV/AIDS care can delay or prevent individuals’ timely 

entrance into, or continuation of, core medical or support services, thus 

reducing the likely success of care. Research shows that minorities, in 

general, often receive a lower quality of health care and face barriers to 

obtaining health care, including services related to cancer screening, 

cardiovascular disease, diabetes, and HIV/AIDS.20 Barriers to HIV/AIDS 

care can include issues such as histories of substance abuse disorders or 

domestic violence. For example, research studies show that individuals 

living with HIV/AIDS who also have substance abuse disorders and are 

actively using substances are less likely to adhere to medical care.21

Barriers to care, such as lack of transportation to medical care or social 

stigma associated with HIV/AIDS, can also affect minority communities. 

For example, we have found in previous work that lack of transportation 

was found to delay, prevent, or interrupt HIV/AIDS treatment for American 

Indian and Alaska Native communities.22 HRSA required MAI applicants to 

Barriers to Care 

 19Application sections include demonstrated need (grantee description of the severity of 

the HIV/AIDS epidemic), impact (description of the use and success of previously funded 

MAI programs), evaluation (of progress toward program goals and client-level outcomes), 

resources, and administration (description of grantee administration and accountability) 

and the budget. 

20See Brian Smedley, Adrienne Y. Stith, and Alan R. Nelson, eds., Unequal Treatment: 

Confronting Racial and Ethnic Disparities in Health Care (Washington, D.C.: National 

Academies Press, 2003), and GAO, Health Care: Approaches to Address Racial and Ethnic

Disparities, GAO-03-862R (Washington, D.C.: July 8, 2003). 

21Gregory Lucas et al., “Detrimental Effects of Continued Drug Use on the Treatment of

HIV-1 Infection.” Journal of Acquired Immune Deficiency Syndromes, vol. 27, no. 3

(2001); Nancy Sohler et al., “Type and Pattern of Illicit Drug Use and Access to Health Care 

Services for HIV-Infected People,” AIDS Patient Care and STDs, vol. 21, supplement 1

(2007) and Chinazo O. Cunningham et al., “Type of Substance Use and Access to HIVRelated Health Care,” AIDS Patient Care and STDs, vol. 20, no. 6 (2006). 

22See GAO, Indian Health Service: HIV/AIDS Prevention and Treatment Services for 

American Indians and Alaska Natives, GAO-08-90 (Washington, D.C.: Dec. 14, 2007). 

Page 12 GAO-09-315 Minority AIDS Initiative
 

describe barriers to care for minorities in their jurisdictions as part of their

MAI applications. Eliminating or decreasing barriers is important to the 

delivery of comprehensive, integrated, quality HIV/AIDS services. 

The new competitive process for Parts A and B resulted in changes in the

amount of funding from what grantees would have received under the old 

formula-based process. Grantees that received MAI funding stated that the 

administrative requirements of the grant increased significantly in fiscal 

year 2007, and some grantees chose not to apply for MAI funds. Grantees 

continued funding existing initiatives to reduce health disparities for 

minorities rather than funding new initiatives, and grantees generally

provided funding to the same service providers as they had in prior years. 

The new MAI competitive process resulted in funding amounts that 

differed from what grantees would have received under the old formulabased process that based funding solely on minority case counts. All 

Part A and B grantees that applied for MAI funds in fiscal year 2007 

received MAI funding.23 However, since RWTMA changed the process by 

which MAI funds were awarded, some grantees’ MAI grant amounts 

differed from what they would have been awarded under the previous 

formula-based process. 

Prior to RWTMA, a Part A or B grantee’s MAI funding was based on its 

share of minority AIDS cases relative to the total number of minority AIDS 

cases in all metropolitan areas or states and territories eligible for funds, 

and a competitive application was not required. For example, if a Part A 

grantee’s minority case count accounted for 4 percent of the total number 

of minority AIDS cases in all eligible metropolitan areas, that grantee 

would receive 4 percent of the total available Part A MAI funds. The new 

competitive MAI process, as implemented by HRSA, considers the 

The New Competitive 

Process for Parts A 

and B Altered MAI 

Funding Amounts, 

Increased 

Administrative 

Requirements for 

Grantees, and 

Generally Funded the 

Same Initiatives 

The New Competitive 

Process Resulted in 

Changes in the Amount of 

Funding from What 

Grantees Would Have 

Received under the Old 

Formula-Based Process 

 23HRSA officials informed us that one state applied for and was allocated Part B MAI

funding in fiscal year 2007 but returned the funding. 

Page 13 GAO-09-315 Minority AIDS Initiative
 

minority case count in determining a grantee’s MAI award, but does so in 

conjunction with the grantee’s MAI application score. Because a grantee’s 

MAI application score is considered along with the number of HIV/AIDS 

cases in the metropolitan area, state, or territory, there is no longer a oneto-one relationship between an applicant’s proportion of cases and its 

proportion of MAI grant funding. As a result, we found differences 

between the amounts many grantees would have received under the old 

formula-based process and the amounts they received under the new 

competitive process. For example, in fiscal year 2007, Phoenix received 

$127,578 (39.8 percent) less than it would have received under the old 

formula, while Houston received $154,018 (10.9 percent) more. In addition, 

in some cases we found that grantees with a lower number of HIV/AIDS 

cases received more funding under MAI than grantees with a higher 

number of HIV/AIDS cases because of their competitive scores. Table 2 

shows Part A MAI grantees’ fiscal year 2007 funding levels under the 

competitive process, and an estimate of what each grantee’s funding level 

would have been under the old formula-based process. For Part A MAI, 30 

of the 56 grantees received lower funding amounts under the new 

competitive process than they would have under the old formula-based 

process. The median difference for all Part A grantees between the actual 

fiscal year 2007 funding and the estimated funding based on the old 

formula-based process was a loss of $3,053. Because of their competitive

scores, 20 Part A grantees experienced changes of greater than 10 percent 

of what they would have received under the old formula-based process. 

Page 14 GAO-09-315 Minority AIDS Initiative
 

Table 2: Ryan White CARE Act Part A MAI Grant Awards for Fiscal Year 2007: Award Amounts Received under the New 

Competitive Process Compared to Estimates of What Award Amounts Would Have Been under the Old Formula-Based 

Process 

EMA/TGA 

Actual FY 2007 MAI 

funding

Estimated FY 2007 

MAI under the

formula-based

process

Difference 

between actual 

and estimated

Percentage

difference between

actual and estimated

Atlanta, Ga. $1,050,229 $1,176,644 $-126,415 -10.7

Austin, Tex. 229,065 208,591 20,474 9.8

Baltimore, Md. 2,100,038 1,925,202 174,836 9.1

Baton Rouge, La. 249,059 327,938 -78,879 -24.1

Bergen-Passaic, N.J. 287,493 310,872 -23,379 -7.5

Boston, Mass. 814,862 802,602 12,260 1.5

Caguas, P.R. 121,984 125,629 3,645 -2.9

Charlotte-Gastonia-Concord, N.C.-S.C. 371,535 391,582 -20,047 -5.1

Chicago, Ill. 1,787,310 1,983,038 -195,728 -9.9

Cleveland, Ohio 316,520 298,191 18,329 6.1

Dallas, Tex. 772,577 833,772 -61,195 -7.3

Denver, Colo. 275,492 282,665 -7,173 -2.5

Detroit, Mich. 644,567 662,988 -18,421 -2.8

Dutchess County, N.Y. 103,571 96,710 6,861 7.1

Fort Lauderdale, Fla. 1,113,452 1,055,045 58,407 5.5

Fort Worth, Tex. 204,310 217,243 -12,933 -6.0

Hartford, Conn. 252,944 255,406 -2,462 -1.0

Houston, Tex. 1,571,727 1,417,709 154,018 10.9

Indianapolis, Ind. 189,079 180,858 8,221 4.5

Jacksonville, Fla. 393,745 387,434 6,311 1.6

Jersey City, N.J. 417,858 394,308 23,550 6.0

Kansas City, Mo. 187,284 194,251 -6,967 -3.6

Las Vegas, Nev. 225,918 266,546 -40,628 -15.2

Los Angeles, Calif. 2,528,561 2,441,109 87,452 3.6

Memphis, Tenn. 556,225 533,330 22,895 4.3

Miami, Fla. 2,565,107 2,374,858 190,249 8.0

Middlesex-Somerset-Hunterdon, N.J. 165,169 189,154 -23,985 -12.7

Minneapolis-St. Paul, Minn. 264,702 237,865 26,837 11.3

Nashville, Tenn. 207,441 234,902 -27,461 -11.7

Nassau-Suffolk, N.Y. 325,286 341,568 -16,282 -4.8

New Haven, Conn. 321,657 385,657 -64,000 -16.6

New Orleans, La. 541,807 559,522 -17,715 -3.2

Page 15 GAO-09-315 Minority AIDS Initiative
 

EMA/TGA 

Actual FY 2007 MAI 

funding

Estimated FY 2007 

MAI under the

formula-based

process

Difference 

between actual 

and estimated

Percentage

difference between

actual and estimated

New York, N.Y. 9,347,777 8,494,045 853,732 10.1

Newark, N.J. 1,284,886 1,267,191 -17,695 -1.4

Norfolk, Va. 379,699 459,967 -80,268 -17.5

Oakland, Calif. 392,080 421,923 -29,843 -7.1

Orange County, Calif. 292,945 282,902 10,043 3.6

Orlando, Fla. 578,713 551,937 26,776 4.9

Philadelphia, Pa. 1,682,127 1,627,841 54,286 3.3

Phoenix, Ariz. 193,368 320,946 -127,578 -39.8

Ponce, P.R. 153,098 200,176 -47,078 -23.5

Portland, Oreg. 78,536 77,155 1,381 1.8

Riverside-San Bernadino, Calif. 255,733 326,398 -70,665 -21.6

Sacramento, Calif. 97,469 98,488 -1,019 -1.0

San Antonio, Tex. 264,661 303,050 -38,389 -12.7

San Diego, Calif. 543,389 514,248 29,141 5.7

San Francisco, Calif. 652,491 608,114 44,377 7.3

San Jose, Calif. 137,156 147,436 -10,280 -7.0

San Juan, P.R. 741,100 1,086,333 -345,233 -31.8

Santa Rosa, Calif. 50,000a25,244 24,756 98.1

Seattle, Wash. 234,009 212,384 21,625 10.2

St. Louis., Mo. 378,174 352,353 25,821 7.3

Tampa-St. Petersburg, Fla. 525,592 498,367 27,225 5.5

Vineland-Millville-Bridgeton, N.J. 68,510 79,762 -11,252 -14.1

Washington, D.C. 1,976,712 2,345,939 -369,227 -15.7

West Palm Beach, Fla. 576,631 646,040 -69,409 -10.7

Total $42,041,430

Sources: HRSA and GAO analysis of HRSA data.

