MINORITY AIDS 

INITIATIVE

Consolidation of 

Fragmented HIV/AIDS 

Funding Could 

Reduce Administrative 

Challenges

Report to Congressional Committees

November 2013

GAO-14-84

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-84, a report to 

congressional committees

November 2013

MINORITY AIDS INITIATIVE

Consolidation of Fragmented HIV/AIDS Funding 

Could Reduce Administrative Challenges

Why GAO Did This Study

According to CDC data, racial and 

ethnic minorities in the United States—

particularly Blacks/African-Americans 

and Hispanics/Latinos—have been 

disproportionately affected by 

HIV/AIDS, representing 72 percent of 

new HIV infections and 74 percent of 

all AIDS diagnoses in 2011. In addition 

to core funding programs through CDC 

and HRSA that are intended to provide 

services to all qualifying individuals 

affected by HIV/AIDS, MAI seeks to 

improve HIV-related health outcomes 

and reduce health disparities for 

minority communities through the 

provision of grant funds. MAI grants 

are distributed to a variety of entities.

The Ryan White HIV/AIDS Treatment 

Extension Act of 2009 required GAO to 

(1) examine the services provided, 

population served, and administrative 

challenges faced by MAI grantees, and 

(2) describe the best practices 

identified by grantees and other 

stakeholders for community outreach 

and capacity building. GAO conducted 

a review of services reported in fiscal 

year 2011 MAI grantee annual reports 

from a generalizable sample of 100 

grantees, and interviewed agency 

officials and other stakeholders. GAO 

also reviewed grant administrative 

requirements, and data on MAI grant 

amounts and populations served.

What GAO Recommends

To enhance HIV/AIDS services to 

minority populations, HHS should 

consolidate MAI funding into core 

HIV/AIDS funding and seek legislation 

as necessary to achieve a

consolidated approach. HHS stated 

that GAO’s recommendations align 

with the National HIV/AIDS Strategy.

What GAO Found

Minority AIDS Initiative (MAI) grantees reported providing services similar to the 

medical services, support services, and HIV testing and prevention services 

provided with core HIV/AIDS funding, which is provided by the Health Resources 

and Services Administration (HRSA) and the Centers for Disease Control and 

Prevention (CDC) to grantees. In addition, MAI grantees faced administrative 

challenges managing HIV/AIDS funding that was fragmented across several 

grants. Various agencies within the Department of Health and Human Services 

(HHS) awarded MAI grants to grantees. The agencies included CDC, HRSA, the 

Substance Abuse and Mental Health Services Administration, and seven other 

offices within HHS. The MAI grantees in GAO’s sample reported providing mostly 

support services with their MAI grants, similar to the types of support services 

grantees provided with core HIV/AIDS funding from CDC and HRSA. These 

support services included community outreach and education, and staff or 

provider training. Twenty percent of the grantees also reported providing medical 

services to their clients. According to the limited data HHS agencies and offices 

maintain on the demographics of the population served with MAI grants, the 

majority of recipients of MAI services were from racial and ethnic minority groups, 

as is also the case with recipients of services provided with core HIV/AIDS funds. 

MAI grantees faced administrative challenges because the fragmented nature of 

MAI and core HIV/AIDS funding required them to manage funding from several 

sources, each of which required them to complete multiple application and 

reporting requirements. For example, one city received nine HHS grants to 

provide HIV/AIDS services – six MAI grants and three core HIV/AIDS grants – 

and for each of these grants, that city had to complete separate administrative 

requirements. In this case, while HHS is funding all of the services, it is doing so 

across multiple funding streams, which raises the possibility of inefficiencies and 

requires unnecessarily duplicative application and reporting requirements of 

grantees that could otherwise be using their resources to provide needed 

services. Additionally, according to HRSA officials, these administrative 

challenges discouraged some grantees from applying for MAI grants. HRSA 

officials stated that some of the states receiving core HIV/AIDS grants chose not 

to request MAI grants because the grants’ small size did not justify the additional 

reporting or other administrative requirements that would accompany them.

MAI grantee reports that GAO reviewed, as well as stakeholder organizations 

GAO interviewed, described a variety of best practices for community outreach 

and capacity building that at times led to improved client recruitment and 

improved capacity of community based organizations to serve communities 

disproportionately affected by HIV/AIDS. For instance, MAI grantees reported 

targeting specific communities, broadening outreach strategies, utilizing social 

media forums, and using various HIV testing strategies as best practices for 

community outreach that at times led to improved recruitment for HIV testing and 

other services. Grantees and some of the stakeholders reported that upgrading 

technology and providing training to grantee staff were the best methods to 

improve capacity to serve clients.

View GAO-14-84. For more information, 

contact Marcia Crosse at (202) 512-7114 or 

crossem@gao.gov.
Page i GAO-14-84 Minority AIDS Initiative

Letter 1 

Background 7

Fragmented Funding for Similar Services to Similar Populations 

Resulted in Administrative Challenges for MAI Grantees 12

MAI Grantees and Stakeholder Organizations Reported a Variety of 

Best Practices for Community Outreach and Capacity Building 20

Conclusions 23

Recommendations for Executive Action 23

Agency Comments 24

Appendix I Minority AIDS Initiative (MAI) Funding, Activities, and 

Grantees Funded, Fiscal Years 1999-2011 26

Appendix II Methodology for Review of Minority AIDS Initiative (MAI) 

Services from Sample of MAI Annual Grantee Reports 37

Appendix III Comments from the Department of Health and Human 

Services 41

Appendix IV GAO Contact and Staff Acknowledgments 44

Tables

Table 1: Minority AIDS Initiative (MAI) Funding Allocations for 

Department of Health and Human Services (HHS) 

Agencies and Offices (in Millions of Dollars), Fiscal Year 

2011 9

Table 2: The City of Chicago’s MAI and Core HIV/AIDS Grant 

Administrative Requirements, Fiscal Year 2012 17

Table 3: Department of Health and Human Services (HHS) Minority 

AIDS Initiative (MAI) Funding (in Millions of Dollars), 

Fiscal Years 1999-2011 27

Table 4: Secretary’s Minority AIDS Fund (SMAIF) Funding to HHS 

Offices (in Millions of Dollars), Fiscal Years 1999-2011 28

Contents 
Page ii GAO-14-84 Minority AIDS Initiative

Table 5: Health Resources and Services Administration (HRSA) 

Minority AIDS Initiative Funding (in Millions of Dollars) 

and Number of Grantees, by Part, Fiscal Years 2007-2011 30

Table 6: Centers for Disease Control and Prevention (CDC) 

Minority AIDS Initiative (MAI) Funding (in Millions of 

Dollars) and Number of Grantees, Fiscal Years 2007-2011 31

Table 7: Substance Abuse and Mental Health Services 

Administration (SAMHSA) Minority AIDS Initiative (MAI) 

Funding (in Millions of Dollars) and Number of Grantees, 

Fiscal Years 2007-2011 33

Table 8: Indian Health Service (IHS) Secretary’s Minority AIDS 

Initiative Funding (in Millions of Dollars) and Number of 

Grantees, Fiscal Years 2007-2011 33

Table 9: Office of HIV/AIDS and Infectious Disease Policy 

(OHAIDP) Secretary’s Minority AIDS Initiative Funding (in 

Millions of Dollars) and Number of Grantees, Fiscal Years 

2007-2011 34

Table 10: Office of Minority Health (OMH) Secretary’s Minority 

AIDS Initiative Funding (in Millions of Dollars) and 

Number of Grantees, Fiscal Years 2007-2011 35

Table 11: Office of Population Affairs (OPA) Secretary’s Minority 

AIDS Initiative Funding (in Millions of Dollars) and 

Number of Grantees, Fiscal Years 2007-2011 35

Table 12: Office on Women’s Health (OWH) Secretary’s Minority 

AIDS Initiative Funding (in Millions of Dollars) and 

Number of Grantees, Fiscal Years 2007-2011 36

Table 13: Regional Health Administrators (RHA) Secretary’s 

Minority AIDS Initiative Funding (in Millions of Dollars) 

and Number of Grantees, Fiscal Years 2007-2011 36

Table 14: Categories of Services and Best Practices Identified in 

MAI Annual Grantee Reports 38
Page iii GAO-14-84 Minority AIDS Initiative

Abbreviations

AIDS acquired immunodeficiency syndrome

CARE Act Ryan White Comprehensive AIDS Resources Emergency 

 Act of 1990

CBO community-based organization

CDC Centers for Disease Control and Prevention

HHS Department of Health and Human Services

HIV human immunodeficiency virus

HRSA Health Resources and Services Administration

IHS Indian Health Service

MAI Minority AIDS Initiative

OAH Office of Adolescent Health

OHAIDP HHS Office of HIV/AIDS and Infectious Disease Policy

OMH Office of Minority Health

OPA Office of Population Affairs

OWH Office on Women’s Health

RHA Regional Health Administrators

SAMHSA Substance Abuse and Mental Health Services 

 Administration

SMAIF Secretary’s Minority AIDS Initiative Fund

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Page 1 GAO-14-84 Minority AIDS Initiative

441 G St. N.W.

Washington, DC 20548

November 22, 2013

The Honorable Tom Harkin

Chairman

The Honorable Lamar Alexander

Ranking Member

Committee on Health, Education, Labor and Pensions

United States Senate

The Honorable Fred Upton

Chairman

The Honorable Henry Waxman

Ranking Member

Committee on Energy and Commerce

House of Representatives

An estimated 1.2 million people in the United States were living with 

human immunodeficiency virus (HIV) infections in 2012, and 

approximately 50,000 new infections occur annually. Since the first cases 

of acquired immunodeficiency syndrome (AIDS) were reported in June 

1981, more than 600,000 people with AIDS have died. Racial and ethnic 

minorities in the United States —particularly African-Americans and 

Hispanics/Latinos—have been disproportionately affected by HIV/AIDS.1

According to the most recent data from the Centers for Disease Control 

and Prevention (CDC), part of the Department of Health and Human 

Services (HHS), racial and ethnic minorities represented 72 percent of 

new HIV infections and 74 percent of all AIDS diagnoses in 2011.2

Two agencies within HHS, the Health Resources and Services 

Administration (HRSA) and CDC, administer grant programs that provide 

 

1

HIV is the virus that causes AIDS. 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

CDC releases data on the number of diagnoses of HIV infection annually and the total 

number AIDS cases annually in its surveillance reports. Data from 2011 are the most 

recent available for these measures.

 
 

Page 2 GAO-14-84 Minority AIDS Initiative

core HIV/AIDS funding for HIV/AIDS services.3 HRSA awards core 

HIV/AIDS grants pursuant to the Ryan White Comprehensive AIDS 

Resources Emergency Act of 1990 (CARE Act), which was enacted to 

address the treatment needs of uninsured and underinsured persons 

living with HIV/AIDS.4

Independent of HRSA’s core grant programs under the CARE Act, CDC’s 

Division of HIV/AIDS Policy awards core HIV/AIDS grants for prevention 

programs, research and evaluation, surveillance, and policy development 

to reduce the impact of HIV/AIDS. In fiscal year 2011, CDC’s budget for 

its core HIV/AIDS programs was approximately $666.4 million. Goals for 

CDC’s core HIV/AIDS funding in fiscal year 2011 included decreasing 

annual HIV incidence, decreasing the HIV transmission rate, increasing 

the proportion of HIV-infected people in the United States who know they 

are infected, improving HIV/AIDS surveillance, and ensuring that all 

persons diagnosed with HIV are linked to care.

In fiscal year 2011, HRSA’s budget for core CARE 

Act programs for HIV/AIDS treatment through the provision of medical 

services, support services, and education was approximately $2.1 billion.

