GAO 

United States Government Accountability Office

Report to Congressional Requesters

HIV/AIDS

Federal and State 

Efforts to Identify 

Infected Individuals 

and Connect Them to 

Care 

September 2009 

GAO-09-985 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

September 2009

HIV/AIDS

Federal and State Efforts to Identify Infected 

Individuals and Connect Them to Care 

Highlights of GAO-09-985, a report to 

congressional requesters 

Of the estimated 1.1 million 

Americans living with HIV, not all 

are aware of their HIV-positive 

status. Timely testing of HIVpositive individuals is important to 

improve health outcomes and to 

slow the disease’s transmission. It 

is also important that individuals 

have access to HIV care after being 

diagnosed, but not all diagnosed 

individuals are receiving such care. 

The Centers for Disease Control 

and Prevention (CDC) provides 

grants to state and local health 

departments for HIV prevention 

and collects data on HIV. In 2006, 

CDC recommended routine HIV 

testing for all individuals ages 13-

64. The Health Resources and 

Services Administration (HRSA) 

provides grants to states and 

localities for HIV care and services. 

GAO was asked to examine issues 

related to identifying individuals 

with HIV and connecting them to 

care. This report examines: 1) CDC 

and HRSA’s coordination on HIV 

activities and steps they have taken 

to encourage routine HIV testing; 2) 

implementation of routine HIV 

testing by select state and local 

health departments; 3) available 

information on CDC funding for 

HIV testing; and 4) available data 

on the number of HIV-positive 

individuals not receiving care for 

HIV. GAO reviewed reports and 

agency documents and analyzed 

CDC, HRSA, and national survey 

data. GAO interviewed federal 

officials, officials from nine state 

and five local health departments 

chosen by geographic location and 

number of HIV cases, and others 

knowledgeable about HIV. 

The Secretary of Health and Human Services (HHS) is required to ensure that 

HHS agencies, including CDC and HRSA, coordinate HIV programs to enhance 

the continuity of prevention and care services. CDC and HRSA have 

coordinated to assist health care professionals who provide HIV-related 

services. For example, in 2007 and 2008, CDC provided funding to HRSA to 

expand consultation services at the National HIV/AIDS Clinicians’ 

Consultation Center. Both CDC and HRSA have taken steps to encourage 

routine HIV testing—that is, testing all individuals in a health care setting 

without regard to risk. For example, CDC has funded initiatives on routine 

HIV testing and HRSA has provided for training as part of these initiatives. 

Officials from over half of the 14 selected state and local health departments 

in GAO’s review reported implementing routine HIV testing in their 

jurisdictions. However, according to officials we interviewed, those that 

implemented it generally did so at a limited number of sites. Officials from 

most of the selected health departments and other sources knowledgeable 

about HIV have identified barriers that exist to implementing routine HIV 

testing, including lack of funding and legal barriers. 

CDC officials estimated that approximately 30 percent of the agency’s annual 

HIV prevention funding is spent on HIV testing. For example, according to 

CDC officials, in fiscal 2008, this would make the total amount spent on HIV 

testing about $200 million out of the $652.8 million CDC allocated for 

domestic HIV prevention to its Division of HIV/AIDS Prevention. However, 

CDC officials said that they could not provide the exact amount the Division 

spends on HIV testing, because they do not routinely aggregate how much all 

grantees spend on a given activity, including HIV testing. 

CDC estimated that 232,700 individuals with HIV were undiagnosed—that is, 

unaware that they were HIV positive—in 2006, and were therefore not 

receiving care for HIV. CDC has not estimated the total number of 

diagnosed HIV-positive individuals not receiving care, but has estimated that 

32.4 percent, or approximately 12,000, of HIV-positive individuals diagnosed in 

2003 did not receive care for HIV within a year of diagnosis. State-level 

estimates of the number of undiagnosed and diagnosed HIV-positive 

individuals not receiving care for HIV are not available from CDC. HRSA 

collects states’ estimates of the number of diagnosed individuals not receiving 

care, but data are not consistently collected or reported by states, and 

therefore estimates are not available for comparison across all states. 

HHS provided technical comments on a draft of this report, which GAO 

incorporated as appropriate. 

View GAO-09-985 or key components.

For more information, contact Marcia Crosse 

at (202) 512-7114 or crossem@gao.gov. 
Page i GAO-09-985 

Contents 

Letter 1

Background 7 

CDC and HRSA Have Coordinated on HIV Activities to Assist 

Health Care Professionals, and Both Agencies Have Taken Steps 

to Encourage Routine HIV Testing 13 

Most Selected State and Local Health Departments Reported Not 

Widely Implementing Routine HIV Testing in Their Jurisdictions 

and Barriers Exist to Its Implementation 19 

CDC Officials Estimated That About 30 Percent of the Agency’s 

Annual HIV Prevention Funding Is Spent on HIV Testing 24 

National Data Suggest That Most HIV Tests and Nearly Half of HIVPositive Results Occur in a Private Doctor’s Office, HMO, or 

Hospital Setting, but the Data on Settings Where People Test 

Positive Have Limitations 25 

A National Estimate of the Number of Undiagnosed HIV-Positive 

Individuals Is Available, but an Estimate Is Not Available for the 

Total Number of Diagnosed Individuals Not Receiving Care 

Nationally and Neither Estimate Is Available at the State Level 27 

Officials We Interviewed Identified Barriers to Care That Exist for 

HIV, but Agencies Have Implemented Initiatives to Connect HIVPositive Individuals to Care 29 