Note: In calculating the estimated funding amounts, we held the total funding allocated for fiscal year 

2007, $42,041,430, constant. We did not adjust funding amounts to reflect the minimum grant awards

set in fiscal year 2007 because these were not in place when the formula grants were awarded. 

a

Santa Rosa, California, received the minimum grant award of $50,000. The maximum grant award 

was set at $10,750,000; however, no grantee qualified for the maximum. 

Table 3 shows Part B MAI grantees’ fiscal year 2007 funding levels under 

the competitive process and an estimate of what each grantee’s funding 

level would have been under the old formula-based process. For Part B 

MAI, 20 of the 29 grantees that applied for funding received higher funding 

amounts under the new competitive process than they would have under 

Page 16 GAO-09-315 Minority AIDS Initiative
 

the old formula-based process. For these Part B grantees, the median 

difference between the actual fiscal year 2007 funding and the estimated 

funding based on the old formula-based process was a gain of $2,779. (See 

app. III for a comparison of the fiscal year 2006 and fiscal year 2007 Part A 

and B MAI funding amounts and MAI as a proportion of total funding.) 

Because of their competitive scores, 20 Part B grantees experienced 

changes of greater than 10 percent of what they would have received

under the old formula-based process. 

Table 3: Ryan White CARE Act Part B MAI Grant Awards for Fiscal Year 2007: Award Amounts Received under the New 

Competitive Process Compared to Estimates of What Award Amounts Would Have Been under the Old Formula-Based 

Process 

State/territory

Actual FY 2007 

MAI fundinga

Estimated FY 2007 MAI 

under the formulabased processDifference between

actual and estimated 

Percentage difference 

between actual 

and estimated

Alabama $109,917 $87,480 $22,437 25.6

Alaska 4,412 3,390 1,022 30.1

Arizona – 53,634 – –

Arkansas – 27,664 – –

California 856,348 658,233 198,115 30.1

Colorado 36,113 43,562 -7,449 -17.1

Connecticut 83,285 81,697 1,588 1.9

Delaware 4,360 28,134 -23,774 -84.5

District of Columbia 204,224 157,311 46,913 29.8

Florida 1,087,726 811,755 275,971 34.0

Georgia 267,205 225,945 41,260 18.3

Hawaii – 7,465 – –

Idaho – 1,610 – –

Illinois 72,966 270,518 -197,552 -73.0

Indiana – 44,260 – –

Iowa 8,377 5,598 2,779 49.6

Kansas – 12,564 – –

Kentucky – 17,693 – –

Louisiana 140,731 149,946 -9,215 -6.1

Maine 2,500 1,553 947 61.0

Maryland 304,838 323,141 -18,303 -5.7

Massachusetts – 113,893 – –

Michigan 141,887 106,968 34,919 32.6

Minnesota 26,875 32,679 -5,804 -17.8

Page 17 GAO-09-315 Minority AIDS Initiative
 

State/territory

Actual FY 2007 

MAI fundinga

Estimated FY 2007 MAI 

under the formulabased process

Difference between

actual and estimated 

Percentage difference 

between actual 

and estimated

Mississippi – 78,762 – –

Missouri 69,743 65,899 3,844 5.8

Montana – 399 – –

Nebraska – 7,564 – –

Nevada – 36,283 – –

New Hampshire – 3,390 – –

New Jersey 414,015 350,235 63,780 18.2

New Mexico – 15,955 – –

New York 1,476,866 1,216,350 260,516 21.4

North Carolina – 200,047 – –

North Dakota – 556 – –

Ohio 62,201 99,461 -37,260 -37.5

Oklahoma 20,313 21,610 -1,297 -6.0

Oregon 14,031 10,898 3,133 28.8

Pennsylvania – 152,311 – –

Puerto Rico 142,792 213,509 -70,717 -33.1

Rhode Island – 8,832 – –

South Carolina 177,810 146,185 31,625 21.6

South Dakota – 1,567 – –

Tennessee 130,743 106,925 23,818 22.3

Texas 597,547 480,622 116,925 24.3

Utah – 7,664 – –

Vermont – 527 – –

Virginia 203,896 164,590 39,306 23.9

Washington 34,333 36,240 -1,907 -5.3

West Virginia – 6,211 – –

Wisconsin 41,046 31,767 9,279 29.2

Wyoming – 541 – –

Guam – 1,097 – –

Virgin Islands – 6,738 – –

American Samoa – 28 – –

Marshall Islands – 14 – –

North Marianas – 57 – –

Republic of Palau – – – –

Page 18 GAO-09-315 Minority AIDS Initiative
 

State/territory

Actual FY 2007 

MAI fundinga

Estimated FY 2007 MAI 

under the formulabased process

Difference between

actual and estimated 

Percentage difference 

between actual 

and estimated

Federated States of Micronesia 2,500b71 2,429 3409.9

Total $6,739,600

Sources: HRSA and GAO analysis of HRSA data.

Note: In calculating the estimated funding amounts, we held the total funding allocated for fiscal year 

2007, $6,739,600, constant. We did not adjust funding amounts to reflect the minimum grant awards

set in fiscal year 2007 because these were not in when the formula grants were awarded. 

a

States that did not apply for funding in fiscal year 2007 have a dash. No difference between actual 

and estimated or percentage difference between actual and estimated was calculated for these 

states. 

b

The Federated States of Micronesia received the minimum grant award of $2,500. No maximum 

grant award was set. 

The New Competitive 

Process Increased the 

Administrative 

Requirements for 

Grantees, and Some 

Grantees Chose Not to 

Apply for MAI Funds 

Many MAI grantees said that the new competitive process increased their 

administrative requirements. Part A and B grantees that applied for MAI 

grants in fiscal year 2007 reported that the new MAI grant application and 

reporting requirements are time-consuming and duplicative of the 

requirements for the Part A and Part B base and supplemental funding. 

Prior to the implementation of the MAI competitive process, grantees 

answered a few MAI-related questions on their base and supplemental 

applications. However, the amount of funding a grantee received was 

based on the grantee’s number of AIDS cases relative to the overall 

number of AIDS cases among all grantees, not its responses to these 

questions. 

Several grantees we interviewed that did apply and received MAI grants 

stated that the administrative requirements increased significantly with the 

new competitive process. Grantees explained that integrating the Part A 

and Part B base funding program activities with MAI activities has become 

difficult because under the new process, these activities must be reported

separately. Reporting on MAI activities has also been made substantially 

more difficult because of HRSA’s designation of different fiscal years for 

different CARE Act grant programs. The fiscal year for Part A base and 

supplemental funding is March 1 to February 28. For Part B base and 

supplemental funding the fiscal year is April 1 to March 31. The Part A and 

Part B MAI fiscal year is August 1 to July 31.24 Some grantees said that the

 24HRSA officials said that they changed the beginning and ending dates of the MAI fiscal 

year for 2007 so that HRSA could complete the new guidance necessitated by the changes

made by RWTMA. 

Page 19 GAO-09-315 Minority AIDS Initiative
 

separate fiscal years increased their administrative requirements. For 

example, one grantee told us that the separate reporting and different 

fiscal years act as an “artificial separation” of funding for services to the 

same client population. While grant guidance states that “HRSA expects 

grantees to implement and administer MAI-funded services and activities 

in a manner that is consistent with the Part A and Part B programs,”25 some

grantees stated that the different funding cycles make such integration 

difficult. Many grantees also explained that the separate applications and 

different funding cycles complicated the contracting process, thus 

requiring them to write more contracts, file more reports, and conduct 

additional monitoring without extra funding for this added administration. 

In addition, HRSA officials explained that some states and territories did 

not apply for MAI funding because in past years they had received 

relatively small amounts of funding, and would have to undergo increased 

requirements because of the new competitive application process to 

receive that funding in fiscal year 2007. In total, 22 states and territories 

that were Part B grantees in fiscal year 2006 chose not to apply for MAI in 

fiscal year 2007. Grantees that chose to apply in fiscal year 2007 received 

MAI funding that amounted to less than 1 percent of their total Part B 

funding (see app. III for funding tables for total CARE Act awards for 

Part B grantees). Moreover, some grantees explained that they only had 

about a month to complete the MAI application after new application 

guidance was issued, which they did not consider to be enough time to 

prepare the application. In addition, one grantee we interviewed also 

explained that the narrow scope of Part B MAI funding, that is, that it 

could only be used for ADAP-related outreach and education services, also

made it less likely to apply. As indicated in table 3, because there was a 

fixed amount of funding and fewer applications were received, there were 

more MAI funds available to each grantee that submitted an application.

The New Competitive 

Process Generally 

Resulted in the Funding of 

the Same Initiatives 

Some Part A and B grantees reported that they have continued to fund the 

same initiatives to reduce minority health disparities that they did prior to

the implementation of the new MAI competitive process. Grantees we 

interviewed whose fiscal year 2007 MAI funding increased from the 

previous year stated that they funded their service providers to continue 

 25Department of Health and Human Services, Health Resources and Services 

Administration, Part A Minority AIDS Initiative Grant Program: Application Guidance 

for New Competing Discretionary Grants, HRSA Announcement No. 07-135 (Washington,

D.C., 2007). 