In addition to the core HIV/AIDS grant programs, CDC, HRSA, and 

numerous other HHS agencies and offices award grants to implement the 

Minority AIDS Initiative (MAI). First known as the Congressional Black 

Caucus Initiative, MAI originated in 1998 in response to provisions in a 

house conference report accompanying the Omnibus Consolidated and 

Emergency Supplemental Appropriations Act, 1999.5

 

3

We use the term “core funding” to refer to those funding programs administered by CDC 

and HRSA that are intended to provide services to all qualifying individuals affected by 

HIV/AIDS, as opposed to targeted funding programs within HHS’s Minority Aids Initiative.

The conference 

report instructed HRSA to target funds to reduce HIV-related treatment 

outcome disparities in communities of color, noting that this funding 

4

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

300ff-121). The 1990 CARE Act added title XXVI to the Public Health Service Act. Unless 

otherwise indicated, references to the CARE Act refer to current title XXVI. The CARE Act 

programs have been reauthorized by the Ryan White CARE Act Amendments of 1996 

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

(Pub. L. No. 106-345, 114 Stat. 1319), the Ryan White HIV/AIDS Treatment 

Modernization Act of 2006 (Pub. L. No. 109-415, 120 Stat. 2767), and the Ryan White 

HIV/AIDS Treatment Extension Act of 2009 (Pub. L. No. 111-87, 123 Stat. 2885).

5

Pub. L. No. 105-277, 112 Stat. 2681 (1998).
 

Page 3 GAO-14-84 Minority AIDS Initiative

should be used to complement existing and previously planned targeted 

HIV/AIDS minority activities.6

In the context of HIV/AIDS grants, applicants may be eligible to receive 

core HIV/AIDS grants and/or MAI grants. These grant programs carry 

different administrative requirements that grantees must observe for each 

of the separate grants they may receive. Agencies and offices that 

administer grants maintain these requirements to ensure that the funds 

are being used in the way intended by the grant program.

The Ryan White HIV/AIDS Treatment Extension Act of 2009 required us 

to report on MAI and related issues.7

To examine the services provided, population served, and administrative 

challenges faced by MAI grantees, we interviewed all ten HHS agencies 

and offices that awarded MAI grants in fiscal year 2011. These HHS 

agencies and offices include HRSA, the primary federal agency for 

improving access to health care services for uninsured, isolated or 

medically vulnerable individuals; the Substance Abuse and Mental Health 

Services Administration (SAMHSA), which leads public health efforts to 

advance the behavioral health of the nation; CDC, which seeks to protect 

health and promote quality of life through the prevention and control of 

disease, injury, and disability; the Indian Health Service (IHS), which 

provides federal health services to American Indians and Alaska Natives; 

the Office of Population Affairs (OPA), which aims to be the leader in 

family planning and reproductive health care services, training and 

research; the Office of Minority Health (OMH); which aims to improve the 

In this report, we (1) examine the 

services provided, population served, and administrative challenges faced 

by MAI grantees, and (2) describe the best practices identified by 

grantees and other stakeholders for community outreach and capacity 

building of CBOs serving the communities that are disproportionately 

affected by HIV/AIDS. The Ryan White HIV/AIDS Treatment Extension 

Act of 2009 also requires us to report on the history of MAI activities 

within each relevant HHS agency and office to provide a description of 

activities conducted and types of grantees funded. We provide 

information from prior years on MAI funding, activities, and grantees in 

appendix I.

 

6

H.R. Conf. Rep. No. 105-825, at 1265 (1998).

7

Pub. L. No. 111-87, § 2(g), 123 Stat. 2885, 2887 (codified at 42 U.S.C. § 300ff-86).
 

Page 4 GAO-14-84 Minority AIDS Initiative

health of racial and ethnic minority populations through the development 

of health policies and programs; the Office of HIV/AIDS and Infectious 

Disease Policy (OHAIDP), which advises HHS officials on the 

implementation and development of policies, programs, and activities 

related to HIV/AIDS and other infectious diseases; the Office on Women’s 

Health (OWH), which seeks to improve the health and sense of well-being 

of women and girls; the Regional Health Administrators (RHA), which 

seeks to perform essential functions for HHS in prevention, 

preparedness, and agency-wide coordination; and the Office of 

Adolescent Health (OAH), which seeks to improve the health and well 

being of adolescents. We also interviewed staff from six stakeholder 

organizations, including national HIV/AIDS organizations that represent 

MAI grantees: the Black AIDS Institute, Latino Commission on AIDS, 

National Alliance of State and Territorial AIDS Directors, National Council 

of Urban Indian Health, National Minority AIDS Council, and National 

Native American AIDS Prevention Center. In addition, we interviewed the 

Kaiser Family Foundation, a subject matter expert. We interviewed these 

organizations to obtain their perspectives on MAI. Information we 

obtained from these interviews is not generalizable. We conducted a 

review of MAI services reported in MAI annual grantee reports from a 

generalizable sample of 100 MAI grantees from fiscal year 2011.8 To 

select our sample, we created a list of all MAI grantees from the ten HHS 

agencies and offices that awarded MAI grants in fiscal year 2011 and 

then selected a generalizable sample of 100 grantees from these 

agencies and offices.9

 

8

We obtained fiscal year 2011 MAI annual grantee reports because this was the most 

recent information available for most agencies and offices. Some grantees had not yet 

submitted their fiscal year 2011 reports at the time we did our work. Where this was the 

case, we used the fiscal year 2010 reports. MAI grantees submit annual grantee reports to 

the agency that awarded their MAI grants that typically include information on the types of 

services they provided with their MAI funds. Grantees that receive more than one MAI 

grant often have to submit a separate report to each agency from which they receive 

grants. 

We then obtained MAI annual grantee reports for 

these grantees from the respective agencies and offices and used NVivo 

software to identify the types of MAI services in these reports (app. II 

9

We identified a total of 1067 organizations awarded MAI grants by the ten HHS agencies 

and offices in fiscal year 2011. In addition to grants, some agencies may have awarded 

MAI funding to recipients through other mechanisms such as cooperative agreements, 

contracts, or interagency agreements. We have treated these recipients as “grantees” for 

purposes of this report regardless of the funding mechanism by which they received their 

funds. 
 

Page 5 GAO-14-84 Minority AIDS Initiative

provides more detail on our sample design.).10

In addition, to identify the population served by MAI, we obtained and 

reviewed the available demographic data on the race and ethnicity of the 

clients served with MAI grants as well as aggregate historical funding 

data that we requested and obtained from HHS agencies and offices for 

fiscal years 2007-2012. Some agencies and offices could not provide 

demographic data on their clients, but we assessed the reliability of the 

demographic data that the agencies and offices could provide by 

interviewing agency officials about how their demographic data was 

collected, and we also discussed any inconsistencies we found in the 

data. We found the data provided to be sufficiently reliable for presenting 

information about the race and ethnicity of MAI grantee populations. We 

also obtained, reviewed, and analyzed the core HIV/AIDS grant amounts 

that MAI grantees in our sample were awarded in order to understand the 

total amount of HIV/AIDS funding that MAI grantees received. We then 

compared the core HIV/AIDS grant amounts to their MAI grant amounts. 

To determine core HIV/AIDS grant amounts, we used CDC and HRSA 

funding data in addition to publicly available funding data. We compared 

publically available data to data provided to us, and confirmed the data 

with the agencies where there were discrepancies. We found these data 

to be reliable for our purposes.

Estimates of the services 

provided and population served from this sample are generalizable to the 

population of MAI grantees. We summarize the statistical precision of our 

estimates using a 95 percent confidence interval, which is the interval that 

would contain the population value in 95 percent of the samples we could 

have drawn. Since the size of the confidence intervals varies widely 

across the estimates, we specify these intervals where we refer to the 

estimates. We categorized MAI services described in the grantee reports 

into six categories. We then analyzed and compared the services 

identified in these categories by HHS agency and office, grant amount, 

source of grant, and organizational type. We also reviewed agency 

guidance on which services grantees are expected to provide with their 

MAI and core HIV/AIDS grants.

Furthermore, to assist us in reviewing the administrative challenges faced 

by MAI grantees, we evaluated grantee administrative requirements 

 

10NVivo is a qualitative data analysis software system that allows organization and 

analysis of information from a variety of sources including complex nonnumeric or 

unstructured data. 
 

Page 6 GAO-14-84 Minority AIDS Initiative

including applications and reporting requirements for MAI and core 

HIV/AIDS grants, and considered our past work on federal programs or 

activities government-wide that have evidence of fragmentation, overlap, 

or duplication.11

To describe the best practices identified by grantees for community 

outreach and capacity building of CBOs serving communities 

disproportionately affected by HIV/AIDS, we conducted a review of MAI 

annual grantee reports from our generalizable sample of 100 MAI 

grantees using NVivo software in order to identify and categorize what 

grantees considered to be best practices. Specifically, we identified and 

analyzed MAI services that grantees considered were best practices, 

which included best practices for community outreach or capacity building 

of CBOs that serve communities disproportionally affected by HIV/AIDS. 

We defined the term best practices to include any successes, lessons 

learned, or challenges overcome by grantees regarding their MAI 

activities. Because grantees generally were not required to discuss best 

practices in their MAI annual grantee reports, we cannot estimate the 

proportion of grantees identifying such practices. Instead, we can simply 

count the number of best practices reported in our sample that we 

identified using our definition of best practices. As a result, our estimates 

are not generalizable for this purpose, unlike our estimates of services 

provided. In addition, we also obtained information on best practices for 

community outreach and capacity building from the six stakeholder 

organizations and one subject matter expert we interviewed.

In that work, we found that the presence of fragmentation 

can lead to instances of overlap and duplication among government 

agencies or programs that have similar goals or activities.

We conducted this performance audit from October 2012 to November

2013 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

 

11Fragmentation occurs when one or more federal agencies or agency organizations are 

involved in the same broad area of national need and opportunities exist to improve 

service delivery. Overlap occurs when multiple agencies or programs have similar goals, 

engage in similar activities or strategies to achieve them, or target similar beneficiaries. 

Duplication occurs when two or more agencies or programs are engaged in the same 

activities or provide the same services to the same beneficiaries. See GAO, 2013 Annual 

Report: Actions Needed to Reduce Fragmentation, Overlap, and Duplication and Achieve 

Other Financial Benefits, GAO-13-279SP (Washington, D.C.: Apr. 9, 2013).
 

Page 7 GAO-14-84 Minority AIDS Initiative

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.

MAI was established in 1998 in response to growing concern about the 

impact of HIV/AIDS on racial and ethnic minorities in the United States. 

According to the most recent CDC data, there were an estimated 23,734 

AIDS diagnoses in 2011 among persons of minority races/ethnicities, 

accounting for 74 percent of total AIDS diagnoses in the United States 

and dependent areas; these data reflect an overall trend present since 

1994. National HIV/AIDS data indicate that since 1994 minorities have 

become a significant majority of persons with HIV/AIDS. In 2011, 

Blacks/African-Americans accounted for 13 percent of the U.S. 

population, but accounted for 49 percent of AIDS diagnoses; 

Hispanics/Latinos accounted for 17 percent of the population, but 

accounted for 21 percent of AIDS diagnoses; and Caucasians/Whites 

accounted for 74 percent of the population, but accounted for 26 percent 

of AIDS diagnoses.12

HRSA’s MAI program was codified into law as part of the 2006 

reauthorization of the CARE Act.13

 

12Those who identify as Hispanic or Latino may be any race, therefore CDC data on AIDS 

diagnoses may combine Hispanics/Latinos with other races. “Hispanic or Latino,” as 

defined in the 2010 Census, refers to a person of Cuban, Mexican, Puerto Rican, South or 

Central American, or other Spanish culture or origin regardless of race. Additionally, 

Asian-Americans accounted for two percent of the AIDS diagnoses, and Native 

American/Alaskan Native/Native Hawaiian/other Pacific Islanders accounted for less than 

two percent of the AIDS diagnoses in 2011.

To be eligible for MAI grants under the 

CARE Act, grantees must also have received CARE Act grants under 

Parts A through D or F, these MAI grants provide funding in addition to 

13Pub. L. No. 109-415, § 603, 120 Stat. 2767, 2818 (codified at 300ff-121).