Agency Comments 32 

Appendix I Information on Transitioning Prisoners with 

HIV to Care Upon Their Release 33 

Appendix II Part A Grantees’ Living HIV/AIDS Cases Used by 

HRSA to Determine Fiscal Year 2009 CARE Act 

Base Grants 41 

Appendix III Part B Grantees’ Living HIV/AIDS Cases Used by 

HRSA to Determine Fiscal Year 2009 CARE Act 

Base Grants 43 

HIV/AIDS Testing and Care 
Appendix IV GAO Contact and Staff Acknowledgments 45 

Abbreviations 

AETC AIDS Education and Training Centers 

AIDS acquired immunodeficiency syndrome 

CARE Act Ryan White Comprehensive AIDS Resources Emergency 

 Act of 1990 

CDC Centers for Disease Control and Prevention 

HAART highly active antiretroviral therapy 

HHS Department of Health and Human Services 

HIV human immunodeficiency virus 

HMO health maintenance organization 

HRSA Health Resources and Services Administration 

NASTAD National Alliance of State and Territorial AIDS Directors 

NHIS National Health Interview Survey 

STD sexually transmitted disease 

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Page ii GAO-09-985 HIV/AIDS Testing and Care
Page 1 GAO-09-985 

 

United States Government Accountability Office

Washington, DC 20548 

 

September 23, 2009 

The Honorable Michael B. Enzi 

Ranking Member 

Committee on Health, Education, Labor, and Pensions 

United States Senate 

The Honorable Richard Burr 

United States Senate 

The Honorable Tom A. Coburn 

United States Senate 

The Honorable Lisa Murkowski 

United States Senate 

It has been more than 28 years since the first cases of acquired 

immunodeficiency syndrome (AIDS) in the United States were reported in 

June 1981. Since that time, approximately 1.7 million Americans have been 

infected with human immunodeficiency virus (HIV), including more than 

580,000 who have died.1

 The most recent data available from the 

Department of Health and Human Services’ (HHS) Centers for Disease 

Control and Prevention (CDC) estimates that there were 1.1 million people 

living with HIV in the United States at the end of 2006, and that 56,300 new 

HIV infections occurred that year.2

Not all of those living with HIV are aware of their HIV-positive status. 

Timely testing of individuals who are HIV positive but have not yet been 

diagnosed is important both in improving health outcomes for those 

individuals and in slowing transmission of the disease. Research has 

shown that the earlier individuals are treated for HIV the better their 

prognosis becomes. In addition, many individuals who know that they are 

HIV positive adopt behaviors that reduce their risk of spreading the 

1

HIV is the virus that causes AIDS. In this report, except where noted, we use the term HIV 

to refer to HIV disease, inclusive of cases that have and have not progressed to AIDS. When 

we use the term AIDS alone it refers exclusively to HIV disease that has progressed to 

AIDS. 

2

CDC estimates HIV case counts based on information it receives from states, the District 

of Columbia, and the U.S. territories and associated jurisdictions. 

HIV/AIDS Testing and Care 
disease, while those who are unaware of their status are more likely to 

pass HIV on to others. According to CDC, it has been estimated that the 

majority of new HIV infections are transmitted from individuals who are 

unaware of their status. 

Testing for HIV can occur in health care settings,3

 such as public health 

clinics, private doctors’ offices, health maintenance organizations (HMO), 

and emergency rooms, or in non-health care settings, such as communitybased organizations.4

 According to data from the 2007 National Health 

Interview Survey (NHIS), less than 40 percent of adults in the United 

States reported having ever been tested for HIV.5

 Further, CDC estimates 

that in 2006, 36 percent of those who were diagnosed with HIV were not 

tested until late in the course of their disease, meaning that they were 

diagnosed with AIDS within 1 year of receiving an HIV-positive result. A 

number of studies have shown that late testing can occur after HIVpositive individuals have made numerous visits to health care settings, 

indicating missed opportunities to test for HIV. 

HIV testing is the first step to connecting HIV-positive individuals to the 

care that they need. Connecting HIV-positive individuals to care can occur 

through, for example, assistance in scheduling appointments and by 

providing transportation to and from appointments. It is also important to 

ensure that individuals have access to and remain in care after they have 

been diagnosed. New advances in HIV treatments have reduced mortality 

rates and have the potential to extend the lives of individuals diagnosed 

with HIV. However, not all diagnosed HIV-positive individuals are 

accessing care options. 

CDC provides funding to state and local health departments for HIV 

prevention, including counseling, testing, and referral services, through 

 

3

For the purposes of this report, we use the term setting to refer to a type of facility, for 

example, emergency rooms. Settings can include multiple sites. We use the term site to 

refer to an individual facility, for example, a specific hospital’s emergency room. 

4

Community-based organizations are organizations that provide social services at the local 

level. 

5

NHIS, which has been conducted since 1957, collects information on a broad range of 

health topics through personal household interviews. Information on HIV testing has been 

included in the NHIS since 1997. The survey is one of the major data collection programs of 

the National Center for Health Statistics, which is part of CDC. 