Page 20 GAO-09-315 Minority AIDS Initiative
 

funding existing initiatives to reduce health disparities for minorities. 

Some grantees whose fiscal year 2007 MAI funding decreased from the 

prior year reported to us that they reduced or eliminated the amount of 

funding they awarded to service providers. One grantee reported that a 

service provider the grantee had intended to fund declined to provide 

services because the service provider lacked the resources needed to

comply with MAI reporting requirements. 

Part A grantees generally used the same request for proposal (RFP) 

process to select service providers under the new MAI competitive 

process as they had used before.26 Of the 43 Part A grantees that responded 

to our survey, 33 stated that they used an RFP selection process to choose 

service providers in the first year under the new competitive process, and 

35 stated that they used an RFP prior to RWTMA. Of the 8 grantees that 

did not use an RFP process, 5 generally stated that they did not need RFPs

in the first year of the change to the new competitive process because they

used an RFP process in an earlier year to select service providers and 

awarded multiple-year contracts. 

Most of the Part B grantees that responded to our survey changed how 

they selected service providers after the switch to a competitive process. 

While 20 out of 44 Part B survey respondents that received MAI funding 

before the change to the new competitive process used an RFP to select 

service providers, only 7 out of 26 Part B survey respondents that received 

MAI funding after the change used an RFP process to select service 

providers. Some grantees stated that they provided funding to one or two 

organizations with which they were familiar, applied the funds to existing 

contracts, or used the funds themselves, instead of issuing an RFP. 

MAI grantees under all parts of the CARE Act reported funding a range of 

core medical and support services using MAI funds. These services can be

provided either directly by the grantees or through service providers. We 

found that Part A grantees generally used MAI funds to fund services 

similar to those funded through base or supplemental grants. This is in 

accordance with HRSA’s guidance, which states that it is appropriate to 

implement similar types of services using MAI and base and supplemental

Part A funds. Only rarely did Part A grantees use MAI funds exclusively to

Grantees Fund a 

Range of Core 

Medical and Support 

Services under MAI 

 26We use “request for proposal” (RFP) to describe all forms of solicitation whether they are

used in conjuction with the award of contracts or subgrants.

Page 21 GAO-09-315 Minority AIDS Initiative
 

fund a specific type of service, such as outreach to minority individuals or

nonmedical case management not otherwise supported with CARE Act 

funds. Some Part A grantees reported that they take a coordinated 

approach to the prioritization and expenditure of base, supplemental, and 

MAI funds. 

Part A grantees reported funding a range of core medical and support 

services under MAI. According to our survey, four of the top five services 

most commonly funded in fiscal year 2007 were categorized as core 

medical services—medical case management, outpatient and ambulatory 

health services, substance abuse outpatient care, and mental health 

services. (See table 4.) Outreach was the only support service among the 

top five most commonly funded services.27 In addition, nine Part A 

grantees responded that they funded a range of services other than those 

listed in our survey, including early intervention services, residential 

substance abuse treatment, and psychosocial support. 

 27According to HRSA, CARE Act outreach services help to identify persons at high risk for 

HIV infection and to bring HIV-infected persons into care. Outreach services include 

services to both HIV-infected persons who know their status and are not in care and HIVinfected persons who do not know their status and are not in care. 

Page 22 GAO-09-315 Minority AIDS Initiative
 

Table 4: Core Medical and Support Services Funded by Ryan White CARE Act 

Part A Grantees in Fiscal Year 2007 under the Minority AIDS Initiative 

Services 

Grantees providing

services (of 43)

Core medical 

Medical case management 29

Outpatient and ambulatory health services 24

Substance abuse outpatient care 12

Mental health services 12

AIDS pharmaceutical assistance 8

HIV counseling and testing 5

Oral health 5

Medical nutrition therapy 4

Home health care 1

Support 

Outreach services 16

Case management (nonmedical) 10

Medical transportation 7

Housing services 6

Referrals to health care/supportive services 4

Emergency financial assistance 2

Food bank 2

Legal services 2

Child care 1

Family advocacy 1

Health insurance premium and cost-sharing assistance 1

Home and community-based health services 1

Linguistic services 1

Source: GAO analysis of survey data. 

Note: In our survey, the list of services that a grantee could potentially provide was based on 

information obtained from grantee applications. 

Similar to Part A grantees, Part C and D grantees used MAI funding for a 

range of core medical and support services, while Part B and F grantees 

used MAI funding for specific services designated by the MAI provisions in 

the CARE Act. In interviews, Part C and D MAI grantees generally reported 

funding core medical and support services based on their clients’ needs as

well as their organizational missions. For example, five Part D MAI 

grantees reported focusing their services on the needs of women and 

Page 23 GAO-09-315 Minority AIDS Initiative
 

youth, including offering child care services and targeted case 

management. The CARE Act restricts the use of Part B MAI funds to 

efforts related to increasing the number of minorities in ADAP. Part F MAI 

grantees told us that they use MAI funds for education efforts targeting 

health care professionals who are from, or primarily serve, minority 

communities. These education efforts are similar to services they fund 

using other CARE Act grants. 

Some MAI grantees reported changing the mix of services they funded 

from fiscal year 2005 through fiscal year 2007. Grantees we interviewed 

said that they changed the mix of services they funded to comply with the 

requirement added by RWTMA that at least 75 percent of grant funding be

spent for core medical services. Among the 43 respondents to our survey 

of Part A grantees, the number of MAI grantees funding medical case 

management more than doubled from fiscal year 2005 through fiscal year 

2007, while the number funding nonmedical case management decreased 

by a third.28 In addition, Part A grantees indicated changes in the types of 

support services they funded from fiscal year 2005 through fiscal year 

2007. Survey results showed increases in the number of grantees providing 

referrals to health care services and transportation services and a decrease 

in the number providing outreach services. Some Part A grantees reported

that since the enactment of RWTMA, they have had to curtail support 

services such as housing, emergency financial assistance, and client 

advocacy as well as capacity building in historically underrepresented 

communities. Furthermore, in interviews, some grantees reported 

changing the types of services they funded as a result of RWTMA’s 

enactment. For example, two grantees, one Part A and one Part B, 

reported changing existing case management services to fit within the 

medical case management definition, which includes, for example, the 

coordination and follow-up of medical treatments. 

 28According to HRSA, nonmedical case management includes the provision of advice and

assistance in obtaining medical, social, community, legal, financial, and other needed

services. It does not involve coordination and follow-up of medical treatments as medical 

case management does. 

Page 24 GAO-09-315 Minority AIDS Initiative
 

MAI grantees identified multiple barriers that make it difficult for 

minorities to obtain services through HIV/AIDS programs.29 Similar to the 

barriers minorities face, in general, in obtaining health care, these barriers 

present challenges for individuals in obtaining HIV/AIDS services that may

not only prevent or delay entry into care but could also decrease 

adherence to treatment.30 Barriers to minorities’ access to HIV/AIDS 

services are often interconnected and include issues such as a lack of 

transportation to HIV/AIDS services, mistrust of service providers, lacking

or insufficient insurance, homelessness, poverty, and language issues. 

Language issues, for example, suggest the need for the linguistic services 

of an interpreter or translated materials to receive HIV/AIDS services. If a

minority must overcome language issues in order to receive HIV/AIDS 

services and cannot do so, then these issues become a barrier to obtaining

HIV/AIDS services. Complications for care, such as comorbidities, also 

were reported as barriers to minorities obtaining HIV/AIDS services.31

MAI Grantees 

Identified Multiple 

Barriers to Minorities’ 

Access to the Services 

Provided by HIV/AIDS 

Programs 

We found that Part A and B grantees generally identified similar barriers in 

their MAI applications. Table 5 shows the 10 barriers to minorities 

obtaining HIV/AIDS services most frequently identified by Part A and B 

MAI grantees. They identified co-morbidities, housing issues, and poverty 

as the top three barriers to care, with at least 8 out of 10 grantees 

identifying each barrier. Co-morbidities can include hypertension, mental 

illness, sexually transmitted infections/diseases, and tuberculosis. 

Unstable housing can prevent minorities with HIV/AIDS from accessing 

health care and adhering to complex HIV/AIDS treatments because they 

often must attend to more immediate needs, such as obtaining food and 

shelter. Poverty, defined by the federal government according to income 

thresholds that vary by family size and composition, can have similar 

implications. Appendix IV provides descriptions and a more complete list 

of barriers identified by Part A and B grantees in their fiscal year 2007 MAI 

competitive grant applications. 

 29We focus our discussion on barriers to minorities in obtaining HIV/AIDS services. 

However, research shows that many of the same barriers apply more generally to all 

individuals with HIV/AIDS. 

30Our recent work found that barriers to access to HIV/AIDS services may exist for 

American Indians and Alaska Natives. These barriers include issues such as stigma 

associated with HIV/AIDS, lack of transportation, housing issues, and the prevalence of 

substance abuse disorders. These barriers and others were found to delay, prevent, or

interrupt the continuity of HIV/AIDS treatment for these minorities. GAO-08-90.

31Comorbidities are conditions that exist at the same time as a primary condition. 

Comorbidities for individuals with HIV/AIDS include diabetes and tuberculosis. 

Page 25 GAO-09-315 Minority AIDS Initiative
 

Table 5: Ten Barriers to Minorities in Obtaining HIV/AIDS Services Most Frequently 

Identified by Ryan White CARE Act Part A and B Minority AIDS Initiative Grantees 

Barrier

Number of Part A 

grantees 

reporting this

barrier (of 56)

Number of Part B 

grantees 

reporting this

barrier (of 30)

Total number of

grantees 

reporting this

barrier (of 86)

Co-morbidities 56 23 79

Housing issues 55 21 76

Poverty 54 19 73

Lack of insurance 56 12 68

Substance abuse 47 20 67

Lack of transportation 51 14 65

Language issues 42 18 60

Prison population issues 45 15 60

Stigma/fear 45 14 59

Lack of health information 41 12 53

Source: GAO analysis of HRSA applications.