Background 

History of MAI
 

Page 8 GAO-14-84 Minority AIDS Initiative

core HIV/AIDs grants awarded by HRSA under other provisions of the 

CARE Act.14

Other HHS agencies and offices, including HRSA, continue to carry out 

MAI grant programs separate from the statutory MAI program that HRSA 

implements under the CARE Act. In particular, CDC, SAMHSA, and the 

Office of the Secretary also award MAI grants to provide services for 

communities disproportionally affected by HIV/AIDS. CDC and SAMHSA 

award MAI grants directly to grantees. In contrast, MAI funds 

administered by the Office of the Secretary, referred to as the Secretary’s 

MAI Fund (SMAIF), are distributed by the Office of HIV/AIDS and 

Infectious Disease Policy (OHAIDP) to HRSA, CDC, SAMHSA, and 

seven other HHS agencies and offices. These agencies and offices, in 

turn, award SMAIF grants. MAI and SMAIF funding are often provided to 

the same grantees that receive core HIV/AIDS funding.

Three HHS agencies, HRSA, SAMSHA, and CDC, allocate a portion of 

their respective annual appropriations to carry out MAI programs. In fiscal 

year 2011, CDC, HRSA, and SAMHSA allocated approximately 

$363.7 million of their respective appropriations for MAI programs. CDC, 

HRSA, and SAMHSA use this funding to award grants for the provision of 

services to racial and ethnic minorities with HIV/AIDS.15

 

14HRSA awards core HIV/AIDS grants under Parts A through D and Part F of the CARE 

Act. Part A provides for grants to selected metropolitan areas that have been 

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

and territories to improve the 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. In addition to the core HIV/AIDs grants provided under Part F of the CARE Act, 

Part F also contains the provisions that form the statutory basis for supplemental MAI 

grants under the CARE Act, which are codified at 42 U.S.C.§ 300ff-121.

In addition, the 

Office of the Secretary receives an annual line item MAI appropriation, 

which it calls SMAIF. The Office of the Secretary received a $52.8 million 

appropriation for SMAIF funding in fiscal year 2011. OHAIDP distributed 

this funding on behalf of the Office of the Secretary to ten HHS agencies 

and offices within HHS, including HRSA, CDC, and SAMHSA, for a 

15CDC may also provide funds to grantees through cooperative agreements and 

contracts. We include these funds in our counts of grants.

MAI Funding Allocations 

in Fiscal Year 2011
 

Page 9 GAO-14-84 Minority AIDS Initiative

variety of activities to address HIV/AIDS in racial and ethnic minority 

communities. In turn, these agencies and offices awarded SMAIF grants 

and cooperative agreements to the same types of organizations and 

entities that receive other MAI funding to provide services. HRSA’s 

SMAIF funding is in addition to the amounts it receives in order to make 

MAI grants under the CARE Act. (See table 1 for fiscal year 2011 MAI 

funding.)

Table 1: Minority AIDS Initiative (MAI) Funding Allocations for Department of Health 

and Human Services (HHS) Agencies and Offices (in Millions of Dollars), Fiscal Year 

2011

HHS Agency or Office

Agency MAI 

Allocations

HHS Allocation of 

MAI (SMAIF) 

Appropriation a

Health Resources and Services Administration 

(HRSA) 

b

$153.4 $7.7

Substance Abuse and Mental Health Services 

Administration (SAMHSA) $116.7 $5.9

Centers for Disease Control and Prevention 

(CDC) $93.6 $10.4

Indian Health Service (IHS) $4.2

Office of Population Affairs (OPA) $7.2

Office of Minority Health (OMH) $5.5

Office of HIV/AIDS and Infectious Disease 

Policy (OHAIDP) $3.4

Office on Women’s Health (OWH) $3.4

Regional Health Administrators (RHA) $2.0

Office of Adolescent Health (OAH) $0.2

Total $363.7 $52.8

Source: GAO analysis of HHS data.

c

Note: Dollar amounts are rounded to one decimal point.

a

HRSA, SAMHSA, and CDC allocate MAI funds from their respective annual appropriations.

b

The HHS Office of the Secretary receives an annual MAI appropriation which is referred to as the 

Secretary’s Minority AIDS Fund (SMAIF), that it distributes to ten HHS agencies, which include 

HRSA, SAMHSA, and CDC.

c

According to agency officials, the expenses associated with the administration of SMAIF funding 

were $2.9M in fiscal year 2011 which we include in the HHS Allocation of MAI (SMAIF) Appropriation.
 

Page 10 GAO-14-84 Minority AIDS Initiative

MAI grantees include a wide variety of organizations.16 MAI grantees 

include health departments, state and local governments, tribal 

governments, community health centers, hospitals and medical centers, 

CBOs, colleges and universities, AIDS Education and Training Centers, 

and national HIV/AIDS organizations such as the National Minority AIDS 

Council.17 MAI grantees also include commercial vendors and businesses 

that are awarded contracts to conduct evaluations of MAI programs. 

Some MAI grantees also receive core HIV/AIDS funding. Where this is 

the case, MAI grants generally account for a small percentage of the 

grantee’s funding to provide HIV/AIDS services.

As part of the federal budget process, HHS requests core HIV/AIDS 

funding and MAI funding, which Congress provides under different 

appropriations provisions. After its annual budget is enacted, HHS 

exercises discretion in allocating core HIV/AIDS funding and MAI funding 

to the extent authorized by law.

With respect to the CARE Act, annual appropriations acts provide an 

amount for all CARE Act programs, as well as requirements to make 

certain sums available for implementing specific parts of the CARE Act 

such as Parts A and B.18 Annual CARE Act appropriations have not 

directed specific amounts for the MAI program, although the authorizing 

legislation provides a schedule of amounts to be reserved for 

supplemental MAI grants from any amounts appropriated for the MAI 

program.19

Congress has not enacted specific appropriations provisions applicable to 

core HIV/AIDS programs administered by CDC or the separate MAI 

programs administered by CDC and SAMSHA. As a result, these 

HRSA derives its annual MAI budget allocation based on the 

schedule of amounts provided in the authorizing legislation.

 

16When we use the term MAI grantees, we are referring to all grantees that receive MAI 

funding, including those that receive SMAIF funding.

17Sixteen AIDS Education and Training Centers provide HIV/AIDS education to health 

professionals such as nurses and physicians. The AIDS Education and Training Centers 

are authorized by the CARE Act.

18For example, see Department of Health and Human Services Appropriations Act, 2010, 

Pub. L. No. 111-117, div. D, title II, 123 Stat. 3034, 3239-3240 (2009).

1942 U.S.C. § 300ff-121(b).

Core HIV/AIDS and MAI 

Budget Request and 

Allocation Process
 

Page 11 GAO-14-84 Minority AIDS Initiative

agencies exercise discretion in making allocation decisions for their 

respective programs, which may be influenced by any applicable 

committee report language accompanying their annual appropriations 

acts. 

During the budget request process, HHS also requests general 

departmental management funds for the Office of the Secretary, including 

an amount for prevention and treatment activities known as SMAIF. 

Congress has provided an annual line item appropriation to the Office of 

the Secretary for this purpose, without specifying how HHS is to allocate 

these funds. As a result, HHS exercises discretion in allocating this 

funding to numerous agencies and offices to implement separate MAI 

grant programs.

About three-quarters of MAI grantees submit applications, and about a 

quarter are not required to submit an application. The application process 

generally consists of an application or request for funding that includes a 

written description of the services the grantee plans to provide using the 

MAI grant. For example, SAMHSA grantees are required to submit 

applications which provide details on how grantees plan to spend their 

MAI grants on programs related to substance abuse and mental health 

services. Agencies and offices that award MAI grants evaluate whether to 

fund grantees based upon whether or not their planned services are 

consistent with MAI. However, grant amounts may be determined by a 

formula that considers the number of racial and ethnic minorities reported 

to have HIV that live in the area the grantee serves. About a quarter of 

MAI grantees receive core HIV/AIDS funding and are not required to 

submit any application for MAI grants. In these instances, the amount of 

the MAI grant is also based upon a formula that considers the number of 

racial and ethnic minorities reported to have HIV that live in areas served 

by the grantee.

According to HHS officials, MAI grantees are required to report to their 

funding agency on how they use their MAI grants. These reports 

generally include a description of the services they provided with the 

grants and an accounting of the grants themselves. HHS officials stated 

that MAI grantees are generally required to submit reports at least 

annually, but some are required to submit reports more frequently. HHS 

officials stated that some grantees report on their use of MAI grants as 

part of their reporting on their use of core HIV/AIDS grants. HHS agencies 

use these reports to evaluate whether the services grantees provided to 

MAI Administrative 

Requirements
 

Page 12 GAO-14-84 Minority AIDS Initiative

racial and ethnic minorities with HIV/AIDS met the objectives they 

outlined in their applications.

MAI grantees reported providing services similar to those provided with 

core HIV/AIDS grants. MAI and core HIV/AIDS grantees provided 

services primarily to minorities. MAI grants were often part of fragmented 

HIV/AIDS funding streams that carried separate administrative 

requirements that caused administrative challenges for MAI grantees.

MAI grantees in our sample reported providing mostly support services, 

similar to the types of support services grantees provided with core 

HIV/AIDS grants. These support services included community outreach 

and education, and staff or provider training.20

Based on our review of the annual reports submitted by 100 MAI grantees 

in our sample, we found

A fraction of the grantees 

reported providing medical services to their clients.

• Eighty-one percent of grantees reported providing community 

outreach and education services for the purposes of recruiting and 

retaining clients to HIV/AIDS services.21

• Seventy-two percent of grantees reported providing assistance to 

clients including care coordination, case management, or referrals to 

care.

For example, grantees 

reported using social media platforms, including Facebook and 

Twitter, to recruit and retain individuals into care and holding 

community HIV/AIDS awareness events.

22

 

20Grantees reported they either provided these services to clients directly or helped 

providers to deliver MAI services.

Activities also included assisting clients with social services 

such as housing, employment, and post-HIV test counseling.

21The 95 percent confidence interval of this estimate ranges from 72 to 89 percent.

22The 95 percent confidence interval of this estimate ranges from 63 to 81 percent.

Fragmented Funding 

for Similar Services to 

Similar Populations 

Resulted in 

Administrative 

Challenges for MAI 

Grantees 

MAI Grantees Provided 

Services Similar to Those 

Provided with Core 

HIV/AIDS Funding
 

Page 13 GAO-14-84 Minority AIDS Initiative

• Sixty-nine percent of grantees reported providing clients with 

HIV/AIDS or other related illnesses testing services, such as rapid HIV 

testing.23

• Fifty-eight percent of grantees reported providing or receiving training 

for grantee staff, providers, or other organizations affiliated with the 

grantee, such as training to keep providers informed about HIV 

related clinical service guidelines.24

• Twenty percent of grantees reported using MAI grants to provide core 

medical services to clients.25 For example, grantees provided primary 

and outpatient medical care to HIV/AIDS-infected clients and 

substance abuse treatment or counseling to clients.26

The services provided by MAI grantees were similar to those provided by 

grantees awarded HRSA’s and CDC’s core HIV/AIDS funding. HRSA’s 

fiscal year 2011 budget justification to Congress indicated that core 

HIV/AIDS funds were used to provide clients with medical care such as 

primary health care; assisting clients by providing early intervention 

services; family support services; training for health care providers; and 

other support services. CDC described using its core HIV/AIDS funding to 

provide support services that included training clients by enhancing 

prevention services among the most affected communities. The services 

described included assisting clients by integrating and providing linkage 

to care services and expanding HIV testing. CDC also described 

community outreach and education services that included developing 

social marketing campaigns.

Two 

stakeholders we interviewed believed MAI funds have not been 

targeted to medical services, and are generally too small to support 

providing medical services.

The services that MAI grantees reported providing are consistent with 

available guidance. Guidance for MAI grantees varied considerably 

across the agencies and offices that receive MAI funding. However, 

agency guidance generally instructed grantees to provide services similar 

 

23The 95 percent confidence interval of this estimate ranges from 61 to 76 percent.