Page 2 GAO-09-985 HIV/AIDS Testing and Care
cooperative agreements, grants, and contracts.6

 CDC also provides funding 

to community-based organizations and a smaller amount to national 

professional organizations such as the National Medical Association. In 

addition to providing funding, CDC conducts research, surveillance, and 

epidemiologic studies on HIV.7

 CDC has also issued a series of 

recommendations related to HIV testing in health care settings, the most 

recent of which were released in 2006.8

 A major component of the 2006 

recommendations is for all health care settings to test all individuals for 

HIV without regard to risk—a practice called routine HIV testing.9

 This 

represents a significant change from prior CDC guidance, which generally 

recommended that health care settings target testing to groups at high risk 

of contracting HIV or to high-prevalence areas.10 Additionally, CDC has 

identified the requirement for separate written informed consent or 

pretest counseling as barriers to routine HIV testing.11 While the 2006 

recommendations suggest these practices not be required for HIV testing, 

there is some disagreement over whether this would take away important 

protections. States and localities are not required to adopt CDC’s 

recommendations, and state HIV testing laws vary. For example, according 

 

6

A cooperative agreement is a mechanism used to provide financial support when 

substantial interaction is expected between a federal agency and a state, local government, 

or other funded entity. In this report, except where noted, we use the term state to include 

all 50 states, the District of Columbia, and the U.S. territories and associated jurisdictions. 

7

Surveillance is an ongoing, systematic collection, analysis, interpretation, and 

dissemination of data regarding a health-related event. CDC’s HIV surveillance system 

observes, records, and disseminates reports about cases of HIV and AIDS. 

8

CDC has also issued HIV testing recommendations for non-heath care settings, such as 

community-based organizations. CDC is currently working on revising these 

recommendations, which were last updated in 2001. For more information on the 2001 

recommendations, see CDC, “Revised guidelines for HIV counseling, testing, and referral,” 

Morbidity and Mortality Weekly Report, Vol. 50, No. RR-19 (2001). 

9

These CDC recommendations apply to adults and adolescents ages 13-64 and specify that 

routine HIV testing should be done on an opt-out basis. Opt-out testing is a type of routine 

testing where a patient is notified that testing will be performed unless the patient elects to 

decline testing and consent is inferred unless the patient declines. 

10CDC defines high prevalence of HIV as greater than 1 percent. However, CDC now 

recommends conducting routine HIV testing unless the prevalence of undiagnosed HIV 

infection has been shown to be less than 0.1 percent. 

11According to CDC, informed consent is a process of communication between a patient 

and a health care provider through which an informed patient can choose whether to 

undergo HIV testing or decline to do so. CDC defines counseling as a process of assessing 

risk, recognizing specific behaviors that increase the risk of acquiring or transmitting HIV, 

and developing a plan to reduce risks. 

Page 3 GAO-09-985 HIV/AIDS Testing and Care
to a study on state HIV testing laws, some states’ laws require separate 

written informed consent for HIV testing and others do not.12

While CDC is the federal agency primarily responsible for HIV prevention, 

HHS’ Health Resources and Services Administration (HRSA) is the agency 

responsible for administering grant programs authorized by the Ryan 

White Comprehensive AIDS Resources Emergency Act of 1990 (CARE 

Act) and subsequent legislation that provide funding to states, localities, 

and others for HIV-related services. The CARE Act was enacted to address 

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

their family members.13 Each year, assistance to over 530,000 mostly lowincome, underinsured, or uninsured individuals living with HIV is provided 

through CARE Act programs. The 2006 reauthorization of CARE Act 

programs, like the 2000 reauthorization, required states to submit an 

estimate of the size and demographics of the population with HIV within 

the state and a determination of those who have HIV but are not receiving 

HIV-related services. HRSA characterizes this as an unmet need estimate, 

that is, the number of individuals in a state who know their HIV-positive 

status but who are not receiving care for HIV.14 In addition to 

administering CARE Act programs, HRSA provides training to health care 

providers and community service workers who work with people with HIV 

and evaluates best-practice models of health care delivery. 

Given their respective roles in funding HIV prevention and care, CDC and 

HRSA have coordinated on HIV activities in the past. Additionally, the 

CARE Act requires the Secretary of HHS to ensure that HHS agencies, 

including CDC and HRSA, coordinate HIV programs to enhance the 

 

12For more information on this study see, A. Mahajan, et al., “Consistency of State Statutes 

with the Centers for Disease Control and Prevention HIV Testing Recommendations for 

Health Care Settings,” Annals of Internal Medicine, Vol. 150, No. 4 (2009). In addition, the 

National HIV/AIDS Clinicians’ Consultation Center continuously revises and releases an 

online Compendium of State HIV Testing Laws. See http://www.nccc.ucsf.edu/ 

StateLaws/Index.html. 

13Pub. L. No. 101-381, 104 Stat. 576 (codified as amended at 42 U.S.C. §§ 300ff through 300ff121). The 1990 CARE Act added title XXVI to the Public Health Service Act. Unless 

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

14Pub. L. No. 106-345, § 205(a)(2), 114 Stat. 1319, 1332 (codified at 42 U.S.C. § 300ff27(b)(2)-(3)(A)). 