In our interviews, grantees under Parts C, D, and F also described many of

the issues in table 5 as barriers to minorities obtaining HIV/AIDS services. 

Grantees explained that HIV/AIDS care may not be the primary issue on an

individual’s list of needs or concerns. Without overall programs to support 

these competing needs, minorities will experience barriers to obtaining 

HIV/AIDS medical services. For example, some grantees discussed 

barriers related to language issues within some minority communities. A 

Part C grantee identified the lack of bilingual health care providers as a 

major barrier to care for minorities served by the grantee. The director of a 

Part C grantee explained that stigma associated with HIV/AIDS is a barrier 

for some minorities because they are less likely to seek services within 

their communities for fear of revealing that they have HIV/AIDS. Part F 

grantees we interviewed stated that the barriers to care included the lack

of specialty care, mistrust of health systems by patients, and the lack of 

insurance. 

HHS provided comments on a draft of this report. The comments are 

reprinted in appendix V. In its comments, HHS suggested that we identify 

the law authorizing Ryan White programs as either Title XXVI of the Public

Health Service Act or the Ryan White HIV/AIDS program. Consistent with 

our previous work, we continue to refer to the law authorizing Ryan White 

programs as the CARE Act. As noted in the report, the current program is 

Agency Comments 

and Our Evaluation 

Page 26 GAO-09-315 Minority AIDS Initiative
 

authorized under the CARE Act, as amended. We have added the Public 

Health Service Act title to our footnote providing the legal citation to the 

statute. In addition, HHS provided technical comments on the report draft, 

which we have incorporated as appropriate. 

We are sending a copy of this report to the Acting Secretary of Health and 

Human Services. The report is also available at no charge 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) 512-7114 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. Other staff who made major contributions to this report are 

Marcia Crosse 

listed in appendix VI. 

Director, Health Care 

Page 27 GAO-09-315 Minority AIDS Initiative
Appendix I: Grantees Reported Few Appendix I: Grantees Reported Few Challenges to Program Integration 

Challenges to Program Integration 

The Ryan White Comprehensive AIDS Resources Emergency Act (CARE 

Act) requires us to report information on the challenges to human 

immunodeficiency virus (HIV) and acquired immunodeficiency syndrome 

(AIDS) program integration experienced by CARE Act grantees. 

Challenges to program integration are issues that can prevent grantees and 

service providers from working together to coordinate HIV/AIDS service 

provision and can prevent clear communication between these 

organizations regarding funding and program requirements. To identify the 

challenges to HIV/AIDS program integration experienced by CARE Act 

grantees, we interviewed staff from selected Part A, B, C, D, and F 

grantees.1

 To gather background information about the challenges to 

HIV/AIDS program integration experienced by CARE Act grantees, we 

interviewed officials from the Health Resources and Services

Administration (HRSA) of the Department of Health and Human Services 

and staff of the National Minority AIDS Council, Kaiser Family 

Foundation, the National Alliance of State and Territorial AIDS Directors, 

and the Communities Advocating Emergency AIDS Relief Coalition. 

Grantees reported that few challenges exist to HIV/AIDS program 

integration. Many grantees and service providers funded under different 

parts of the CARE Act interact with other grantees, service providers, and 

federal and state HIV/AIDS programs to provide services. However, few 

problems were identified. For example, an official from a grantee told us 

that the organization promotes program integration by designing its 

services to create a “seamless flow” of care for individuals. This includes 

using targeted outreach programs to bring minorities into care and 

providing case management services. The service provider then follows up 

with minority individuals through case management services as well as 

mental health, substance abuse, and psychosocial support services, as 

needed. 

 1

CARE Act Part A provides for grants to selected metropolitan areas—known as eligible 

metropolitan areas and transitional grant areas—that have been disproportionately 

affected by the HIV/AIDS epidemic. Part B provides for grants to states and territories to 

improve quality, availability, and organization of HIV/AIDS services. 

Part C provides for grants to public and private nonprofit entities to provide early 

intervention services, such as HIV testing and ambulatory care. Part D provides for grants

to programs for family-centered comprehensive care to children, youth, and women and 

their families. Part F provides for grants for demonstration and evaluation of innovative 

models of HIV/AIDS care delivery for hard-to-reach populations and training of health care

providers. 

Page 28 GAO-09-315 Minority AIDS Initiative
Appendix I: Grantees Reported Few 

Challenges to Program Integration 

Grantees reported few challenges to HIV/AIDS program integration even

though they receive funding from multiple sources to provide HIV/AIDS 

services. Funding for HIV/AIDS programs to provide services can come 

from Medicaid, Medicare, Centers for Disease Control and Prevention 

(CDC) grants, Substance Abuse and Mental Health Services 

Administration (SAMHSA) grants, and state programs. Grantees we 

interviewed may receive funding from a variety of federal and state 

sources. However, CARE Act grants are designated as the “payer of last 

resort” and therefore pay for HIV/AIDS services that are not covered by

other resources, such as Medicaid, Medicare, or private insurance.2

 Some 

grantees reported in interviews that they have mechanisms in place to 

ensure that these CARE Act programs are the payers of last resort, which 

usually consists of closely tracking funding and expenditures on services 

rendered for individuals, and to identify the appropriate program to pay 

for HIV/AIDS services for individuals, including those with specific needs.

One challenge some grantees identified was a lack of uniform data 

collection and reporting requirements across the multiple parts of the 

CARE Act, even though the required data are similar. Some grantees we 

interviewed told us that differences in data collection and reporting 

systems are challenges to program integration across the multiple parts of 

the CARE Act. 

Another challenge to achieving program integration is that definitions of 

services may differ between the CARE Act and other federal and state 

funding sources. Officials from a Part B grantee told us that differing 

definitions present challenges to collaboration and integration because

grantees and service providers may be referencing different services 

despite using the same term. For example, the definition of “case 

management” is different depending on whether one uses the term in 

reference to the CARE Act or to another federally funded program, such as 

the Housing Opportunities for Persons with AIDS program. 

 2

As the “payer of last resort,” the CARE Act pays for HIV/AIDS services that are not 

covered by other resources, such as Medicaid, Medicare or private insurance. U.S.C. 

§§ 300ff-15(a)(6), 300ff-27(b)(7)(F), 300ff-64(f)(1). According to HRSA officials, Part D is a 

payer of last resort by operation of HRSA policy. 

Page 29 GAO-09-315 Minority AIDS Initiative
Appendix II: Objectives, Scope, and

Methodology 

Page 30 GAO-09-315

Appendix II: Objectives, Scope, and 

Methodology 

The CARE Act requires us to report on the Minority AIDS Initiative (MAI) 

and related issues. In this report, we are providing information on (1) the 

effect on grantees and service providers of the new competitive process 

for awarding Part A and B MAI funds, (2) the types of services grantees 

funded under MAI, and (3) barriers to minorities obtaining services from 

HIV/AIDS programs that were identified by grantees. The CARE Act also 

requires us to report on the challenges of integrating CARE Act–funded 

programs with HIV/AIDS programs funded from other sources such as 

Medicaid, Medicare, the Centers for Disease, Control and Prevention and 

SAMHSA. (See app. I for information on the challenges of HIV/AIDS 

program integration experienced by CARE Act grantees.) 

To determine the effect of the new competitive process for awarding MAI 

funds on grantees and service providers, we conducted a Web-based 

survey of CARE Act grantees under Parts A and B. We obtained contact 

information for Part A and Part B grantee officials, including names and 

e-mail addresses, from HRSA. The survey questions focused on how 

grantees applied for MAI funds, distributed funds to service providers, and 

provided oversight, and what services they provided prior to and after the 

passage of the Ryan White HIV/AIDS Treatment Modernization Act of 2006 

(RWTMA). We included in the survey Part B grantees that did not apply for 

MAI funding for fiscal year 2007 in order to obtain their reasons for not 

applying. The survey response rates were about 77 percent (43 out of 56)

for Part A grantees and about 81 percent (48 out of 59) for Part B grantees.

During the development of our survey, we conducted pretests with two 

Part A grantees (in Washington, D.C., and Baltimore, Maryland) and two 

Part B grantees (in Georgia and Pennsylvania). We opened the survey on 

May 15, 2008, and closed it on June 27, 2008. While the survey was open, 

we contacted each nonrespondent by e-mail to follow up and subsequently 

contacted any remaining nonrespondents by telephone to follow up as a 

way to address any problems and to encourage nonrespondents to 

complete the survey. Because this survey was conducted with all of the 

Part A and B grantees, it is not subject to sampling error. However, there

are practical difficulties in conducting any survey that may introduce other 

types of errors, such as nonsampling errors. For example, nonsampling 

error may introduce unwanted variability or bias in the survey results and 

can result when survey respondents inconsistently interpret particular 

survey questions. We took steps to minimize nonsampling errors in 

developing the questionnaire and in data collection and analysis. While the 

response rates of 77 and 81 percent are high, if those not responding 

differed materially from those responding on any particular question we 

analyzed, our analysis may not accurately represent the group surveyed. 

Minority AIDS Initiative
Appendix II: Objectives, Scope, and

Methodology 

Therefore, our results are representative only of those responding to our 

survey and are not generalizable to a larger population. 

In addition, we reviewed HRSA’s policies and reporting requirements for 

Parts A, B, C, D, and F. We interviewed HRSA officials and staff from 

selected grantees for Parts A and B to determine how funds were 

distributed to service providers. 

We estimated funding amounts for Part A and B grantees based on the old 

formula-based process and analyzed the difference between these 

amounts and the actual funding for fiscal year 2007. To create these 

estimated funding amounts, we reviewed CARE Act MAI funding data for 

fiscal years 2006 and 2007, case counts of minorities living with AIDS for 

fiscal year 2006, and case counts of minorities living with HIV/AIDS for 

fiscal year 2007, all of which were provided by HRSA. To estimate funding 

amounts for each Part A and Part B grantee, we followed the old formulabased process, which used a proportion that represented the relationship 

between a grantee’s minority HIV/AIDS case count for fiscal year 2007 and 

the total minority HIV/AIDS case count for all jurisdictions, and then 

multiplied that proportion by the total amount of MAI funding available. 