24The 95 percent confidence interval of this estimate ranges from 51 to 66 percent.

25The 95 percent confidence interval of this estimate ranges from 13 to 30 percent.

26The maximum 95 percent confidence interval of these estimates is 15 percent.
 

Page 14 GAO-14-84 Minority AIDS Initiative

to those provided with core HIV/AIDS grants and instructed grantees to 

ensure that they provided services within racial and ethnic minority 

communities. Some agencies and offices that award MAI grants provide 

specific guidance to grantees on how to use those grants, while others 

provide guidance in the form of application and reporting instructions.

The limited demographic information available from the HHS agencies 

and offices that could provide data suggests that the majority of those 

served with both MAI and core HIV/AIDS grants are racial and ethnic 

minorities.27

HRSA is the only agency that could provide demographic data on the 

recipients of services funded by core HIV/AIDS grants but these data 

combined recipients of services funded by core HIV/AIDS grants with 

recipients of services funded by MAI grants. Although the data included 

recipients of services from MAI grants, they provide a good indication of 

the demographics of recipients of services from core HIV/AIDS grants 

because MAI grants only amount to 7 percent of core HIV/AIDS funding.

This is consistent with the current distribution of HIV/AIDS in 

the United States. HHS officials also said that the majority of clients 

served by MAI grantees are minorities. However, the demographic data 

are not consistently tracked. Agency officials said that HHS did not 

require them to request and compile demographic data from MAI or core 

HIV/AIDS grantees in fiscal year 2011. HHS agencies and offices were 

only able to provide us data for 54 percent of MAI grantees in fiscal year 

2011, representing 34 percent of all MAI funding. These data suggest that 

HHS’s assessment is likely correct. SAMHSA data indicated that 

70 percent of its MAI service recipients were minorities in fiscal year 

2011. Available demographic data from three offices that receive SMAIF 

funding— OPA, OMH, and OWH—indicated that over 80 percent of their 

MAI service recipients were minorities. IHS data indicated it served a MAI 

population that was 100 percent American Indian/Alaska Native.

28

 

27Those who identify as Hispanic or Latino may be any race, therefore agency data may 

combine Hispanics with other races when determining the number and percent of 

minorities served. “Hispanic or Latino,” as defined in the 2010 Census, refers to a person 

of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or 

origin regardless of race. 

The data provided by HRSA, which accounted for 76 percent of core 

28CDC could not provide demographic data on the recipients of services funded by core 

HIV/AIDS funds.

Available Data Suggest 

MAI and Core HIV/AIDS 

Grantees Provide Services 

Primarily to Minorities
 

Page 15 GAO-14-84 Minority AIDS Initiative

HIV/AIDS grants across HHS agencies and offices, indicate that 

73 percent of the recipients were minority. Specifically, 47 percent were 

African-Americans/Blacks, 22 percent identified as Hispanics, and 

4 percent identified as either Asian, American Indian/Alaska Native, 

Native Hawaiian/Pacific Islander or Multi-racial.29 This is consistent with 

the overall demographics of the HIV-positive population in the United 

States, in which racial and ethnic minorities represented 72 percent of 

new HIV infections and 74 percent of all AIDS diagnoses in 2011.While 

the data are insufficient to conclusively determine the extent to which 

each program serves minority clients, the data suggest that both primarily 

serve minority populations.

MAI and core HIV/AIDS funding is often fragmented across several 

grants, sometimes from several different HHS offices or agencies. In past 

work, we have concluded that funding is fragmented when more than one 

agency or more than one organization within an agency provides funding 

in the same broad areas of national need, and opportunities exist to 

improve service delivery. In this work, we identified approaches that 

agencies can take to improve efficiency. These approaches include 

streamlining or consolidating management or operational processes to 

make them more cost-effective.30 MAI and core HIV/AIDS funding is 

fragmented because numerous agencies and offices in HHS receive it 

and all provide services to respond to the same area of national need.

The National HIV/AIDS Strategy of 2010 noted this issue as one that 

could complicate the coordination of HIV/AIDS programs. The Strategy 

stated that “HIV service providers often receive funding from multiple 

sources with different grant application processes and funding schedules, 

and varied reporting requirements.”31

 

29These data are based on CARE Act Parts A, B, C, and D data.

As noted earlier, Congress has not 

enacted specific appropriations provisions applicable to core HIV/AIDS 

programs administered by CDC or the separate MAI programs 

administered by CDC and SAMHSA. As a result, these agencies exercise 

discretion in making allocation decisions for their respective core 

HIV/AIDS and MAI programs, which may be influenced by applicable 

30GAO, 2013 Annual Report: Actions Needed to Reduce Fragmentation, Overlap, and 

Duplication and Achieve Other Financial Benefits, GAO-13-279SP (Washington, D.C.: 

Apr. 9, 2013), 3.

31The White House, National HIV/AIDS Strategy for the United States (July 2010), 42.

MAI Grantees Face 

Challenges Resulting from 

the Administrative 

Requirements of 

Fragmented Funding 

Streams
 

Page 16 GAO-14-84 Minority AIDS Initiative

committee report language accompanying their annual appropriations 

acts. Additionally, annual line item appropriations for SMAIF programs do 

not specify how HHS is to allocate these funds to implement MAI. Thus, 

HHS can exercise discretion to consolidate disparate MAI funding 

streams. In addition, HHS could seek legislation to amend the CARE Act 

or other law, as necessary, to enable HHS to further consolidate amounts 

directed at MAI programs into core HIV/AIDs programs.

The fragmented nature of MAI and core HIV/AIDS funding caused 

administrative challenges for grantees by often forcing grantees to 

manage grants from several sources. These funding sources required 

them to complete multiple administrative requirements. The duplication 

and fragmentation of these requirements across the grant sources create 

inefficiencies for the grantee that could be providing needed HIV/AIDS 

services instead of using resources to complete multiple administrative 

requirements. In fiscal year 2011, 56 percent, or 596, of the 1067 MAI 

grantees received several HIV/AIDS grants, including at least one MAI 

grant and one core HIV/AIDS grant. Of these 596 MAI grantees, 167 

received a core HIV/AIDS grant from both CDC and HRSA.

For example, the city of Chicago received nine grants from HHS to 

provide HIV/AIDS services. These include six MAI grants—one grant from 

MAI Part A and one grant from MAI Part C, and four MAI grants from 

CDC and SAMHSA, one from each agency’s MAI allocation and one from 

each agency’s SMAIF funding. In addition, Chicago received three core 

HIV/AIDS grants—one from CARE Act Part A, one from CARE Act 

Part C, and one from CDC. Chicago is required to submit a report or 

application for one of its HIV/AIDS grants in most months of the year and 

in some months, they are required to produce multiple submissions. 

While the specific services Chicago provided with the 9 grants varied, all 

of the grants were used to provide HIV/AIDS treatment or prevention 

services to residents of the city of Chicago. (See table 2.) Other cities with 

a similar array of grants include Philadelphia, San Francisco, Los 

Angeles, and New York City. MAI grantees face challenges in managing 

the multiple administrative requirements for each of these grants.
 

Page 17 GAO-14-84 Minority AIDS Initiative

Table 2: The City of Chicago’s MAI and Core HIV/AIDS Grant Administrative Requirements, Fiscal Year 2012

Administrative Requirement

Due Date, 

Fiscal Year 2012

Source of Grant

Type of Grant

Targeted Capacity Expansion Grant Application

The grant application is required for the 12 Metropolitan Statistical Areas and 

Metropolitan Divisions most impacted by HIV/AIDS. Award amounts vary 

based on the size of the population most at risk for or living with HIV in the 

jurisdiction, but grantees are required to submit documentation of intent to 

provide required services, ability to collect data and measure performance, 

and budget information.

June 13, 2011 SAMHSA a

MAI

Minority AIDS Initiative Annual Plan

The primary purpose of the Part A MAI Annual Plan is to ensure grants are 

used to link minority clients to HIV care services. The plan is to include a 

planned timeframe for delivering services; a description of service goals and 

objectives; the racial and ethnic communities to be served, and the number of 

service units to be provided during the reporting period.

October 17, 2011 HRSA

MAI, Part A

CARE Act Part A Grant Application

The CARE Act application is required for all 52 CARE Act Part A grantees. 

The application requires grantees to report information on current and new 

program initiatives. The application also outlines the reporting requirements 

and other documentation required from grantees.

November 1, 2011 HRSA

Core HIV/AIDS funding, 

CARE Act Part A

Maintenance of Effort Expenditures Report

The maintenance of effort expenditures report is used to ensure grantees 

have maintained level expenditures for two consecutive grant years. The 

expenditures must be based on the local budget items.

December 5, 2011 HRSA

Core HIV/AIDS funding, 

CARE Act Part A

Program Terms Report

The program terms report includes a planned allocation report, budget and 

budget justification narrative, an implementation plan, the Consolidated List of 

Contractors, and the Contract Review Certification.

December 5, 2011

b

HRSA

Core HIV/AIDS funding, 

CARE Act Part A

Unobligated Balance Estimate and Carryover Request

The CARE Act provides that base and supplemental grant funds were 

available for obligation by the grantee for a 1-year period beginning on the 

first day of the grant year. It also requires HRSA to cancel any unobligated 

balances not subject to a waiver at the end of the grant year, recover funds 

that had been disbursed to grantees, and redistribute these funds to grantees 

in need as supplemental grants. Grantees must estimate their unobligated 

balances during the grant year and provide final amounts in their federal 

financial report. Grantees may request to carryover funds for one additional 

grant year.

January 1, 2012 HRSA

Core HIV/AIDS funding, 

CARE Act Part A

CARE Act HIV/AIDS Program Services Report

The CARE Act HIV/AIDS program services report provides information on 

services provided by grantees and service providers to HRSA. Additionally, 

grantees and service providers use this report to provide information on 

clients, including their demographic status, services received and HIV clinical 

information.

March 15, 2012 HRSA

Core HIV/AIDS funding, 

CARE Act Part A
 

Page 18 GAO-14-84 Minority AIDS Initiative

Administrative Requirement

Due Date, 

Fiscal Year 2012

Source of Grant

Type of Grant

CARE Act Part A Comprehensive Plan

The comprehensive plan is a requirement that is due every 3 years at the 

beginning of the grant year. The plan is to be used as a “road map” for the 

maintenance and improvement of the grantee’s system of care. Grantees are 

required to include appropriate strategies, goals, and timelines.

May 21, 2012 HRSA

Core HIV/AIDS funding, 

CARE Act Part A

Final Expenditure Table, including MAI Expenditures

This expenditure table serves as a monitoring tool to identify the use of grants 

at the end of the grant period. It identifies service categories that have been 

delivered, the use of carry-over grants, and identifies trends in the amount of 

CARE Act grants being used to deliver these services.

June 28, 2012 HRSA

Core HIV/AIDS funding, 

CARE Act Part A

Annual Progress Report

The Annual Progress Report is to inform HRSA of the progress made in the 

administration of Ryan White programs; to identify accomplishments and 

challenges in meeting established goals and objectives; and to address 

grantees’ need for technical assistance.

June 28, 2012 HRSA c

Core HIV/AIDS funding, 

CARE Act Part A

Report on Expenditures for Women, Infants, Children and Youth

The report on expenditures for Women, Infants, Children and Youth is a 

requirement used to determine that a grantee allocates resources for women, 

infants, children, and youth at no less than the percentage constituted by the 

ratio of the population of women, infants, children, and youth with HIV/AIDS 

to the general populations with HIV/AIDS.

July 28, 2012 HRSA

Core HIV/AIDS funding, 

CARE Act Part A

Federal Financial Report

The Federal Financial Report outlines the grantee’s outlays, unliquidated 

obligations, total federal share, and final unobligated balance.