Page 4 GAO-09-985 HIV/AIDS Testing and Care
continuity of prevention and care services for individuals with HIV or 

those at risk of the disease.15

As Congress prepares to reauthorize CARE Act programs, you asked us to 

examine various issues related to identifying and caring for individuals 

with HIV. In this report, we examine: (1) the actions taken by CDC and 

HRSA since 2006 to coordinate on HIV-related activities, and steps the 

agencies have taken to encourage implementation of routine HIV testing; 

(2) the extent to which select state and local health departments have 

implemented routine HIV testing in their jurisdictions and what barriers 

exist to its implementation; (3) available information on how much of 

CDC’s HIV prevention funding is spent on HIV testing;16 (4) national data 

on the types of settings where HIV tests are conducted and the types of 

settings where HIV-positive results occur; (5) available data on national 

and state estimates of the number of undiagnosed and diagnosed HIVpositive individuals who are not receiving care for HIV; and (6) what 

barriers exist to care for HIV and what initiatives are being implemented to 

connect diagnosed HIV-positive individuals to such care. In this report, we 

also provide information on transitioning prisoners with HIV to care upon 

their release. This information is provided in appendix I.17

To examine the actions taken by CDC and HRSA to coordinate on HIVrelated activities, and steps the agencies have taken to encourage 

implementation of routine HIV testing, we reviewed reports that describe 

programs administered by the two agencies. We also reviewed meeting 

minutes from the CDC/HRSA Advisory Committee on HIV and Sexually 

Transmitted Diseases (STD) Prevention to identify HIV activities 

coordinated by CDC and HRSA. In addition, we interviewed officials at 

CDC and HRSA as well as a judgmental sample of officials from 14 state 

 

15See 42 U.S.C. § 300ff-81. 

16Federal funding for HIV testing can come from sources other than HIV prevention 

funding, such as Medicaid reimbursement. Medicaid is a joint federal-state health care 

financing program for certain categories of low-income individuals. However, for this 

report, we focus exclusively on how much of CDC’s HIV prevention funding is spent on 

testing. We focus on CDC because the agency spent more than 85 percent of the nearly 

$900 million that the federal government spent on domestic HIV prevention in fiscal year 

2008. 

17For additional information on the implementation of the CARE Act see GAO, Ryan White 

CARE Act: Effects of Certain Funding Provisions on Grant Awards, GAO-09-894 

(Washington, D.C.: Sept. 18, 2009). 

Page 5 GAO-09-985 HIV/AIDS Testing and Care
and local health departments knowledgeable about these topics.18 We 

selected health departments based on their geographic location and the 

number of HIV cases in their jurisdiction. Our sample is not generalizable 

to all state and local health departments. 

To examine the extent to which select state and local health departments 

have implemented routine HIV testing in their jurisdictions and what 

barriers exist to its implementation, we interviewed our sample of officials 

from state and local health departments as well as officials from the Henry 

J. Kaiser Family Foundation, the National Alliance of State and Territorial 

AIDS Directors (NASTAD), and other organizations that work on HIVrelated issues, including an organization that contracts with state and local 

health departments to coordinate HIV-related issues and an association for 

HIV providers. We also reviewed medical journal articles and reports by 

the Henry J. Kaiser Family Foundation and NASTAD on the 

implementation of routine testing. We did not conduct a state-by-state 

review of all laws related to HIV testing or independently verify 

information related to state laws. 

To examine available information on how much of CDC’s HIV prevention 

funding is spent on HIV testing, we reviewed CDC budget information and 

interviewed officials at CDC. 

To examine national data on the types of settings where HIV tests are 

conducted, we examined NHIS data from 2007 on the number of HIV tests 

conducted by setting type. We performed data reliability checks by testing 

for missing data and outliers and compared our results to published data 

on this topic and determined that these data were sufficiently reliable for 

our purposes. To examine available data on the types of settings where 

HIV-positive results occur, we obtained and reviewed 2007 CDC 

surveillance data on the number of HIV-positive results by facility of 

diagnosis. We reviewed related documentation and interviewed agency 

officials and determined these data were sufficiently reliable for our 

purposes. 

 

18We interviewed officials from nine state health departments and five local health 

departments. We interviewed officials from the following state health departments: 

California, Florida, Hawaii, Indiana, Missouri, North Carolina, Pennsylvania, Rhode Island, 

and Washington. We interviewed officials from the following local health departments: 

Harris County, Tex.; Maricopa County, Ariz.; Memphis, Tenn.; New York, N.Y.; and 

Sacramento County, Calif. 

Page 6 GAO-09-985 HIV/AIDS Testing and Care
To examine available data on national and state estimates of the number 

of undiagnosed and diagnosed HIV-positive individuals who are not 

receiving care for HIV, we reviewed CDC surveillance data and the unmet 

need estimates reported by CARE Act grantees to HRSA. We also obtained 

and reviewed information from CDC and HRSA on how these estimates 

are calculated. We reviewed related documentation and interviewed 

agency officials to determine if national- and state-level data were reliable 

for our purposes. We determined that national data on undiagnosed HIVpositive individuals not receiving care were sufficiently reliable for our 

purposes. We also determined that national data on the number of 

diagnosed HIV-positive individuals not receiving care were reliable, but 

not comprehensive. Finally, we determined that state-level data on the 

number of diagnosed HIV-positive individuals not receiving care are not 

consistently collected or reported across states, and therefore were not 

reliable for our purposes. 

To examine what barriers exist to care for HIV and what initiatives are 

being implemented to connect diagnosed HIV-positive individuals to such 

care, we interviewed officials at CDC and HRSA and our sample of 

officials from state and local health departments. 

We conducted this performance audit from April 2009 through September 

2009 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 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives. 