This gave us the estimated amount of funding for each grantee. We then 

determined the difference between the actual funding the grantee received 

under the new competitive process for 2007 and our estimated funding 

amount to establish the impact of the change to the new competitive 

process. To assess the validity of the funding amounts, we compared data 

we received from HRSA to previously published funding amounts. To 

assess the reliability and validity of the computer-generated estimated 

funding amounts, we provided HRSA officials with a copy of our tables. 

They agreed with our methodology and were able to duplicate our funding

amounts. We determined that the funding data and case count data were 

sufficiently reliable for the purposes of this report. 

To identify the types of services grantees funded under MAI, we conducted 

a Web-based survey of Part A and B grantees, as described above, and 

interviewed selected Part A, B, C, D, and F grantees about services they 

provided under MAI prior to and after the passage of RWTMA. We 

interviewed HRSA officials and staff from six Part A and six Part B 

grantees to determine how funds were distributed. Although there was no 

change in the process for awarding funds under Parts C, D, and F, we 

interviewed grantees under those parts to learn about the services they 

funded. We interviewed staff from six Part C, six Part D, and three Part F 

grantees. We selected grantees to interview based on the amount of MAI 

funding they received and to ensure geographic diversity. All interviews 

Page 31 GAO-09-315 Minority AIDS Initiative
Appendix II: Objectives, Scope, and

Methodology 

were conducted over the telephone using a structured interview guide that 

was provided to the interviewees in advance. Question topics included the 

relationship between HRSA and the grantee and between the grantee and

service providers, the services grantees funded, evaluation of services 

funded by grantees, barriers minorities with HIV/AIDS face in obtaining 

services through HIV/AIDS programs, and program integration barriers. 

We also interviewed staff of the National Minority AIDS Council, Kaiser 

Family Foundation, the National Alliance of State and Territorial AIDS 

Directors, and the Communities Advocating Emergency AIDS Relief 

Coalition. 

To identify the barriers to minorities obtaining services from HIV/AIDS 

programs that were identified by grantees, we reviewed Part A MAI and 

Part B MAI competitive grant applications for fiscal year 2007, which 

included grantees’ responses regarding barriers minorities face in 

accessing HIV/AIDS services. We interviewed staff from selected Part A, B,

C, D, and F grantees about barriers minorities with HIV/AIDS face in

obtaining services through HIV/AIDS programs and budget allocations to 

different HIV/AIDS services. We requested and received from HRSA fiscal 

year 2007 MAI grant applications from all Part A and Part B applicants. We

conducted content analyses on selected sections of the MAI applications 

in which grantees described barriers, co-morbidities, unmet needs, 

coordination of services, implementation plans, and impact of MAI 

services. During the content analyses, we collected information from the 

fiscal year 2007 Part A MAI and Part B MAI applications regarding barriers 

to HIV/AIDS services, co-morbidities for individuals with HIV/AIDS, and 

factors that were complications for care. We also interviewed staff from 

the organizations listed above. 

We conducted our work from January 2008 to February 2009 in 

accordance with all sections of GAO’s Quality Assurance Framework that

are relevant to our objectives. The framework requires that we plan and 

perform the engagement to obtain sufficient and appropriate evidence to 

meet our stated objectives and to discuss any limitations in our work. We 

believe that the information and data obtained, and the analysis 

conducted, provide a reasonable basis for any findings and conclusions. 

Page 32 GAO-09-315 Minority AIDS Initiative
Appendix III: Ryan White CARE Act Title I 

and II Funding for Fiscal Year 2006 and Part 

A and B Funding for Fiscal Year 2007 

Table 6 shows funding for Title I grant awards for fiscal year 2006. Since 

the enactment of RWTMA, CARE Act Title I has been referred to as Part A. 

In fiscal year 2006, 51 Title I grantees received MAI funding, and the grant 

amounts ranged from $29,264 to $11,936,248. Overall, MAI grants 

accounted for 13 percent or less of a Title I grantee’s total CARE Act 

funding. 

Table 6: Ryan White CARE Act Title I Grant Awards and Minority AIDS Initiative 

(MAI) Grant Awards, Fiscal Year 2006 

EMA/TGA 

Total Title I 

grant MAI grant

MAI as 

percentage

of total Title I 

funding

Atlanta, Ga. $18,869,561 $1,609,533 8.5

Austin, Tex. 3,719,076 213,718 5.7

Baltimore, Md. 20,628,895 1,652,985 8.0

Baton Rouge, La.a – – –

Bergen-Passaic, N.J. 4,485,650 210,170 4.7

Boston, Mass. 13,339,141 544,492 4.1

Caguas, P.R. 1,648,356 208,397 12.6

Charlotte-Gastonia-Concord, N.C.-S.C. a– – –

Chicago, Ill. 25,044,633 1,878,231 7.5

Cleveland, Ohio 3,349,096 241,208 7.2

Dallas, Tex. 13,196,377 1,071,248 8.1

Denver, Colo. 4,283,042 186,227 4.3

Detroit, Mich. 8,428,477 597,700 7.1

Dutchess County, N.Y. 1,367,584 112,623 8.2

Fort Lauderdale, Fla. 14,963,638 1,058,833 7.1

Fort Worth, Tex. 3,409,819 219,925 6.4

Hartford, Conn. 4,666,281 266,925 5.7

Houston, Tex. 19,953,520 1,631,702 8.2

Indianapolis, Ind.a – – –

Jacksonville, Fla. 4,913,816 409,699 8.3

Jersey City, N.J. 5,145,142 265,152 5.2

Kansas City, Mo. 2,916,485 125,038 4.3

Las Vegas, Nev. 4,323,627 253,623 5.9

Los Angeles, Calif. 34,895,377 2,507,856 7.2

Appendix III: Ryan White CARE Act Title I 

and II Funding for Fiscal Year 2006 and Part 

A and B Funding for Fiscal Year 2007 

Page 33 GAO-09-315 Minority AIDS Initiative
Appendix III: Ryan White CARE Act Title I 

and II Funding for Fiscal Year 2006 and Part 

A and B Funding for Fiscal Year 2007 

EMA/TGA 

Total Title I 

grant MAI grant

MAI as 

percentage

of total Title I 

funding

Memphis, Tenn.

a

– – –

Miami, Fla. 23,999,914 2,048,496 8.5

Middlesex-Somerset-Hunterdon, N.J. 2,595,663 135,680 5.2

Minneapolis-St. Paul, Minn. 3,046,512 197,755 6.5

Nashville-Davidson-Murfeesboro, Tenn.a– – –

Nassau-Suffolk, N.Y. 6,148,307 464,680 7.6

New Haven, Conn. 6,684,594 342,303 5.1

New Orleans, La. 7,434,812 593,266 8.0

New York, N.Y. 120,423,326 11,936,258 9.9

Newark, N.J. 14,752,254 811,417 5.5

Norfolk, Va. 4,414,760 235,887 5.3

Oakland, Calif. 5,735,837 352,944 6.2

Orange County, Calif. 4,858,579 214,604 4.4

Orlando, Fla. 8,561,273 669,530 7.8

Philadelphia, Pa. 22,384,551 1,585,589 7.1

Phoenix, Ariz. 6,519,338 328,114 5.0

Ponce, P.R. 2,391,444 246,529 10.3

Portland, Oreg. 3,401,956 94,887 2.8

Riverside-San Bernadino, Calif. 7,074,521 274,906 3.9

Sacramento, Calif. 2,778,729 55,868 2.0

San Antonio, Tex. 3,325,881 305,057 9.2

San Diego, Calif. 9,269,256 450,492 4.9

San Francisco, Calif. 27,964,864 534,737 1.9

San Jose, Calif. 2,304,762 110,849 4.8

San Juan, P.R. 13,470,347 1,191,852 8.8

Santa Rosa, Calif. 1,028,634 29,264 2.8

Seattle, Wash. 5,445,484 204,850 3.8

St. Louis. Mo. 4,502,572 250,076 5.6

Tampa-St. Petersburg, Fla. 9,571,830 567,549 5.9

Vineland-Millville-Bridgeton, N.J. 849,715 71,833 8.5

Washington, D.C. 26,923,066 2,667,479 9.9

West Palm Beach, Fla. 8,276,018 673,964 8.1

Page 34 GAO-09-315 Minority AIDS Initiative
Appendix III: Ryan White CARE Act Title I 

and II Funding for Fiscal Year 2006 and Part 

A and B Funding for Fiscal Year 2007 

EMA/TGA 

Total Title I 

grant MAI grant

MAI as 

percentage

of total Title I 

funding

Total $579,686,392 $42,912,000 7.4

Sources: HRSA and GAO analysis of HRSA data.

Note: Since the enactment of RWTMA, CARE Act Title I has been referred to as Part A. EMAs are

eligible metropolitan areas; TGAs are transitional grant areas. 

a

Baton Rouge, Louisiana; Charlotte-Gastonia-Concord, North Carolina/South Carolina; Indianapolis, 

Indiana; Memphis, Tennessee; and Nashville-Davidson-Murfreesboro, Tennessee, were newly

designated as TGAs in fiscal year 2007 and, therefore, did not receive Part A funding in fiscal year 

2006. 

Table 7 shows Part A grant awards for fiscal year 2007. In addition, we 

provide information on the percentage change from fiscal year 2006 

through fiscal year 2007 in Part A MAI grant awards. This change is based 

on several factors in addition to the new competitive process. (See 

pages 13-19 for our analysis of fiscal year 2007 funding that isolates the 

effect of this change.) The reasons for the changes in funding from fiscal 

year 2006 through fiscal year 2007 include the following: 

• The addition of five Part A TGAs, which decreased the amount of 

individual funding for all Part A grantees. 

• Increases or decreases in grantees’ proportion of the total number of living 

minority HIV/AIDS cases, which is used as part of the determination of the 

demonstrated need for funding. From fiscal year 2006 through fiscal year 

2007, HRSA changed the case count method from using the number of 

living minority AIDS cases to using the number of living minorities with 

HIV/AIDS for the most recent year available as reported to CDC. 