July 30, 2012 HRSA

Core HIV/AIDS funding, 

CARE Act Part A

Minority AIDS Initiative Annual Report

CARE Act Part A grantees receiving MAI funds must submit two components 

of the MAI Report annually: (1) the MAI Annual Plan for the use of these 

funds, and (2) the year-end MAI Annual Report documenting program 

outcomes. Each MAI Report has two parts: (1) Web forms for standardized 

quantitative and qualitative information and (2) an accompanying narrative 

providing background information to explain the data submitted and a 

summary of program accomplishments, challenges, and lessons.

January 31, 2013 HRSA

MAI, Part A

CARE Act Part C Grant Application

The application requires CARE Act Part C grantees to provide information on 

the comprehensive continuum of outpatient HIV primary care services in the 

targeted area that they will provide with CARE Act and MAI funds. The 

application also outlines the reporting requirements and other documentation 

required from grantees.

October 14, 2011 HRSA

Core HIV/AIDS Funding, 

CARE Act Part C

Federal Financial Report

The Federal Financial Report is an accounting of expenditures under the 

project that year.

Required within 90 days of 

the end of the budget 

period.

HRSA

Core HIV/AIDS Funding, 

CARE Act Part C
 

Page 19 GAO-14-84 Minority AIDS Initiative

Administrative Requirement

Due Date, 

Fiscal Year 2012

Source of Grant

Type of Grant

Allocation and Expenditure Reports

These reports are an accounting of the allocation and expenditure of all grant 

funds according to the specific core medical services, support services, 

clinical quality management, and administration provided.

Allocation report: 

Required 60 days after the 

start of the budget period

Expenditure report: 

Required 90 days after the 

end of the budget period

HRSA

Core HIV/AIDS Funding, 

CARE Act Part C

Final Report

The final report collects program-specific goals and progress on strategies; 

the overall impact of the project; the degree to which the grantee achieved 

the mission; and any barriers the grantee encountered, among other things.

Required 90 days after the 

end of the project period.

HRSA

Core HIV/AIDS Funding, 

CARE Act Part C

Interim Progress Report

The interim Progress report includes information on the grantee’s budget, 

project narrative, and any additional information requested by CDC.

Due no less than 90 days 

after the end of the budget 

period

CDC

Core HIV/AIDS Funding

Annual Progress Report

The Annual Progress Report includes information on the progress the 

grantee has made in achieving the target levels for each grant objective, 

information on the current budget, and any other additional information CDC 

requests.

Due 90 days after the end

of the budget period

CDC

Core HIV/AIDS funding

Financial Status Report

The Financial Status Report includes a final performance report and a 

financial status report.

Due 90 days after the end 

of the grant

CDC

Core HIV/AIDS funding

Final Progress Report Due 90 days after the end 

of the grant or no cost 

extension

SAMHSA 

MAI

Final Financial Status Report Due 90 days after the end 

of the grant

SAMHSA 

MAI

Source: GAO analysis of HHS information.

a

The Targeted Capacity Expansion Grant Application was due on June 13, 2011, which was in federal 

fiscal year 2011.

b

The allocation report serves as a monitoring tool to track and monitor the use of grants. It identifies 

categories of services that are being delivered, changes in the type of services being provided over 

time and trends in the amount of CARE Act grants being used to deliver these services. The budget 

and budget justification narrative serve as monitoring tools to track and monitor the use of CARE Act 

grants. The implementation plan serves as a monitoring tool to verify implementation of approved 

medical and support services for the current grant year. The plan should include all the services and 

priorities reflected in the allocations report. All funded services must be included in the 

implementation plan. The Consolidated List of Contractors serves as a list of all subgrantees for the 

current grant year. The Contract Review Certification requires the grantee to certify that all 

subgrantees for the current grant year comply with CARE Act program requirements and federal 

grants requirements.

c

Because of the administrative requirements associated with managing 

multiple HIV/AIDS grants, some grantees decided not to apply for MAI 

grants. In fiscal year 2011, according to information provided by HRSA, 

37 percent of CARE Act Part B grantees chose not to apply for MAI 

The Minority AIDS Initiative Annual Report for Part A grantees was due on January 31, 2013, which 

is in federal fiscal year 2013.
 

Page 20 GAO-14-84 Minority AIDS Initiative

grants. Some grantees that chose not to apply were states with sizeable 

minority populations. HRSA officials stated that several grantees reported 

that their reasons for not applying for MAI funds were that the small size 

of MAI grants did not provide enough funding to implement a program 

and justify the additional administrative requirements. For grantees that 

received several HIV/AIDS grants, including at least one MAI grant and 

one core HIV/AIDS grant, the average MAI grant was $391,225, while the 

average core HIV/AIDS grant was approximately $3,823,102. HRSA 

officials stated that one Part B grantee declined an MAI grant because the 

amount it received could not cover the cost of issuing a request for 

proposals for subcontractors to conduct the MAI services. A stakeholder 

that represents state health departments said that some states believe 

that due to the small amount of MAI grants they receive, it is too 

burdensome to justify the effort and expense to apply for and report on 

these grants.32

MAI grantees from our sample, as well as stakeholder organizations, 

reported best practices for community outreach and capacity building that 

at times led to improved client recruitment and improved capacity to 

provide care.33

 

32We found in 2009 that some Part B grantees did not apply for MAI grants because they 

did not think the level of funding justified the effort required to apply for and report on their 

use of the grants. Although MAI applications were required to be synchronized with other 

CARE Act grant applications in the 2009 reauthorization of the CARE Act, some Part B 

grantees have continued to not apply for MAI grants. GAO, Ryan White CARE Act: 

Implementation of the New Minority AIDS Initiative Provisions, GAO-09-315 (Washington, 

D.C.: Mar. 27, 2009). 

33In our review of MAI services from our sample, we found that 57 out of 100 grantees 

reported services that we define to be best practices in their fiscal year 2011MAI annual 

grantee reports. We define the term best practices to include any successes, lessons 

learned and/or challenges overcome that we found grantees to report regarding their MAI 

activities. MAI grantees generally are not required to report best practices in their annual 

grantee reports; therefore, our reporting of these best practices is not generalizable to the 

100 grantees in our sample.

MAI Grantees and 

Stakeholder 

Organizations 

Reported a Variety of 

Best Practices for 

Community Outreach 

and Capacity Building
 

Page 21 GAO-14-84 Minority AIDS Initiative

MAI grantees from our sample of 100 grantees, as well as some of the six 

stakeholder organizations we interviewed, reported best practices for 

community outreach that included targeting specific communities, 

broadening outreach and education strategies, utilizing social media 

forums, collaborating with other organizations, and using various HIV 

testing strategies that at times led to increased recruitment for HIV testing 

and other services to communities disproportionately affected by 

HIV/AIDS.

• 23 grantees from our sample reported various community outreach 

and education services that helped some grantees improve client 

recruitment. For example, seven grantees offered individuals 

incentives (e.g., prizes, food or gift-cards) that led to increased 

participation in services such as testing and education. Four grantees 

utilized social media forums (e.g., Facebook, Twitter, online 

broadcasts, etc.) to conduct outreach and recruit individuals for 

HIV/AIDS services. Additionally, three grantees broadened their 

outreach and education strategies to focus on social issues that put 

individuals at risk for HIV/AIDS, rather than focusing specifically on 

HIV/AIDS, to overcome challenges with recruiting clients due to, for 

example, social stigmas prevalent with HIV/AIDS. One stakeholder 

organization we interviewed also reported tailoring outreach strategies 

to match the needs of targeted communities as a best practice to 

improve community outreach.

• 21 grantees from our sample reported strategies to target outreach 

and education to improve outreach to communities disproportionately 

affected by HIV/AIDS. For example, ten grantees conducted outreach 

at venues in the communities where specific minority groups or 

individuals at high risk for HIV/AIDS (e.g., men who have sex with 

men, drug users, etc.) typically congregate.

• 17 grantees from our sample reported that collaborating with other 

community organizations (e.g., HIV/AIDS organizations, medical 

providers, youth centers, juvenile detention facilities, etc.) enhanced 

the types of services offered to individuals. For example, six grantees 

established memorandums of understanding with organizations to 

help ensure individuals could seamlessly access services such as 

medical care, testing for other sexually transmitted infections and 

substance abuse services. Additionally, one stakeholder organization 

reported working with community health centers to provide culturally 

competent care and education to targeted minority communities.

• 15 grantees from our sample reported HIV testing strategies that they 

found successful in increasing HIV testing rates. For example, three 

MAI Grantees and 

Stakeholder Organizations 

Reported Best Practices 

for Community Outreach 

to Improve Client 

Recruitment
 

Page 22 GAO-14-84 Minority AIDS Initiative

grantees used rapid HIV testing methods that provided clients with 

immediate test results, which one grantee reported prevented 

potential transportation and scheduling challenges for clients to obtain 

test results. Three grantees also provided HIV testing services in 

mobile testing units, with one offering testing on evenings and 

weekends to make testing more convenient and accessible to clients. 

Additionally, one stakeholder organization reported providing HIV 

testing at the same event annually to establish continuity and 

reliability of access to HIV testing for individuals in the community.

MAI grantees from our sample of 100 grantees, as well as some of the six 

stakeholder organizations we interviewed, reported best practices for 

capacity building, such as expanding infrastructure and providing training, 

which at times improved their capacity to provide care to communities 

disproportionately affected by HIV/AIDS.34

• Ten grantees from our sample reported activities such as training staff 

and expanding infrastructure that improved their ability to provide 

HIV/AIDS services to minority communities. For example, four 

grantees from our sample reported planning or conducting trainings 

on topics including cultural diversity which, for some grantees, 

improved staff’s ability to provide care or conduct outreach to high-risk 

populations or minority communities. Two grantees also cross-trained 

staff to conduct different job tasks which helped to alleviate any 

impacts of high staff turnover. Additionally, three grantees increased 

their building space or service delivery areas to help expand the 

services they offered to clients. Two grantees also developed or 

enhanced their technology (e.g., databases) to track client services.

• Some stakeholder organizations that we interviewed also reported 

conducting evaluations and providing training to improve the capacity 

of organizations to provide services to minority communities. For 

example, some stakeholders worked with organizations such as 

CBOs to evaluate program needs or capacity levels in order to 

improve and enhance their leadership capacity and infrastructure. 

Additionally, some stakeholder organizations and an expert we 

interviewed also cited the importance of providing training to build 

staff skills and to build long-term capacity within organizations.

 

34Officials from two HHS agencies told us their MAI funds have been used to implement 

capacity building services to expand their ability to provide services to clients.

MAI Grantees and 

Stakeholder Organizations 

Reported Capacity 

Building Best Practices To 

Improve Capacity to 

Provide Care
 

Page 23 GAO-14-84 Minority AIDS Initiative

Since 1998, MAI grants have been awarded in addition to core HIV/AIDS 

grants in order to improve HIV-related health outcomes and reduce HIVrelated health disparities for racial and ethnic minority populations. Given 

that the majority of individuals living with HIV/AIDS in the United States 

today are racial and ethnic minorities, the populations eligible for the 

services provided through both core HIV/AIDS grants and MAI grants are 

primarily minority. In most cases, MAI grants not only have the same 

purpose as core HIV/AIDS grants but MAI grants go to similar grantees to 

provide similar services. Moreover, HHS agencies and offices are 

required to manage separate, fragmented streams of funding that are 

largely intended for the same purpose.

MAI grantees face a challenge in that they are often required to complete 

duplicative administrative requirements for their HIV/AIDS funding. In past 

work, GAO has determined that federal programs are duplicative when 

they provide similar services to the same populations and fragmented 

when numerous agencies or offices provide the same services. In this 

case, a single department is funding the services, but it is doing so across 

multiple agencies and offices with multiple funding streams. Such a 

situation raises the possibility of inefficiencies and requires unnecessarily 

duplicative administrative processes of grantees that could otherwise be 

using their resources to provide needed services. Opportunities exist for 

HHS to reduce unnecessarily fragmented funding streams through its 

budget request and allocation process. For example, HHS can 

consolidate disparate MAI funding streams when making discretionary 

budget allocations, and it can restructure its annual budget requests to 

concentrate funding in core HIV/AIDS programs. HHS can also seek 

legislative solutions to achieve a more consolidated funding approach, for 

example, by amendments to the CARE Act or other law, as necessary.