According to 2007 NHIS data, fewer than 40 percent of adults in the United 

States reported ever having been tested for HIV. In a recent survey by the 

Henry J. Kaiser Family Foundation, the primary reason people gave for not 

being tested is that they do not think they are at risk.19 The second most 

common reason was that their doctor never recommended HIV testing. 

While 38 percent of adults said that they had talked to their doctor about 

HIV, only 17 percent said that their doctor had suggested an HIV test. 

According to this survey, African Americans and Latinos were more likely 

Background 

 

19The Henry J. Kaiser Family Foundation, Survey Brief: Views and Experiences with HIV 

Testing in the U.S. (Menlo Park, CA: June 2009). 

Page 7 GAO-09-985 HIV/AIDS Testing and Care
than adults overall to have had such a conversation with their doctor and 

for the doctor to have suggested testing. Sixty-seven percent of African 

Americans and 45 percent of Latinos said that they had talked to their 

doctor about HIV and 29 percent of African Americans and 28 percent of 

Latinos said that their doctor had suggested an HIV test. 

Technological advances have increased the benefits associated with HIV 

testing as well as with regular care and treatment for HIV. First, advances 

in testing methods, such as rapid HIV tests, have made testing more 

feasible in a variety of different settings and increased the likelihood that 

individuals will receive their results. Rapid tests differ from conventional 

HIV tests in that results are ready sometime from immediately after the 

test is performed to 20 minutes after the test is performed, which means 

that individuals can get tested and receive their results in the same visit.20

Second, the advent of highly active antiretroviral therapy (HAART) has 

transformed HIV from a fatal disease to a treatable condition.21 For 

example, a 25-year-old individual who is in care for HIV can expect to live 

only 12 years less than a 25-year-old individual who does not have HIV. 

In addition, studies have found that people generally reduce risky 

behaviors once they learn of their HIV-positive status. According to one 

study, people who are unaware that they are HIV positive are 3.5 times 

more likely to transmit the disease to their partners than people who know 

their status.22 At the same time, research has shown that individuals are 

often unaware of their status until late in the course of the disease despite 

visits to health care settings. For example, one study looked at HIV case 

reporting in a state over a 4-year period. The study found that of people 

who were diagnosed with HIV late in the course of the disease, 73 percent 

 

20Rapid tests also do not require any special equipment and thus can be performed outside 

of health care settings. Rapid test results require further testing to confirm a positive test 

result. 

21HAART means any combination of three or more antiretroviral drugs. While HAART has 

greatly improved survival rates of individuals living with HIV, there is currently no cure for 

the disease. 

22G. Marks, N. Crepaz, and R.S. Janssen, “Estimating Sexual Transmission of HIV from 

Persons Aware and Unaware that they are Infected with the Virus in the USA,” AIDS, 

Vol. 20, No. 10 (2006). 

Page 8 GAO-09-985 HIV/AIDS Testing and Care
made at least one visit to a health care setting prior to their first reported 

positive HIV test, and the median number of prior visits was four.23

Funding for HIV Testing Funding for HIV testing can come from insurance reimbursement by 

private insurers as well as Medicaid and Medicare, although these payers 

do not cover HIV testing under all circumstances.24 Funding for HIV testing 

can also come from other government sources, such as CDC, CARE Act 

programs, or state and local funding. A study by CDC and the Henry J. 

Kaiser Family Foundation that looked at the insurance coverage of 

individuals at the time of their HIV diagnosis from 1994-2000 found that 

22 percent were covered by Medicaid, 19 percent were covered by other 

public-sector programs, and 27 percent were uninsured. 

The cost of an HIV test varies based on a number of factors, including the 

type of test performed, the test result, and the amount of counseling that is 

associated with the test. For example, from a payer’s perspective, the 

costs of a rapid HIV test are higher for someone who is HIV positive than 

for someone who is not, primarily because rapid testing requires an initial 

rapid test and a confirmatory test when the result is positive with 

counseling conducted after both tests. Additionally, eliminating pretest 

counseling can lower the cost of HIV testing by about $10, regardless of 

the type of test. According to the most recent data available from CDC, in 

2006, the cost of an HIV test could range from $10.16 to $86.84 depending 

on these and other factors. 

CDC HIV Testing 

Recommendations 

CDC issued its first recommendations for HIV testing in health care 

settings in 1987. These recommendations focused on individuals engaged 

in high-risk behaviors and specifically recommended that people who 

were seeking treatment for STDs be tested for HIV on a routine basis. 

Throughout the 1990s and 2000s CDC updated these recommendations 

periodically to reflect new information about HIV. For example, in 2001, 

CDC modified its recommendations for pregnant women to emphasize 

that HIV testing should be a routine part of prenatal care and that the 

 

23CDC, “Missed Opportunities for Earlier Diagnosis of HIV Infection—South Carolina, 

1997–2005,” Morbidity and Mortality Weekly Report, Vol. 55, No. 47 (2006). 

24Medicare is the federal health care financing program for elderly and certain disabled 

individuals. Medicaid is a joint federal-state health care financing program for certain 

categories of low-income individuals. 