• Scoring of grantees’ competitive applications. The competitive process 

determines the funding level of each grantee partly by the score of its 

application.

In fiscal year 2007, 56 Part A grantees received MAI funding, and the grant 

amounts ranged from $50,000 to $9,347,777. Overall, MAI grants accounted 

for 10 percent or less of a Part A grantee’s total CARE Act funding in fiscal 

year 2007. 

Page 35 GAO-09-315 Minority AIDS Initiative
Appendix III: Ryan White CARE Act Title I 

and II Funding for Fiscal Year 2006 and Part 

A and B Funding for Fiscal Year 2007 

Table 7: Ryan White CARE Act Part A Grant Awards and Minority AIDS Initiative (MAI) Grant Awards for Fiscal Year 2007, 

Including Percentage Change from Fiscal Year 2006 

EMA/TGA Total Part A grant MAI grant

MAI as percentage of

total Part A funding 

Percentage change in 

MAI funding from 

FY 2006 to FY 2007

Atlanta, Ga. $17,124,514 $1,050,229 6.1 -35

Austin, Tex. 3,614,135 229,065 6.3 7

Baltimore, Md. 20,388,061 2,100,038 10.3 27

Baton Rouge, La.a 3,259,580 249,059 7.6 –

Bergen-Passaic, N.J. 3,869,966 287,493 7.4 37

Boston, Mass. 13,675,999 814,862 6.0 50

Caguas, P.R. 1,082,464 121,984 11.3 -41

Charlotte-Gastonia-Concord, N.C.-S.C.a- 4,200,378 371,535 8.8 –

Chicago, Ill. 25,153,442 1,787,310 7.1 -5

Cleveland, Ohio 3,983,088 316,520 7.9 31

Dallas, Tex. 13,550,581 772,577 5.7 -28

Denver, Colo. 7,061,342 275,492 3.9 48

Detroit, Mich. 8,366,462 644,567 7.7 8

Dutchess County, N.Y. 1,162,194 103,571 8.9 -8

Fort Lauderdale, Fla. 14,284,795 1,113,452 7.8 5

Fort Worth, Tex. 3,443,293 204,310 5.9 -7

Hartford, Conn. 3,170,527 252,944 8.0 -5

Houston, Tex. 19,472,799 1,571,727 8.1 -4

Indianapolis, Ind.a3,230,389 189,079 5.9 –

Jacksonville, Fla. 4,886,573 393,745 8.1 -4

Jersey City, N.J. 4,535,846 417,858 9.2 58

Kansas City, Mo. 3,724,815 187,284 5.0 50

Las Vegas, Nev. 4,670,529 225,918 4.8 -11

Los Angeles, Calif. 35,263,560 2,528,561 7.2 1

Memphis, Tenn.

a

 5,574,928 556,225 10.0 –

Miami, Fla. 25,061,316 2,565,107 10.2 25

Middlesex-Somerset-Hunterdon, N.J. 2,465,279 165,169 6.7 22

Minneapolis-St. Paul, Minn. 4,468,112 264,702 5.9 34

Nashville-Davidson-Murfeesboro, Tenn.a3,688,043 207,441 5.6 –

Nassau-Suffolk, N.Y. 4,814,937 325,286 6.8 -30

New Haven, Conn. 5,101,747 321,657 6.3 -6

New Orleans, La. 7,256,199 541,807 7.5 -9

New York, N.Y. 110,213,357 9,347,777 8.5 -22

Page 36 GAO-09-315 Minority AIDS Initiative
Appendix III: Ryan White CARE Act Title I 

and II Funding for Fiscal Year 2006 and Part 

A and B Funding for Fiscal Year 2007 

EMA/TGA Total Part A grant MAI grant

MAI as percentage of

total Part A funding 

Percentage change in 

MAI funding from 

FY 2006 to FY 2007

Newark, N.J. 13,927,385 1,284,886 9.2 58

Norfolk, Va. 5,054,931 379,699 7.5 61

Oakland, Calif. 5,837,061 392,080 6.7 11

Orange County, Calif. 4,966,678 292,945 5.9 37

Orlando, Fla. 8,062,483 578,713 7.2 -14

Philadelphia, Pa. 21,639,722 1,682,127 7.8 6

Phoenix, Ariz. 6,974,852 193,368 2.8 -41

Ponce, P.R. 1,699,838 153,098 9.0 -38

Portland, Oreg. 3,156,465 78,536 2.5 -17

Riverside-San Bernadino, Calif. 6,720,094 255,733 3.8 -7

Sacramento, Calif. 2,259,806 97,469 4.3 74

St. Louis. Mo. 5,273,629 378,174 7.2 51

San Antonio, Tex. 3,655,732 264,661 7.2 -13

San Diego, Calif. 10,224,751 543,389 5.3 21

San Francisco, Calif. 19,459,344 652,491 3.4 22

San Jose, Calif. 2,338,369 137,156 5.9 24

San Juan, P.R. 12,709,679 741,100 5.8 -38

Santa Rosa, Calif.b 1,040,934 50,000 4.8 71

Seattle, Wash. 5,953,167 234,009 3.9 14

Tampa-St. Petersburg, Fla. 9,201,080 525,592 5.7 -7

Vineland-Millville-Bridgeton, N.J. 783,864 68,510 8.7 -5

Washington, D.C. 27,631,723 1,976,712 7.2 -26

West Palm Beach, Fla. 8,295,497 576,631 7.0 -14

Total $578,686,334 $42,041,430 7.3 -2

Sources: HRSA and GAO analysis of HRSA data.

a

Baton Rouge, Louisiana; Charlotte-Gastonia-Concord, North Carolina/South Carolina; Indianapolis, 

Indiana; Memphis, Tennessee; and Nashville-Davidson-Murfreesboro, Tennessee, were newly

designated as TGAs in fiscal year 2007 and, therefore, did not receive Part A funding in fiscal year 

2006. 

b

Santa Rosa, California, received the minimum grant award of $50,000. The maximum grant award 

was set at $10,750,000; however, no one qualified for the maximum.

Table 8 shows funding for Title II grant awards for fiscal year 2006. Since 

the enactment of RWTMA, CARE Act Title II has been referred to as 

Part B. In fiscal year 2006, 51 Title II grantees received MAI funding, and

funding amounts ranged from $415 to $1,606,289. Overall, MAI grants 

Page 37 GAO-09-315 Minority AIDS Initiative
Appendix III: Ryan White CARE Act Title I 

and II Funding for Fiscal Year 2006 and Part 

A and B Funding for Fiscal Year 2007 

accounted for 1 percent or less of a Part B grantee’s total CARE Act 

funding.1

Table 8: Ryan White CARE Act Title II Grant Awards and Minority AIDS Initiative 

(MAI) Grant Awards, Fiscal Year 2006 

State/territory

Total Title II 

grant MAI grant

a

MAI as percentage of

total Part B funding

Alabama $12,379,760 $71,621 0.58

Alaska 1,038,349 3,425 0.33

Arizona 12,732,077 53,353 0.42

Arkansas 5,161,119 18,580 0.36

California 121,734,064 587,814 0.48

Colorado 8,042,203 28,960 0.36

Connecticut 15,824,810 76,604 0.48

Delaware 5,432,326 26,676 0.49

District of Columbia 19,495,237 180,403 0.93

Florida 116,883,905 798,318 0.68

Georgia 37,822,590 294,166 0.78

Hawaii 3,298,130 8,719 0.26

Idaho 987,627 – –

Illinois 36,322,297 244,239 0.67

Indiana 11,631,445 42,454 0.36

Iowa 2,181,764 6,124 0.28

Kansas 3,130,712 10,587 0.34

Kentucky 7,190,340 19,514 0.27

Louisiana 23,891,181 167,947 0.70

Maine 1,333,909 1,972 0.15

Maryland 36,055,252 303,301 0.84

Massachusetts 20,190,874 73,697 0.37

Michigan 15,983,050 85,842 0.54

Minnesota 4,318,987 25,742 0.60

Mississippi 10,679,221 77,642 0.73

Missouri 10,500,632 44,011 0.42

 1

We did not include the Federates States of Micronesia in this analysis because they 

received the minimum grant award. 

Page 38 GAO-09-315 Minority AIDS Initiative
Appendix III: Ryan White CARE Act Title I 

and II Funding for Fiscal Year 2006 and Part 

A and B Funding for Fiscal Year 2007 

State/territory

Total Title II 

grant MAI grant

a

MAI as percentage of

total Part B funding

Montana 824,817 – –

Nebraska 1,815,394 7,162 0.39

Nevada 6,654,115 32,593 0.49

New Hampshire 1,281,115 2,595 0.20

New Jersey 47,641,537 234,586 0.49

New Mexico 3,489,677 16,400 0.47

New York 175,602,454 1,606,289 0.91

North Carolina 24,681,830 175,005 0.71

North Dakota 320,858 727 0.23

Ohio 16,858,517 82,001 0.49

Oklahoma 6,121,483 16,712 0.27

Oregon 5,943,054 13,079 0.22

Pennsylvania 39,891,047 217,355 0.54

Puerto Rico 33,850,327 242,163 0.72

Rhode Island 3,189,276 15,985 0.50

South Carolina 21,163,384 128,607 0.61

South Dakota 734,916 1,453 0.20

Tennessee 21,178,234 102,969 0.49

Texas 76,656,747 533,838 0.70

Utah 3,329,533 4,463 0.13

Vermont 883,059 – –

Virginia 21,832,964 106,913 0.49

Washington 11,198,763 33,631 0.30

West Virginia 2,167,287 5,190 0.24

Wisconsin 5,404,657 20,137 0.37

Wyoming 372,887 623 0.17

Guam 147,415 415 0.28

Virgin Islands 1,007,176 5,398 0.54

American Samoa 50,000 – –

Marshall Islands 50,000 – –

Northern Marianas Islands 50,000 – –

Republic of Palau 50,000 – –

Page 39 GAO-09-315 Minority AIDS Initiative
Appendix III: Ryan White CARE Act Title I 

and II Funding for Fiscal Year 2006 and Part 

A and B Funding for Fiscal Year 2007 

State/territory

Total Title II 

grant MAI grant

a

MAI as percentage of

total Part B funding

Federated States of 

Micronesia 

50,000 – –

Total $1,078,734,384 $6,858,000 0.64

Sources: HRSA and GAO analysis of HRSA data.