In order to reduce the administrative costs associated with a fragmented 

MAI grant structure that diminishes the effective use of HHS’s limited 

HIV/AIDS funding, and to enhance services to minority populations, HHS 

should take the following two actions:

• Consolidate disparate MAI funding streams into core HIV/AIDS 

funding during its budget request and allocation process, and

• Seek legislation to amend the CARE Act or other provisions of law, as 

necessary, to achieve a consolidated approach. 

Conclusions 

Recommendations for 

Executive Action
 

Page 24 GAO-14-84 Minority AIDS Initiative

We provided a copy of this report to HHS for its review and HHS provided 

written comments (see app. III). HHS stated that GAO’s 

recommendations align with the National HIV/AIDS Strategy and federal 

program accountability goals, but also stated that any restructuring of its 

HIV/AIDS funding approach must ensure continued responsiveness to 

minorities who are disproportionately affected by HIV/AIDS. HHS 

welcomed an expanded discussion of strategies to more efficiently 

administer MAI, reduce duplicative requirements for grantees, and more 

effectively administer HIV/AIDS funding streams. HHS also described 

some of its efforts to make SMAIF more efficient, responsive, and 

accountable since the release of the National HIV/AIDS Strategy in July 

2010. 

HHS noted in its comments that it has several things to consider before it 

moves to restructure its HIV/AIDS core funding streams and consolidate 

MAI within core funding streams. HHS also noted that grantees’ 

administrative challenges are important but aren’t the only consideration 

in assessing the merits of funding streams and the programs they 

produce. HHS commented that any restructuring of core HIV/AIDS and 

MAI funding streams and programs must ensure that HHS maintains its

responsiveness to the needs of communities and populations 

disproportionately impacted by the HIV/AIDS epidemic. Our 

recommendations that HHS take steps to consolidate disparate funding 

streams provide HHS with discretion in defining grant eligibility 

requirements or activities to address the issues HHS said it needs to 

consider before restructuring funding streams. Consolidation can reduce 

unnecessary, fragmented funding streams without compromising the 

issues HHS needs to consider to ensure access to services for 

disproportionately affected minorities. 

HHS also provided technical comments, which we incorporated as 

appropriate.

We are sending copies of this report to the Secretary of Health and 

Human Services and interested congressional committees. In addition, 

the report is available at no charge on the GAO website at 

http://www.gao.gov. 

Agency Comments
 

Page 25 GAO-14-84 Minority AIDS Initiative

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. GAO staff who made key contributions to this 

report are listed in appendix IV. 

Marcia Crosse

Director, Health Care
Appendix I: Minority AIDS Initiative (MAI) 

Funding, Activities, and Grantees Funded, 

Fiscal Years 1999-2011

Page 26 GAO-14-84 Minority AIDS Initiative

The Ryan White HIV/AIDS Treatment Extension Act of 2009 requires us 

to report on the history of MAI program activities within each relevant 

Department of Health and Human Services (HHS) agency and to provide 

a description of activities conducted and types of grantees funded. To 

provide this information, we requested data from each of the HHS 

agencies and offices that have awarded MAI grants from 1999 through 

2011 using either their own MAI program funding or transferred funding 

from a department-level MAI account, known as the Secretary’s Minority 

AIDS Fund (SMAIF).1

Tables 3 and 4 show annual MAI funding from 1999 to 2011.

Three HHS agencies, the Centers for Disease 

Control (CDC), the Health Resources and Services Administration 

(HRSA), and the Substance Abuse and Mental Health Services 

Administration (SAMHSA), reported using their own MAI program funds to 

award grants to provide services in communities disproportionately 

affected by human immunodeficiency virus/acquired immunodeficiency 

syndrome (HIV/AIDS). In addition, the Office of HIV/AIDS and Infectious 

Disease Policy (OHAIDP), acting on behalf of the HHS Office of the 

Secretary, distributed SMAIF funding to HRSA, CDC, SAMHSA, and 

seven other HHS agencies and offices which, in turn, awarded MAI grants 

to provide services for communities disproportionally affected by 

HIV/AIDS. For HRSA, CDC and SAMSHA, we report the total funding 

level, by fiscal year, for their respective MAI programs as well as the total 

SMAIF funding they received each fiscal year. For the other seven HHS 

agencies, we report the total SMAIF funding they received each fiscal 

year.

 

1

In addition to grants, some agencies may have awarded MAI (including SMAIF) funding 

to recipients through other mechanisms such as cooperative agreements, contracts, or 

interagency agreements. We have treated these recipients as “grantees” for purposes of 

this report regardless of the funding mechanism by which they received their MAI or 

SMAIF funds.

Appendix I: Minority AIDS Initiative (MAI) 

Funding, Activities, and Grantees Funded, 

Fiscal Years 1999-2011
Appendix I: Minority AIDS Initiative (MAI) 

Funding, Activities, and Grantees Funded, 

Fiscal Years 1999-2011

Page 27 GAO-14-84 Minority AIDS Initiative

Table 3: Department of Health and Human Services (HHS) Minority AIDS Initiative 

(MAI) Funding (in Millions of Dollars), Fiscal Years 1999-2011

Health Resources 

and Services 

Administration 

(HRSA)

Centers for Disease 

Control and 

Prevention (CDC)

Substance Abuse and 

Mental Health Services 

Administration 

(SAMHSA)

Fiscal 

Year MAI SMAIFa MAI SMAIF MAI SMAIF

1999 $22.3 $5.8 $46.9 N/A $37.1 $12.5

2000 $73.1 $5.0 $58.7 N/A $55.6 $12.0

2001 $109.2 $6.1 $84.4 N/A $100.2 $11.4

2002 $123.2 $6.2 $92.9 $15.0 $110.4 $11.9

2003 $131.2 $5.6 $97.1 $13.1 $112.1 $12.0

2004 $130.3 $6.9 $97.3 $10.2 $112.0 $11.0

2005 $129.6 $8.2 $91.8 $9.7 $112.4 $11.3

2006 $128.6 $8.6 $96.1 $8.4 $111.5 $9.5

2007 $131.2 $8.6 $95.6 $7.7 $111.1 $10.2

2008 $135.1 $7.2 $94.0 $7.3 $111.7 $8.7

2009 $139.1 $5.3 $94.0 $1.8 $117.1 $9.6

2010 $146.1 $5.3 $94.0 $3.4 $116.6 $8.7

2011 $153.4 $7.7 $94.0 $10.4 $116.7 $5.9

Source: GAO analysis of Department of Health and Human Services (HHS) data.

Note: Dollar amounts are rounded to one decimal point.

a

Secretary’s Minority AIDS Initiative Fund
Appendix I: Minority AIDS Initiative (MAI) 

Funding, Activities, and Grantees Funded, 

Fiscal Years 1999-2011

Page 28 GAO-14-84 Minority AIDS Initiative

Table 4: Secretary’s Minority AIDS Fund (SMAIF) Funding to HHS Offices (in Millions of Dollars), Fiscal Years 1999-2011

Fiscal Year

Indian

Health 

Service

Office of 

Adolescent 

Health

Office of HIV/AIDS 

and Infectious 

Disease Policy

Office of 

Minority 

Health

Office of 

Population 

Affairs 

Office on 

Women’s 

Health

Regional 

Health 

Administrators

1999 $0 $0 $2.5 $5.0 $0.5 $0 $0

2000 $0.8 $0 $3.0 $6.5 $0.6 $0.5 $0

2001 $1.1 $0 $3.4 $7.8 $3.0 $0.5 $0

2002 $1.5 $0 $3.2 $7.9 $3.0 $0.6 $0

2003 $1.5 $0 $3.2 $7.9 $3.0 $0.6 $0

2004 $1.5 $0 $3.2 $7.7 $6.0 $1.6 $0

2005 $2.1 $0 $3.0 $7.7 $6.0 $3.1 $0

2006 $2.0 $0 $6.0 $7.0 $6.1 $3.0 $0

2007 $1.9 $0 $4.3 $6.8 $6.0 $4.0 $0

2008 $2.3 $0 $2.2 $8.8 $7.1 $4.0 $1.3

2009 $3.2 $0 $3.3 $8.9 $8.1 $6.1 $1.8

2010 $4.4 $0 $3.7 $8.9 $7.9 $7.0 $1.7

2011 $4.2 $0.2 $3.4 $5.5 $7.2 $3.4 $2.0

Source: GAO analysis of Department of Health and Human Services (HHS) data.

Note: The National Institutes of Health is not listed in the chart above because it only received funding 

from the Secretary’s Minority AIDS Initiative Fund in fiscal years 1999 and 2000. It received 

$2.7 million in fiscal year 1999 and $1.2 million in fiscal year 2000. Dollar amounts are rounded to 

one decimal point.

HRSA’s MAI program was codified into law pursuant to the 2006 

reauthorization of the Ryan White Comprehensive AIDS Resources 

Emergency Act of 1990 (CARE Act).2

• Part A MAI provides for grants to selected metropolitan areas—known 

as eligible metropolitan areas and transitional grant areas—that have 

To be eligible for MAI grants under 

the CARE Act, grantees must also have received grants under other 

provisions of the CARE Act. HRSA reserves amounts from its annual 

CARE Act appropriation for making supplemental MAI grants. There are 

five primary sections of the CARE Act under which HRSA awards grants, 

including MAI grants—Parts A, B, C, D and F. According to HRSA,

 

2

See Ryan White HIV/AIDS Treatment Modernization Act of 2006, Pub. L. No. 109-415, 

§ 603, 120 Stat. 2767, 2818 (codified at 42 U.S.C. § 300ff-121).

HRSA
Appendix I: Minority AIDS Initiative (MAI) 

Funding, Activities, and Grantees Funded, 

Fiscal Years 1999-2011

Page 29 GAO-14-84 Minority AIDS Initiative

been disproportionately affected by the HIV/AIDS epidemic.3

• Part B MAI provides for grants to states and territories. Part B 

grantees provide targeted outreach and educational activities to 

increase minority participation in the AIDS Drug Assistance Program.

Part A 

MAI grantees provide outpatient medical care, mental health and oral 

health services, local pharmacy assistance, substance abuse 

treatment, outreach, case management, early intervention services, 

treatment adherence, and health education/risk reduction.

• Part C MAI provides for grants to community health centers, health 

departments, hospitals, medical centers and community-based 

organizations (CBOs). Part C MAI grantees provide outpatient early 

invention services including: primary medical care, oral health care, 

mental health screening and treatment, substance abuse screening 

and treatment, adherence counseling, nutritional services, and 

specialty care.

• Part D MAI provides for grants to state health departments, hospitals 

or university based clinics, and other CBOs. Part D MAI grantees 

provide family centered outpatient primary medical care, oral health 

care, mental health screening and treatment, substance abuse, 

screening and treatment, adherence counseling, nutritional services, 

specialty care, pediatric care, women’s health, and access to clinical 

trials.

• Part D Youth MAI provides grants to hospitals, universities and other 

CBOs. Part D Youth grantees identify HIV infected youth who are not 

in care; enroll them in medical and supportive care; and retain them in 

care. They also provide family centered outpatient primary medical 

care, oral health care, mental health screening and treatment, 

substance abuse screening and treatment, adherence counseling, 

nutritional services, specialty care, and access to clinical trials.

• Part F provides for grants to hospitals and universities. Part F MAI 

grantees provide technical assistance, training, and education to other 

MAI grantees.