Page 9 GAO-09-985 HIV/AIDS Testing and Care
testing process should be simplified to eliminate barriers to testing, such 

as requiring pretest counseling.25 CDC’s 2001 recommendations also 

recommended that HIV testing be conducted routinely in all health care 

settings with a high prevalence of HIV; in low-prevalence settings it was 

recommended that HIV testing be conducted based on an assessment of 

risk. In 2003, CDC introduced a new initiative called “Advancing HIV 

Prevention: New Strategies for a Changing Epidemic.” The initiative had a 

number of strategies, including two that specifically applied to health care 

settings: (1) making HIV testing a routine part of medical care; and 

(2) further reducing perinatal transmission of HIV by universally testing all 

pregnant women and by using HIV rapid tests during labor and delivery or 

postpartum if the mother had not been tested previously. 

Elements of the Advancing HIV Prevention initiative were incorporated 

into CDC’s revised HIV testing recommendations for heath care settings in 

2006.26 The 2006 recommendations represent a major shift from prior 

recommendations for health care settings in that they no longer base HIV 

testing guidelines on risk factors. Rather, they recommend that routine 

HIV testing be conducted for all patients ages 13 through 64 in all health 

care settings on an opt-out basis.27 CDC also recommends that persons at 

high risk of HIV be tested annually; that general consent for medical care 

encompass consent for HIV testing (i.e., separate written consent is not 

necessary); and that pretest information, but not pretest counseling be 

required.28

CDC HIV and AIDS 

Surveillance 

According to CDC, tracking the prevalence of HIV is necessary to help 

prevent the spread of the disease. CDC’s surveillance system consists of 

case counts submitted by states on the number of HIV and AIDS 

 

25According to CDC, many health care providers have since adopted these 

recommendations leading to increased prenatal screening and a 95 percent decline in 

perinatally acquired AIDS cases. 

26CDC, “Revised Recommendations for HIV Testing of Adults, Adolescents, and 

Pregnant Women in Health-Care Settings,” Morbidity and Mortality Weekly Report, Vol. 55, 

No. RR-14 (September 2006). In this report we refer to these recommendations as CDC’s 

2006 routine HIV testing recommendations. 

27CDC specified that if routine testing yields a prevalence of undiagnosed HIV infection of 

less than 0.1 percent in a health care setting, routine testing is no longer necessary. 

28The 2006 recommendations also included updated recommendations regarding HIV 

testing for pregnant women. However, for the purposes of this report we focus on HIV 

testing for the general population. 

Page 10 GAO-09-985 HIV/AIDS Testing and Care
diagnoses, the number of deaths among persons with HIV, the number of 

persons living with HIV or AIDS, and the estimated number of new HIV 

infections. HIV laboratory tests, specifically CD4 or viral load tests, can be 

used to determine the stage of the disease, measure unmet health care 

needs among HIV-infected persons, and evaluate HIV testing and screening 

activities.29

Current CDC estimates related to HIV are not based on data from all states 

because not all states have been reporting such data by name long enough 

to be included in CDC’s estimates. While all states collect AIDS case 

counts through name-based systems, prior to 2008 states collected HIV 

data in one of two different formats, either by name or by code.30 CDC 

does not accept code-based case counts for counting HIV cases because 

CDC does not consider them to be accurate and reliable, primarily 

because they include duplicate case counts. In order for CDC to use HIV 

case counts from a state for CDC’s estimated diagnoses of HIV infection, 

the name-based system must be mature, meaning that the state has been 

reporting HIV name-based data to CDC for 4 full calendar years. CDC 

requires this time period to allow for the stabilization of data collection 

and for adjustment of the data in order to monitor trends. In its most 

recent surveillance report, CDC used the name-based HIV case counts 

from 34 states and 5 territories and associated jurisdictions in its national 

 

29CD4 cells help the body fight infection and are susceptible to attack by the HIV virus. A 

CD4 test is used to determine the number of CD4 cells in the blood to assess the 

functioning of the immune system. An HIV-positive individual will have a lower CD4 cell 

count than an individual without HIV. A viral load test measures the amount of HIV in the 

blood. 

30In name-based systems, cases are collected by name, while in a code-based system cases 

are collected using a code identifier. Even though all states collect AIDS cases by name, 

some states had to transition their reporting systems for cases of HIV that have not 

progressed to AIDS from code to name. Due to the differences in reporting and CDC’s use 

of these data, when we refer to name-based HIV reporting systems or the data collected 

through those systems, we are referring to cases of HIV that have not progressed to AIDS. 

Page 11 GAO-09-985 HIV/AIDS Testing and Care
estimates.31 Name-based HIV reporting had been in place in these 

jurisdictions since the end of 2003 or earlier. 

The CARE Act Under the CARE Act, approximately $2.2 billion in grants were made to 

states, localities, and others in fiscal year 2009. Part A of the CARE Act 

provides for grants to selected metropolitan areas that have been 

disproportionately affected by the HIV epidemic to provide care for HIVpositive individuals. Part B provides for grants to states and territories and 

associated jurisdictions to improve quality, availability, and organization 

of HIV services. Part A and Part B base grants are determined by formula 

based on the number of individuals living with HIV and AIDS in the 

grantee’s jurisdiction.32 For the living HIV/AIDS case counts HRSA used to 

determine fiscal year 2009 Part A and Part B base grants, see appendices II 

and III. Part C provides for grants to public and private nonprofit entities 

to provide early intervention services, such as HIV testing and ambulatory 

care.33 Part F provides for grants for demonstration and evaluation of 

innovative models of HIV care delivery for hard-to-reach populations, 

training of health care providers, and for Minority AIDS Initiative grants.34

Since the 2006 reauthorization of CARE Act programs, HRSA has placed 

an emphasis on states’ unmet need, which is the number of individuals in a 

state’s jurisdiction who know they are HIV positive but who are not 

receiving care for HIV. According to the framework used by HRSA, 

addressing unmet need is a three-step process. First, states are required to 

produce an unmet need estimate, which is submitted to HRSA on the 

 