Note: Since the enactment of RWTMA, CARE Act Title II has been referred to as Part B. 

a

States and territories that did not receive MAI funding in fiscal year 2006 have a dash. 

Table 9 shows funding for Part B grant awards for fiscal year 2007. In 

addition, we provide information on the percentage change from fiscal 

year 2006 through fiscal year 2007 in Part B MAI grant awards. This change

is based on several factors in addition to the new competitive process. 

(See pages 13-19 for our analysis of fiscal year 2007 funding that isolates 

the effect of this change.) The reasons for the changes in funding include 

the following: 

• A decreased number of Part B MAI grantees applying for and accepting

MAI funding, which increased the funds available to all Part B MAI 

grantees. 

• Increases or decreases in grantees’ proportion of the total number of living 

minority HIV/AIDS cases, which is a factor used as part of the 

determination of the demonstrated need for funding. From fiscal year 2006 

through fiscal year 2007, HRSA changed the case count method from using 

the number of living minority AIDS cases to using the number of living 

minorities with HIV/AIDS for the most recent year available as reported to 

CDC. 

• Scoring of grantees’ competitive applications. The competitive process 

determines the funding level of each grantee partly by the score of its 

application.

In fiscal year 2007, 30 Part B grantees received MAI funding, and grant 

amounts ranged from $2,500 to $1,476,866. Overall, MAI grants accounted

for 1 percent or less of a Part B grantee’s total CARE Act funding. 

Page 40 GAO-09-315 Minority AIDS Initiative
Appendix III: Ryan White CARE Act Title I 

and II Funding for Fiscal Year 2006 and Part 

A and B Funding for Fiscal Year 2007 

Table 9: Ryan White CARE Act Part B Grant Awards and Minority AIDS Initiative 

(MAI) Grant Awards for Fiscal Year 2007, Including Percentage Change from Fiscal 

Year 2006 

State/Territory

Total Part B 

grant MAI grant

a

MAI as 

percentage

of total 

Part B 

funding

Percentage

Change in MAI 

funding from 

FY 2006

to FY 2007

Alabama $19,791,847 $109,917 0.56 53

Alaska 1,129,894 4,412 0.39 29

Arizona 13,543,748 – – –

Arkansas 7,901,902 – – –

California 122,936,034 856,348 0.70 46

Colorado 13,396,954 36,113 0.27 25

Connecticut 15,044,081 83,285 0.55 9

Delaware 5,270,515 4,360 0.08 -84

District of Columbia 18,834,754 204,224 1.08 13

Florida 117,413,102 1,087,726 0.93 36

Georgia 40,350,086 267,205 0.66 -9

Hawaii 3,237,348 – – –

Idaho 1,105,364 – – –

Illinois 36,392,873 72,966 0.20 -70

Indiana 12,996,706 – – –

Iowa 2,874,145 8,377 0.29 37

Kansas 3,434,675 – – –

Kentucky 7,608,908 – – –

Louisiana 21,542,485 140,731 0.65 -16

Maine 1,399,166 2,500 0.18 27

Maryland 35,050,493 304,838 0.87 1

Massachusetts 19,567,006 – – –

Michigan 16,950,334 141,887 0.84 65

Minnesota 7,088,148 26,875 0.38 4

Mississippi 13,997,861 – – –

Missouri 13,786,156 69,743 0.51 58

Montana 866,238 – – –

Nebraska 2,381,505 – – –

Nevada 8,010,232 – – –

New Hampshire 1,502,980 – – –

New Jersey 45,995,066 414,015 0.90 76

Page 41 GAO-09-315 Minority AIDS Initiative
Appendix III: Ryan White CARE Act Title I 

and II Funding for Fiscal Year 2006 and Part 

A and B Funding for Fiscal Year 2007 

State/Territory

Total Part B 

grant MAI grant

a

MAI as 

percentage

of total 

Part B 

funding

Percentage

Change in MAI 

funding from 

FY 2006

to FY 2007

New Mexico 4,065,724 – – –

New York 169,488,721 1,476,866 0.87 -8

North Carolina 34,000,911 – – –

North Dakota 343,556 – – –

Ohio 23,352,802 62,201 0.27 -24

Oklahoma 9,110,963 20,313 0.22 22

Oregon 6,709,281 14,031 0.21 7

Pennsylvania 38,649,989 – – –

Puerto Rico 32,563,575 142,792 0.44 -41

Rhode Island 3,348,666 – – –

South Carolina 29,068,516 177,810 0.61 38

South Dakota 805,924 – – –

Tennessee 18,374,749 130,743 0.71 27

Texas 89,342,110 597,547 0.67 12

Utah 4,275,389 – – –

Vermont 902,212 – – –

Virginia 28,922,603 203,896 0.70 91

Washington 11,757,722 34,333 0.29% 2

West Virginia 2,457,104 – – –

Wisconsin 9,475,779 41,046 0.43 104

Wyoming 680,188 – – –

Guam 291,084 – – –

Virgin Islands 1,272,874 – – –

American Samoa 51,979 – – –

Marshall Islands 52,968 – – –

Northern Mariana 

Islands 

53,958 – – –

Republic of Palau 50,000 – – –

Federated States of 

Micronesiab

57,447 2,500 4.35 –

Total $1,150,927,400 $6,739,600 0.59

Sources: HRSA and GAO analysis of HRSA data.

a

States and territories that did not apply for funding in fiscal year 2007 have a dash. 

b

Federated States of Micronesia received the minimum grant award of $2,500. No maximum grant 

award was set. 

Page 42 GAO-09-315 Minority AIDS Initiative
Appendix IV: Explanation of Barriers to 

Minorities Obtaining HIV/AIDS Services 

We analyzed fiscal year 2007 Part A MAI and Part B MAI grant applications

to identify the barriers to minorities obtaining HIV/AIDS services identified

most frequently by grantees. Barriers are issues that can delay or prevent 

clients from receiving HIV/AIDS services on a timely basis, thus reducing 

the likely success of those services. Table 10 provides definitions for each 

barrier identified by Part A and B MAI grantees in their fiscal year 2007 

MAI grant applications and the number of grantees from each part that 

identified the barrier. 

Table 10: Barriers to Minorities in Obtaining HIV/AIDS Services Identified by Ryan White CARE Act Part A and B Minority AIDS 

Initiative (MAI) Grantees 

Barrier Description

Number of Part A MAI 

grantees identifying

this barrier (of 56) 

Number of Part B MAI 

grantees identifying

this barrier (of 30)

The 75/25 core

medical/support services 

split 

Parts A, B, and C grantees may not use less than 

75 percent of funding to provide core medical 

services that are needed in the eligible area for 

individuals with HIV/AIDS. This requirement could 

be a barrier to obtaining services because it may 

limit the ability of grantees to provide services that 

are responsive to the needs of individuals they 

serve. 

5 0

Co-morbidities Co-morbidities are other diseases or conditions 

that an individual with a primary condition, such as 

HIV/AIDS, may also have, including hypertension, 

mental illness, sexually transmitted 

infections/diseases, and tuberculosis. Comorbidities may complicate the delivery of or

access to medical care. 

56 23

Cultural or religious barriers Culture and religion influence health beliefs and 

behaviors, which may affect compliance with

medical treatment. For example, an individual may 

have an aversion to revealing personal 

information, which could hamper provider-patient 

communication. In addition, prior adverse 

experiences may make some individuals distrustful 

of the health care system. 

40 18

Data collection and 

reporting

CARE Act grantees and service providers report 

information on programs and the individuals they 

serve to HRSA. These efforts may divert 

resources from the delivery of HIV/AIDS services. 

16 0

Discrimination Prejudicial and unequal treatment of individuals 

living with HIV/AIDS may occur because HIV/AIDS 

is a life-threatening disease, people are afraid of 

contracting HIV, and some believe that HIV/AIDS 

has been contracted because of unacceptable

lifestyle choices. 

12 0

Appendix IV: Explanation of Barriers to 

Minorities Obtaining HIV/AIDS Services 

Page 43 GAO-09-315 Minority AIDS Initiative
Appendix IV: Explanation of Barriers to 

Minorities Obtaining HIV/AIDS Services 

Barrier Description

Number of Part A MAI 

grantees identifying

this barrier (of 56) 

Number of Part B MAI 

grantees identifying

this barrier (of 30)

Familial responsibilities Responsibilities involving children, partners, 

grandparents, and other family members may 

present competing needs that potentially 

compromise access to and continuing in HIV/AIDS 

care. 

10 0

Geographic factors The geographic variation in the availability of

HIV/AIDS services can limit individuals’ access to 

those services. This is especially true in rural 

areas that lack health care providers or services, 

thus requiring individuals to travel long distances 

to access HIV/AIDS services. 

21 9

Housing issues Persons living with HIV/AIDS may lose their 

housing because of compounding factors, such as 

increased medical costs and limited incomes or 

reduced ability to keep working because of 

HIV/AIDS and related illnesses. The instability that 

stems from homelessness can compromise

access to and continuing in HIV/AIDS care. 

55 21

Immigrant issues Undocumented workers and other immigrants may 

face barriers to accessing and maintaining 

continuity of care for HIV and other health care 

because these individuals may lack proper 

documentation, fear legal action, or lack insurance 

or other means to pay for care. This population is 

also vulnerable to barriers caused by limited

English proficiency. 

31 10

Increasing cost to treat 

HIV/AIDS 

The increasing cost to treat HIV/AIDS is usually 

borne by the grantee and could result in the 

grantee being unable to serve all those in need. 