 

3

Eligible metropolitan areas 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. Transitional grant areas 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. 
Appendix I: Minority AIDS Initiative (MAI) 

Funding, Activities, and Grantees Funded, 

Fiscal Years 1999-2011

Page 30 GAO-14-84 Minority AIDS Initiative

HRSA reported that it also received SMAIF funding which it used for 

grants for outreach to minority populations and training to HIV providers, 

contracts promoting linkages to care for HIV/AIDS clients, and 

cooperative agreements to support networks of HIV care by enhancing 

primary medical care. HRSA’s SMAIF funding was also used in 

connection with interagency agreements with CDC and its HIV/AIDS 

Bureau. (See HRSA funding amounts and number of organizations 

funded in table 5.)

Table 5: Health Resources and Services Administration (HRSA) Minority AIDS Initiative Funding (in Millions of Dollars) and 

Number of Grantees, by Part, Fiscal Years 2007-2011

2007 2008 2009 2010 2011

Ryan White Part Funding

Number 

of 

Grantees Funding

Number 

of 

Grantees Funding

Number 

of 

Grantees Funding

Number 

of 

Grantees Funding

Number 

of 

Grantees

Part A $43.8 56 $45.4 56 $47.1 56 $46.7 56 $49.1 52

Part B $7.0 30 $7.3 26 $7.5 26 $8.8 36 $9.2 36

Part C $53.4 206 $55.4 208 $57.4 204 $61.3 203 $64.4 212

Part D $17.1 57 $17.1 55 $17.2 58 $18.9 58 $20.0 61

Part D Youth $1.4 10 $1.4 10 $1.4 10 $1.5 10 $1.5 10

Part F $8.5 15 $8.5 15 $8.5 15 $8.8 15 $9.2 16

SMAIF $8.6 a 24 $7.2 20 $5.3 26 $5.3 19 $7.7 33

Source: GAO analysis of HRSA and Office of HIV/AIDS and Infectious Disease Policy data.

Note: Dollar amounts are rounded to one decimal point.

a

Secretary’s Minority AIDS Initiative Fund.

In fiscal year 2007-2011 CDC reported that it awarded MAI funding 

through cooperative agreements, contracts, interagency agreements, and 

grants. Organizations that are awarded MAI funds by CDC include 

business and commercial vendors, colleges and universities, CBOs, 

federal agencies, hospitals, health departments, and national or regional 

organizations. These organizations used MAI awards to provide capacity 

building, evaluation, HIV prevention, demonstration projects, and 

research activities to individuals disproportionately affected by HIV/AIDS.

CDC reported that it awarded SMAIF funding through contracts, 

cooperative agreements and interagency agreements to a federal agency 

and a national/regional organization, health departments, universities, 

business/commercial vendors, and CBOs for capacity building, 

evaluation, HIV prevention, surveillance, demonstration projects, and 

CDC
Appendix I: Minority AIDS Initiative (MAI) 

Funding, Activities, and Grantees Funded, 

Fiscal Years 1999-2011

Page 31 GAO-14-84 Minority AIDS Initiative

research efforts. (See CDC funding amounts and number of organizations 

funded in table 6.)

Table 6: Centers for Disease Control and Prevention (CDC) Minority AIDS Initiative 

(MAI) Funding (in Millions of Dollars) and Number of Grantees, Fiscal Years 2007-

2011

Fiscal Year MAI Number of Grantees SMAIF Number of Grantees a

2007 $95.6 239 $7.7 36

2008 $94.0 241 $7.3 27

2009 $94.0 252 $1.8 5 

2010 $94.0 218 $3.4 29

2011 $94.0 217 $10.4 60

Source: GAO analysis of CDC and Office of HIV/AIDS and Infectious Disease Policy data.

Note: Dollar amounts are rounded to one decimal point.

a

Secretary’s Minority AIDS Initiative Fund.

SAMHSA reported that they award MAI grants through three Centers: the 

Center for Mental Health Services, the Center for Substance Abuse 

Prevention, and the Center for Substance Abuse Treatment.

• The Center for Mental Health Services reported that in fiscal years 

2007-2010 it awarded cooperative agreements to domestic public 

and private nonprofit entities. These cooperative agreements are 

intended to enhance and expand the provision of effective, culturally 

competent HIV/AIDS-related mental health services in minority 

communities for persons living with HIV/AIDS and having a mental 

health need. In fiscal year 2011, SAMHSA awarded funds to city and 

state health departments in 11 cities, specifically among recipients of 

the CDC’s Enhanced Comprehensive HIV Prevention Planning and 

Implementation for Metropolitan Statistical Areas Most Affected by 

HIV/AIDS grant program. According to agency documentation, these 

entities intended to ensure that individuals that are either at high risk 

for or have a mental or substance use disorder, and who are most at

risk for or are living with HIV/AIDS, had access to and received 

appropriate behavioral health services (including prevention and 

treatment), HIV/AIDS care, and medical treatment in integrated 

behavioral health and primary care settings. Under this project, 

activities were also targeted to integrate behavioral health and 

primary care networks for HIV and medical treatment in minority 

communities.

SAMHSA 
Appendix I: Minority AIDS Initiative (MAI) 

Funding, Activities, and Grantees Funded, 

Fiscal Years 1999-2011

Page 32 GAO-14-84 Minority AIDS Initiative

• The Center for Substance Abuse Treatment reported that in fiscal 

years 2007-2010 it awarded grants to CBOs, faith-based 

organizations, national organizations, colleges and universities, clinics 

and hospitals, research institutions, state and local government 

agencies, and tribal entities to enhance and expand substance abuse 

treatment and/or outreach and pretreatment services in conjunction 

with HIV/AIDS services in African-American, Latino/Hispanic, and/or 

other racial or ethnic communities highly affected by substance abuse 

and HIV/AIDS. According to agency documentation, the Center also 

awarded SMAIF grants to cohorts of organizations to expand the 

capacity for providers to deliver rapid HIV testing, counseling and 

referrals to care for fiscal year 2011.

• The Center for Substance Abuse Prevention reported that in fiscal 

years 2007-2011 it awarded cooperative agreements to CBOs 

targeting at risk minority populations as well as colleges and 

universities to provide a variety of activities including substance abuse 

prevention services, HIV testing and outreach services; pre-post 

counseling, reentry programs hepatitis education, and technical 

assistance. Additionally, in this same timeframe contracts were 

awarded for the review of grants, evaluation activity, technical 

assistance to MAI grantees such as faith-based and community 

organizations and the organization of grantee meetings. The Center 

also awarded contracts to for-profit organizations and tribal 

organizations with SMAIF funding during fiscal years 2007-2011. For 

example, according to agency documentation, these organizations 

provided training and technical assistance to coordinate substance 

abuse education, HIV outreach and awareness, as well as testing on 

college campuses and universities. (See SAMHSA funding and 

number of grantees funded in Table 7.)
Appendix I: Minority AIDS Initiative (MAI) 

Funding, Activities, and Grantees Funded, 

Fiscal Years 1999-2011

Page 33 GAO-14-84 Minority AIDS Initiative

Table 7: Substance Abuse and Mental Health Services Administration (SAMHSA) 

Minority AIDS Initiative (MAI) Funding (in Millions of Dollars) and Number of 

Grantees, Fiscal Years 2007-2011

Fiscal Year MAI Number of Grantees SMAIF Number of Grantees a

2007

b

$111.1 287 $10.2 115

2008 $111.7 276 $8.7 133

2009 $117.1 295 $9.6 148

2010 $116.6 275 $8.7 142

2011 $116.7 269 $5.9 139

Source: GAO analysis of SAMHSA and Office of HIV/AIDS and Infectious Disease Policy data.

Note: Dollar amounts are rounded to one decimal point.

a

Secretary’s Minority AIDS Initiative Fund.

b

Some of SAMHSA’s grants were funded with both MAI and SMAIF funds.

IHS reported that it awarded SMAIF funding through grants, cooperative 

agreements, contracts and interagency agreements in fiscal years 2007 

through 2011. Specifically, the agency reported that Urban Indian Health 

programs received grants to provide HIV screening services and IHS 

established interagency agreements with federal sites for capacity 

building and access to care services. Additionally, contractors provided 

capacity building services, online HIV training for clinicians, and 

educational videos. Cooperative agreements, grants, and interagency 

agreements were made to increase HIV screening services. Lastly, grants 

were used to provide effective behavioral interventions for tribal 

communities. (See IHS MAI funding and number of grantees funded in 

table 8.)

Table 8: Indian Health Service (IHS) Secretary’s Minority AIDS Initiative Funding (in 

Millions of Dollars) and Number of Grantees, Fiscal Years 2007-2011

Fiscal Year SMAIF Number of Grantees a

2007 $1.9 11

2008 $2.3 19

2009 $3.2 42

2010 $4.4 31

2011 $4.2 46

Source: GAO analysis of Office of HIV/AIDS and Infectious Disease Policy and IHS data.

Note: Dollar amounts are rounded to one decimal point.

a

Indian Health Service 

(IHS)

Secretary’s Minority AIDS Initiative Fund.
Appendix I: Minority AIDS Initiative (MAI) 

Funding, Activities, and Grantees Funded, 

Fiscal Years 1999-2011

Page 34 GAO-14-84 Minority AIDS Initiative

OAH reported that it received $200,000 in SMAIF funding in fiscal year 

2011 that it used for a cooperative agreement with a university to provide 

management of a resource center website and technical assistance. OAH 

did not receive SMAIF funds prior to fiscal year 2011.

OHAIDP reported that it used its SMAIF funding to award contracts to 

national technology and health communications firms and consultants to 

provide technical assistance, education, and outreach via AIDS.gov 

during fiscal years 2007-2011. (See OHAIDP funding amounts and 

number of organizations funded in table 9.) Additionally, CBOs and faithbased organizations, health departments, universities and colleges, and 

training centers were awarded contracts by OHAIDP. These entities 

provided outreach, education, technical assistance, HIV testing, and 

capacity building for the Minority Serving Institutions HIV/AIDS Prevention 

Demonstration Initiative. OHAIDP officials also reported that SMAIF funds 

were used for the National HIV testing mobilization campaign, and to 

coordinate for the National HIV/AIDS Strategy during this timeframe.

Table 9: Office of HIV/AIDS and Infectious Disease Policy (OHAIDP) Secretary’s 

Minority AIDS Initiative Funding (in Millions of Dollars) and Number of Grantees, 

Fiscal Years 2007-2011

Fiscal Year SMAIF Number of Grantees a

2007 $4.3 6 

2008 $2.2 7 

2009 $3.3 11

2010 $3.7 13

2011 $3.4 12

Source: GAO analysis of OHAIDP data.

Note: Dollar amounts are rounded to one decimal point.

a

Secretary’s Minority AIDS Initiative Fund.

OMH reported that it used its SMAIF funding to award grants and 

cooperative agreements to CBOs and national organizations during fiscal 

years 2007 through 2011. (See OMH funding amounts and number of 

organizations funded in table 10.) Specifically, these funding mechanisms 

provided capacity building, technical assistance, health promotion and 

education, access to testing and care, counseling, peer education, and 

links to social and support services.

Office of Adolescent 

Health (OAH)

OHAIDP

HHS Office of 

Minority Health 

(OMH)
Appendix I: Minority AIDS Initiative (MAI) 

Funding, Activities, and Grantees Funded, 

Fiscal Years 1999-2011

Page 35 GAO-14-84 Minority AIDS Initiative

Table 10: Office of Minority Health (OMH) Secretary’s Minority AIDS Initiative 

Funding (in Millions of Dollars) and Number of Grantees, Fiscal Years 2007-2011

Fiscal Year SMAIF Number of Grantees a

2007 $6.8 24

2008 $8.8 42

2009 $8.9 51

2010 $8.9 43

2011 $5.5 34

Source: GAO analysis of Office of HIV/AIDS and Infectious Disease Policy and OMH data.

Note: Dollar amounts are rounded to one decimal point.

a

Secretary’s Minority AIDS Initiative Fund.

OPA reported that it used its SMAIF funding to award grants to health 

departments, community health centers, Planned Parenthood, as well as 

other organizations including non-profits, universities, hospitals, faithbased organizations, tribal health centers, and free-standing family 

planning organizations during fiscal years 2007 through 2011. (See OPA 

funding amounts and number of organizations funded in table 11.) 