31The 34 states and 5 territories and associated jurisdictions that had mature name-based 

HIV reporting systems were: Alabama, Alaska, Arizona, Arkansas, Colorado, Florida, 

Georgia, Idaho, Indiana, Iowa, Kansas, Louisiana, Michigan, Minnesota, Mississippi, 

Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North 

Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, 

West Virginia, Wisconsin, Wyoming, American Samoa, the Commonwealth of the Northern 

Mariana Islands, the Commonwealth of Puerto Rico, Guam, and the U.S. Virgin Islands. See 

CDC, HIV/AIDS Surveillance Report, 2007, Vol. 19 (2009). 

32Most other Part A and Part B grants are distributed competitively. For more information 

on Part A and Part B grants, see GAO-09-894, 2-4. 

33The CARE Act also allows Part A and B grantees some flexibility to use funding for HIV 

testing through early intervention services. 

34There is also a Part D, which provides for grants to private nonprofit and public entities 

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

and a Part E, which does not provide for funding for HIV services, but rather includes 

provisions to address various administrative functions. 

Page 12 GAO-09-985 HIV/AIDS Testing and Care
state’s annual Part B grant application.35 To calculate the unmet need, the 

state must determine the total number of individuals who are aware of 

their HIV positive status in their jurisdiction, and then subtract the number 

of individuals who are receiving care for HIV.36 Second, the state must 

assess the service needs and barriers to care for individuals who are not 

receiving care for HIV, including finding out who they are and where they 

live. Third, the state must address unmet need by connecting these 

individuals to care. 

CDC and HRSA have coordinated on activities to assist health care 

professionals who provide HIV-related services. HRSA has encouraged 

routine HIV testing by providing for training for health care providers, as 

part of CDC-funded initiatives. CDC has taken other steps to encourage 

routine HIV testing by funding special initiatives that focus on certain 

populations. 

CDC and HRSA Have 

Coordinated on HIV 

Activities to Assist 

Health Care 

Professionals, and 

Both Agencies Have 

Taken Steps to 

Encourage Routine 

HIV Testing 

CDC and HRSA Have 

Coordinated Activities to 

Assist Health Care 

Professionals Who Provide 

HIV-Related Services 

Since 2006, CDC and HRSA have coordinated activities to assist health 

care professionals who provide HIV-related services. In 2007, CDC and 

HRSA initiated a clinic-based research study to develop, implement, and 

test the efficiency and effectiveness of an intervention designed to 

increase client appointment attendance among patients at risk of missing 

scheduled appointments in HIV clinics, “Increasing Retention in Care 

among Patients Being Treated for HIV Infection.” An interagency 

agreement outlined the responsibilities of CDC and HRSA with respect to 

 

35For purposes of this report, we look only at the unmet need estimates of states that are 

reported in their CARE Act Part B grant applications. 

36According to HRSA’s unmet need framework, an individual diagnosed with HIV is 

considered to be in care if there is evidence that the individual has received a viral load 

test, CD4 count, or provision of antiretroviral therapy within a 12-month time frame. 

Reported CD4 or viral load tests can be used to determine if an individual has entered into 

care because these tests are monitored routinely in the clinical setting. 

Page 13 GAO-09-985 HIV/AIDS Testing and Care
the study.37 For example, under the agreement, CDC is responsible for 

maintaining data gathered from the study and HRSA is responsible for 

presenting their findings at national and international conferences. Each 

agency provided $1.3 million for the study in fiscal year 2009 and will 

continue to provide funds for the study until its final year of operation in 

2011. 

In coordination with a federal interagency work group, CDC and HRSA 

have also participated in the development and publication of a document 

for case managers who work with individuals with HIV.38 The document, 

“Recommendations for Case Management Collaboration and Coordination 

in Federally Funded HIV/AIDS Programs,” outlines best practices for, and 

six recommended components of, HIV case management for federally 

funded HIV case management agencies.39 The document also describes 

how case management is practiced in different settings and methods for 

strengthening linkages among case management programs.40 CDC and 

HRSA were the lead authors of the document and shared staff time and 

production expenses. The agencies published the document in February 

2009. 

CDC also provided HRSA with funding to expand HIV consultation 

services offered to health care professionals at the National HIV/AIDS 

Clinicians’ Consultation Center. The National HIV/AIDS Clinicians’ 

Consultation Center is a component of the HRSA-administered AIDS 

 

37Interagency Agreement Numbers: HAB0700301 (HRSA) and ST07-012.01(CDC), Retaining 

HIV Positive Patients in Medical Care (August 2008). 

38The interagency work group included HRSA’s HIV/AIDS Bureau; CDC’s Division on 

HIV/AIDS Prevention; Centers for Medicare & Medicaid Services; the Substance Abuse and 

Mental Health Services Administration’s Center for Mental Health Services; the National 

Institutes of Health’s National Institute on Drug Abuse; the Department of Housing and 

Urban Development’s Housing Opportunities for Persons with AIDS; and the National 

Association of Social Workers. 