6 0

Lack of adequate nutrition Inadequate nutrition can contribute to impaired

immune response, accelerate disease 

progression, and impede the effectiveness of

medications. 

31 7

Lack of child care Individuals, most often women, caring for children 

can have problems securing reliable, affordable 

child care in order to attend medical appointments 

and therefore may delay or miss such HIV/AIDS 

care. 

16 0

Lack of funds (source not 

specified) 

Low amounts or lack of available funding 

challenges grantees’ provision of HIV/AIDS 

services and therefore may prevent individuals 

from receiving these services. 

0 5

Lack of health information If individuals with HIV/AIDS are not provided with 

services that educate them about HIV 

transmission or the medical and support services 

that are designed to improve health status, they 

might not access or continue HIV/AIDS care. 

41 18

Page 44 GAO-09-315 Minority AIDS Initiative
Appendix IV: Explanation of Barriers to 

Minorities Obtaining HIV/AIDS Services 

Barrier Description

Number of Part A MAI 

grantees identifying

this barrier (of 56) 

Number of Part B MAI 

grantees identifying

this barrier (of 30)

Lack of insurance Individuals without insurance or those who are 

underinsured may delay, never seek, or not 

continue HIV/AIDS care. 

56 12

Lack of providers with 

nontraditional hours 

Clients who work during typical business hours 

may have difficulty accessing HIV/AIDS services 

from medical and social service programs that are 

open only during these times.

13 0

Lack of qualified 

organizations or physicians 

Without adequately qualified organizations or

physicians to serve individuals with HIV/AIDS, 

individuals may not be able to access specialized

care or HIV/AIDS-specific services. 

21 0

Lack of transportation Lack of reliable transportation, including affordable 

and convenient public transportation, and the need 

to travel long distances to receive HIV/AIDS 

services can prevent minorities from accessing or 

continuing HIV/AIDS services. 

51 14

Language issues Language issues include limits to understanding, 

speaking, or reading English. Individuals with

limited English proficiency often require 

interpretation and translation to receive HIV/AIDS 

services, but these may not be readily available. 

42 18

Late entry into care Many individuals do not know their HIV status or 

do not seek care immediately when they do know 

their status. Those who delay care are often sicker 

when they do enter care, thus presenting more

complex care needs. Such needs may make it 

difficult for the available HIV/AIDS services to be 

successful. 

25 0

Limited psychosocial 

support 

Social and emotional support includes counseling 

activities, HIV support groups, pastoral care,

caregiver support, and bereavement counseling. 

Limited provision of these support services may 

negatively affect an individual’s adherence to 

HIV/AIDS care. 

11 0

Mental illness Individuals with mental illness and HIV/AIDS often 

delay medical treatment and require complex

management of both illnesses, which may not all 

be addressed by HIV/AIDS services. 

36 13

Physical abuse Some women may not seek HIV/AIDS or other 

medical care out of fear of being abused by a 

partner. 

9 0

Page 45 GAO-09-315 Minority AIDS Initiative
Appendix IV: Explanation of Barriers to 

Minorities Obtaining HIV/AIDS Services 

Barrier Description

Number of Part A MAI 

grantees identifying

this barrier (of 56) 

Number of Part B MAI 

grantees identifying

this barrier (of 30)

Poverty Poverty is defined by the federal government 

according to income thresholds that vary by family 

size and composition. If a family’s total income is 

less than the family’s threshold, then that family 

and every individual in it is considered in

poverty. Poverty increases the likelihood of 

unemployment, inadequate or no health insurance, 

and limited access to high quality health care.

54 19

Prison population issues Current and newly released inmates have 

increased prevalence of HIV/AIDS. Newly 

released inmates may experience difficulties 

accessing HIV/AIDS services. 

45 15

Restrictive Medicaida or 

Medicareb

 eligibility or 

benefit reductions 

Most adults are not eligible for Medicaid, though 

some states have applied for a waiver to expand 

Medicaid eligibility for low-income individuals with 

HIV prior to disability. Medicaid beneficiaries often 

lose eligibility for Medicaid if they return to work as 

a result of effective medical care. Those who are 

not eligible but cannot afford insurance may be 

unlikely to access or continue HIV/AIDS care. 

Eligibility criteria for Medicare are restrictive, but 

once an individual becomes eligible, not all 

HIV/AIDS-related services may be covered. For 

example, Medicare has limited support for 

nonmedical services that are important for 

HIV/AIDS care, such as case management. 

27 0

Ryan White CARE Act 

funding decline

A grantee’s Ryan White Care Act funding might 

decline or remain level, but if the number of HIV 

positive individuals to whom the grantee must 

provide services increases, the grantee might not 

be able to provide services to all those in need. 

25 1

Service appointment wait 

times 

Long waits to schedule appointments may 

discourage individuals from accessing or 

continuing HIV/AIDS care. 

5 0

Staff turnover Frequent turnover in management and staff can 

hinder program implementation. Additionally, staff 

turnover can adversely affect the knowledge and 

experience of the organization. The increased 

caseload makes it more difficult for case managers 

to monitor their clients and ensure that they are 

continuing care. 

6 6

Stigma/fear HIV-related stigma refers to all unfavorable 

attitudes, beliefs, and policies directed toward

people perceived to have HIV/AIDS. HIV/AIDSrelated stigma affects individuals’ willingness to be 

tested for HIV and individuals’ responses to testing 

positive, and can lead to delays in accessing

HIV/AIDS services. 

45 14

Page 46 GAO-09-315 Minority AIDS Initiative
Appendix IV: Explanation of Barriers to 

Minorities Obtaining HIV/AIDS Services 

Barrier Description

Number of Part A MAI 

grantees identifying

this barrier (of 56) 

Number of Part B MAI 

grantees identifying

this barrier (of 30)

Substance abuse disorders Substance abuse disorders are defined as 

dependence on or abuse of a substance. 

Associated problems may include negative health 

consequences, such as an increase in HIV 

transmission and a delay in seeking medical care. 

47 20

Unemployment Unemployment may result in an individual’s loss of 

health insurance or have financial consequences 

that may affect access to and continuation of 

HIV/AIDS care. 

26 8

Waiting lists for services Individuals may not receive care because of long 

waits for medical services. Additionally, not being 

eligible to participate in programs such as 

Medicaida because of income requirements may 

prevent individuals from accessing or continuing 

HIV/AIDS care. 

12 5

Source: GAO analysis of Part A and Part B MAI fiscal year 2007 competitive grant applications. 

Note: Barriers reported by fewer than five Part A grantees or five Part B grantees were not included in 

the table. If five or more grantees from either part reported the barrier, the barrier is included in the 

table with the number of grantees reporting the barrier for both parts. 

a

Medicaid is a jointly funded, federal-state health program that covers certain low-income individuals, 

including those who are aged or disabled, and families.

b

Medicare is a federal health program for people 65 years of age and older and for certain disabled 

adults. 

Page 47 GAO-09-315 Minority AIDS Initiative
Appendix V: Comments from the Department Appendix V of Health and Human Services : Comments from the Department 

of Health and Human Services 

Page 48 GAO-09-315 Minority AIDS Initiative
Appendix V: Comments from the Department 

of Health and Human Services 

Page 49 GAO-09-315 Minority AIDS Initiative
Appendix V: Comments from the Department 

of Health and Human Services 

Page 50 GAO-09-315 Minority AIDS Initiative
Appendix VI: 

A

GAO Contact and Staff 

cknowledgments 

Page 51 GAO-09-315

Appendix VI: GAO Contact and Staff 

Acknowledgments 

GAO Contact Marcia Crosse, (202) 512-7114 or crossem@gao.gov 

In addition to the contact named above, Tom Conahan, Assistant Director; 

Romonda McKinney Bumpus; Stefanie Bzdusek; Melanie Egorin; Jill 

Evancho; Cathleen Hamann; Martha Kelly; Justin Mausel; Deborah Miller; 

and Jennifer Whitworth made key contributions to this report. 

Minority AIDS Initiative

Acknowledgments 

(290666) 
GAO’s Mission The Government Accountability Office, the audit, evaluation, and 

investigative arm of Congress, exists to support Congress in meeting its 

constitutional responsibilities and to help improve the performance and 

accountability of the federal government for the American people. GAO 

examines the use of public funds; evaluates federal programs and policies; 

and provides analyses, recommendations, and other assistance to help

Congress make informed oversight, policy, and funding decisions. GAO’s 

commitment to good government is reflected in its core values of 

accountability, integrity, and reliability. 

The fastest and easiest way to obtain copies of GAO documents at no cost

is through GAO’s Web site (www.gao.gov). Each weekday afternoon, GAO 

posts on its Web site newly released reports, testimony, and 

correspondence. To have GAO e-mail you a list of newly posted products, 

go to www.gao.gov and select “E-mail Updates.” 

The price of each GAO publication reflects GAO’s actual cost of 

production and distribution and depends on the number of pages in the 

publication and whether the publication is printed in color or black and 

white. Pricing and ordering information is posted on GAO’s Web site, 

http://www.gao.gov/ordering.htm. 

Place orders by calling (202) 512-6000, toll free (866) 801-7077, or 

TDD (202) 512-2537. 

Orders may be paid for using American Express, Discover Card, 

MasterCard, Visa, check, or money order. Call for additional information. 

Contact: 

Web site: www.gao.gov/fraudnet/fraudnet.htm

E-mail: fraudnet@gao.gov

Automated answering system: (800) 424-5454 or (202) 512-7470 

Ralph Dawn, Managing Director, dawnr@gao.gov, (202) 512-4400 

U.S. Government Accountability Office, 441 G Street NW, Room 7125 

Washington, DC 20548 

Chuck Young, Managing Director, youngc1@gao.gov, (202) 512-4800 

U.S. Government Accountability Office, 441 G Street NW, Room 7149 

Washington, DC 20548 

Obtaining Copies of 

GAO Reports and 

Testimony

Order by Phone 

To Report Fraud,

Waste, and Abuse in 

Federal Programs 

Congressional 

Relations 

Public Affairs 

Please Print on Recycled Paper