Specifically, these grants provided for expanded HIV testing, prevention 

education, and referrals to care.

Table 11: Office of Population Affairs (OPA) Secretary’s Minority AIDS Initiative 

Funding (in Millions of Dollars) and Number of Grantees, Fiscal Years 2007-2011

Fiscal Year SMAIF Number of Grantees a

2007 $6.0 47

2008 $7.1 50

2009 $8.1 51

2010 $7.9 54

2011 $7.2 54

Source: GAO analysis of Office of HIV/AIDS and Infectious Disease Policy and OPA data.

Note: Dollar amounts are rounded to one decimal point.

a

Secretary’s Minority AIDS Initiative Fund.

OWH reported that it used its SMAIF funding in fiscal years 2007-2011 to 

award grants for HIV prevention and education services for women, 

including adolescents and youths at risk of HIV/AIDS. OWH reported that 

SMAIF funds were used for contracts and cooperative agreements to 

provide services to women living in the United States Virgin Islands, 

Office of Population 

Affairs (OPA)

Office on Women’s 

Health (OWH)
Appendix I: Minority AIDS Initiative (MAI) 

Funding, Activities, and Grantees Funded, 

Fiscal Years 1999-2011

Page 36 GAO-14-84 Minority AIDS Initiative

Puerto Rico, and Native American women, as well as women sexually 

involved with an incarcerated or recently released partner. (See OWH 

funding and number of grantees funded in table 12.) Additionally, OWH 

awarded grants for outreach and education services and events including 

the National HIV/AIDS Awareness Day and the Young Women’s 

Mobilization project.

Table 12: Office on Women’s Health (OWH) Secretary’s Minority AIDS Initiative 

Funding (in Millions of Dollars) and Number of Grantees, Fiscal Years 2007-2011

Fiscal Year SMAIF Number of Grantees a

2007 $4.0 36

2008 $4.0 37

2009 $6.1 50

2010 $7.0 43

2011 $3.4 30

Source: GAO analysis of Office of HIV/AIDS and Infectious Disease Policy and OWH data.

Note: Dollar amounts are rounded to one decimal point.

a

Secretary’s Minority AIDS Initiative Fund.

RHA reported that it used its SMAIF funding to contract with a for-profit, 

publicly owned, and traded company to provide capacity building services 

in fiscal years 2008-2011. (See RHA funding and number of grantees 

funded in table 13.)

Table 13: Regional Health Administrators (RHA) Secretary’s Minority AIDS Initiative 

Funding (in Millions of Dollars) and Number of Grantees, Fiscal Years 2007-2011

Fiscal Year SMAIF Number of Grantees a

2007 $0 0 

2008 $1.3 1 

2009 $1.8 1 

2010 $1.7 1 

2011 $2.0 1 

Source: GAO analysis of Office of HIV/AIDS and Infectious Disease Policy and RHA data.

Note: Dollar amounts are rounded to one decimal point.

a

Regional Health 

Administrators (RHA)

Secretary’s Minority AIDS Initiative Fund.
Appendix II: Methodology for Review of 

Minority AIDS Initiative (MAI) Services from 

Sample of MAI Annual Grantee Reports

Page 37 GAO-14-84 Minority AIDS Initiative

To identify the types of services provided by grantees under MAI, we 

selected a generalizable sample from 100 fiscal year 2011 grantees in 

order to review their MAI annual grantee reports. To select our sample, 

we created a list of all MAI grantees from the ten Department of Health 

and Human Services (HHS) agencies and offices that awarded MAI 

grants in fiscal year 2011.1 We selected a generalizable sample of 100 

grantees that were approximately proportional to MAI funding amounts for 

the respective agencies and offices. We then requested fiscal year 2011 

MAI annual grantee reports for the 100 grantees from these agencies and 

offices and uploaded the reports into NVivo.2

We used NVivo to conduct a review of MAI services using the MAI annual 

grantee reports we obtained from the generalizable sample of 100 MAI 

grantees we selected.

This sample is generalizable 

to the whole population of MAI grantees. The sample was selected within 

agency strata, with strata sample sizes defined to ensure that the 

distribution of grantee spending for each agency was approximately 

proportional to its distribution in the population of grantees. We calculated 

sampling weights that reflected this design, which allowed us to 

appropriately combine data across the agency strata and make estimates 

that generalized to the whole population of MAI grantees.

3,4

 

1

We identified a total of 1067 organizations awarded MAI grants by the ten HHS agencies 

and offices in fiscal year 2011. In addition to grants, some agencies may have awarded 

MAI funding to recipients through other mechanisms such as cooperative agreements, 

contracts, or interagency agreements. We have treated these recipients as “grantees” for 

purposes of this report regardless of the funding mechanism by which they received their 

funds. Fiscal year 2011 was the most recent year that grantee data was available for most 

HHS agencies and offices.

In order to identify the types of MAI services, we 

categorized MAI services into six categories based on an initial review of 

the reports: (1) administrative; (2) medical services; (3) client assistance; 

(4) community outreach/education; (5) training; and (6) testing. We 

2

We obtained fiscal year 2010 MAI annual grantee reports for some grantees who had not 

yet submitted their fiscal year 2011 reports. We reviewed all grantee reports in our sample 

for accuracy and to ensure they contained information on MAI services.

3

NVivo is a qualitative data analysis software system that allows organization and analysis 

of information from a variety of sources including complex nonnumeric or unstructured 

data. 

4

MAI grantees submit annual grantee reports to the agency that awarded their MAI grants 

that typically include information on the types of services they provide with their MAI 

grants. Grantees that receive more than one MAI grant often have to submit a separate 

report to each agency from which they receive funds. 

Appendix II: Methodology for Review of 

Minority AIDS Initiative (MAI) Services from 

Sample of MAI Annual Grantee Reports
Appendix II: Methodology for Review of 

Minority AIDS Initiative (MAI) Services from 

Sample of MAI Annual Grantee Reports

Page 38 GAO-14-84 Minority AIDS Initiative

created an additional category to identify best practices reported by 

grantees to inform our second objective on best practices for community 

outreach and capacity building of community-based organizations serving 

communities that are disproportionately affected by human 

immunodeficiency virus/acquired immunodeficiency syndrome 

(HIV/AIDS). We defined the term best practices to include any successes, 

lessons learned, or challenges overcome by grantees regarding their MAI 

activities. We also created sub-categories for medical services and best 

practices in order to obtain more detailed information on these categories 

(see table 14 for the definitions of MAI categories and sub-categories).

Table 14: Categories of Services and Best Practices Identified in MAI Annual Grantee Reports

Category Definition

Administrative Grantee performs activities to help maintain its ability to conduct MAI activities, daily procedures 

and operation including assisting providers or other organizations in planning or implementing 

MAI activities, providing technical assistance, collaborating with organizations, etc.

Medical Services Grantee provides or assists in providing direct medical services to clients, including dental, 

substance abuse, mental health, etc. 

• HIV Primary and Outpatient Care: grantee provides primary care to clients in an inpatient or 

outpatient setting.

Sub-categories

• Substance Abuse Treatment/Counseling: grantee provides substance abuse treatment or 

care to clients in an inpatient or outpatient setting.

• Mental Health Treatment/Counseling: grantee provides mental health treatment or 

counseling to clients in an inpatient or outpatient setting.

• Screening/Testing for other sexually transmitted infections: grantee screens or tests clients 

for sexually transmitted diseases besides HIV.

• Administrative/Collaboration: grantee assists or collaborates with providers who provide 

direct medical services.

Client Assistance Grantee provides or assists providers in facilitating, referring or supporting client’s care 

coordination, case management, counseling, as well as assisting clients with obtaining social 

services. 

Community Outreach/ Education Grantee provides or assists in providing outreach and education services to clients and 

individuals with HIV/AIDS through social media, marketing, community events, training, etc.

Training Grantee provides or receives training for grantee staff, providers, other organizations, etc. 

Testing Grantee directly provides or assists providers with clients testing services for HIV/AIDS, or other 

related illnesses.

Best Practices Grantee cites any best practices, lessons learned and/or challenges overcome related to their 

MAI activities.
Appendix II: Methodology for Review of 

Minority AIDS Initiative (MAI) Services from 

Sample of MAI Annual Grantee Reports

Page 39 GAO-14-84 Minority AIDS Initiative

Category Definition

• Collaboration: grantee cites collaborating with other organizations that aided its ability to 

provide services to clients.

Sub-categories

• Targeted Community Outreach/Education: grantee cites activities that are specifically 

targeted to improve outreach to communities disproportionately affected by HIV/AIDS.

• Community Outreach/Education: grantee cites activities to improve outreach and marketing 

to clients.

• Client Assistance: grantee cites activities to help improve or facilitate linking clients to care, 

social support or medical services.

• Testing: grantee cites activities to encourage clients to get tested for HIV/AIDS/other 

sexually transmitted infections.

• Medical Services: grantee cites activities to improve their ability to provide or facilitate 

medical care for their clients.

• Capacity Building: grantee cites activities to improve their infrastructure and expand their 

ability to provide services to clients.

• Administrative: grantee cites activities to help maintain its ability to conduct MAI activities, 

daily procedures and operation.

Source: GAO. 

We conducted a review of MAI services from the sample of 100 MAI 

annual grantee reports in which three members of the team 

independently coded a selection of reports to identify MAI services. We 

reviewed each other’s coding to ensure its accuracy and resolved any 

disagreements or inconsistencies in coding through a discussion between 

team members to ensure mutual agreement that the services identified in 

the annual grantee reports were consistent with the categories of services 

listed in Table 14 above.

We identified the services provided in the 100 MAI annual grantee reports 

through several rounds of NVivo coding and review. We then analyzed 

our coding results in order to identify the types and frequency of MAI 

services conducted by MAI grantees in our sample. We analyzed and 

compared the MAI services identified in the six categories by grant 

amount, HHS agency and office (e.g., the Health Resources and Services 

Administration, Centers for Disease Control and Prevention, etc.), source 

of grant (e.g., agency MAI allocation or funding from the Secretary’s MAI 

Fund) and organization type (e.g., community-based organization, city, 

etc). We also analyzed the output to identify best practices reported by 

grantees that were associated with providing MAI services and/or in 

serving communities disproportionally affected by HIV/AIDS. However, 

because MAI grantees generally were not required to discuss best 

practices in their annual grantee reports, we could not estimate the 
Appendix II: Methodology for Review of 

Minority AIDS Initiative (MAI) Services from 

Sample of MAI Annual Grantee Reports

Page 40 GAO-14-84 Minority AIDS Initiative

proportion of grantees identifying such practices and, as a result, our 

estimates are not generalizeable for this purpose.

Estimates of the services provided and population served from this 

sample are generalizable to the population of MAI grantees. We 

summarize the statistical precision of our estimates using a 95 percent 

confidence interval, which is the interval that would contain the population 

value in 95 percent of the samples we could have drawn. Since the size 

of the confidence intervals varies widely across the estimates, we specify 

these intervals where we refer to the estimates.
Appendix III: Comments from the Department 

of Health and Human Services

Page 41 GAO-14-84 Minority AIDS Initiative

Appendix III: Comments from the 

Department of Health and Human Services
Appendix III: Comments from the Department 

of Health and Human Services

Page 42 GAO-14-84 Minority AIDS Initiative
Appendix III: Comments from the Department 

of Health and Human Services

Page 43 GAO-14-84 Minority AIDS Initiative
Appendix IV: GAO Contact and Staff 

Acknowledgments 

Page 44 GAO-14-84 Minority AIDS Initiative

Marcia Crosse, (202) 512-7114 or crossem@gao.gov

In addition to the contact named above, key contributors to this report 

were Tom Conahan, Assistant Director; Romonda McKinney Bumpus; 

Cathleen Hamann; Seta Hovagimian; Jessica Morris; Steven Putansu; 

Jeff Tessin; and Jennifer Whitworth.

Appendix IV: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Acknowledgments 

(291069)
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