39HHS, Recommendations for Case Management Collaboration and Coordination in 

Federally Funded HIV Programs (Washington, D.C.: August 2008). 

http://www.cdcnpin.org/scripts/features/CaseManagement.pdf. 

40In the context of HIV, case management is a process through which programs facilitate 

access to care, stable housing, and support services for individuals with HIV and their 

families. 

Page 14 GAO-09-985 HIV/AIDS Testing and Care
Education and Training Centers (AETC) program.41 The Consultation 

Center operates hotline systems to provide consultation to health care 

professionals, including the PEPline and Perinatal Hotline. Health care 

professionals access the PEPline to receive information on post-exposure 

management for health care professionals exposed to blood-borne 

pathogens and the Perinatal Hotline for information on treatment and care 

for HIV-diagnosed pregnant women and their infants. CDC provided HRSA 

with $169,000 to support the PEPline and Perinatal Hotline in fiscal year 

2007 and $90,000 to support the PEPline in fiscal year 2008. In addition, 

CDC provided HRSA with $180,000 during fiscal years 2007 and 2008 for 

the enhancement of existing consultation services at the Consultation 

Center for health care professionals who expand HIV testing and need 

assistance in managing a resulting increase in patients who are HIV 

positive. 

In addition, CDC and HRSA have coordinated to prevent duplication of 

HIV training provided to health care professionals. The CDC-funded 

National Network of STD/HIV Prevention Training Centers, HRSA-funded 

AETCs, and other federal training centers, participate in the Federal 

Training Centers Collaboration to ensure that HIV training opportunities 

are not duplicated among the centers.42 The agencies hold biennial 

national meetings to increase training coordination of STD/HIV prevent

and treatment, family planning/reproductive health, and substance abu

prevention to maximize the use of training resources.

ion 

se 

 

43

In addition to coordinating on HIV activities that assist health care 

professionals, CDC and HRSA have participated in the CDC/HRSA 

Advisory Committee on HIV and STD Prevention and Treatment. The 

Advisory Committee was established by the Secretary of HHS in 

November 2002 to assess HRSA and CDC objectives, strategies, policies, 

41HRSA funds AETCs under Part F of the CARE Act. Specifically, HRSA provides grants to a 

network of 11 regional AETCs that conduct training programs for health care providers 

treating individuals with HIV. HRSA oversees AETCs by conducting a number of activities, 

including reviewing grantee progress reports, conducting site visits at AETC locations, and 

scheduling meetings to discuss AETCs activities. 

42In addition to the National Network of STD/HIV Prevention Training Centers and AETCs, 

other organizations that participate in the Federal Training Centers Collaboration include 

the Regional Training Centers for Family Planning, Addiction Technology Transfer Centers, 

Viral Hepatitis Education and Training Projects, and Tuberculosis Regional Training and 

Medical Consultation Centers. 

43The participating agencies held meetings in 2002, 2004, 2006, and 2008. 

Page 15 GAO-09-985 HIV/AIDS Testing and Care
and priorities for HIV and STD prevention and care and serves as a forum 

to discuss coordination of HIV activities. The committee meets twice a 

year and is comprised of 18 individuals who are nominated by the HHS 

Secretary to serve 2- to 4-year terms and are knowledgeable in such public 

health fields as epidemiology, infectious diseases, drug abuse, behavioral 

science, health care delivery and financing, state health programs, clinical 

care, preventive health, and clinical research. The members assess the 

activities administered by HRSA and CDC, including HIV testing initiatives 

and training programs, and make recommendations for improving 

coordination between the two agencies to senior department officials, 

including the HHS Secretary. Officials from CDC and HRSA regularly 

attend the meetings to present current HIV initiatives administered by 

their agencies. 

Officials from 6 of the 14 state and local health departments we 

interviewed said that CDC and HRSA coordination on HIV activities could 

be improved. For example, officials from 3 of these health departments 

attributed the lack of coordination to differing guidelines CDC and HRSA 

use for their grantees. Officials from 1 health department stated that 

although they have the same desired outcome, CDC and HRSA do not 

always coordinate on activities that they fund. They noted that the two 

agencies have inconsistent policies for HIV-related activities, such as 

confidentiality guidelines and policies for data sharing. Officials from 

another health department stated that the two agencies could improve 

coordination on HIV testing and guidelines for funding HIV testing 

initiatives. 

HRSA Has Encouraged 

Routine HIV Testing by 

Providing for Training for 

Health Care Providers as 

Part of CDC-Funded 

Initiatives 

Since the release of CDC’s 2006 routine HIV testing recommendations, 

HRSA has encouraged routine HIV testing by providing for training for 

health care providers, as part of CDC-funded initiatives. CDC and HRSA 

developed interagency agreements through which CDC provided 

$1.75 million in 2007 and $1.72 million in 2008 to HRSA-funded AETCs to 

develop curricula, training, and technical assistance for health care 

providers interested in implementing CDC’s 2006 routine HIV testing 

recommendations.44 As of June 2008, AETCs had conducted over 2,500 

 

44Interagency Agreement Numbers: HAB0600521 (HRSA) and 07FED705251(CDC), 

Training and Technical Assistance to Support the Adoption of CDC’s Recommendation 

for HIV Testing in Health-Care Settings (August 2007) and Interagency Agreement 

Numbers: HAB0700403 (HRSA) and 07FED705251-1(CDC), Training and Technical 

Assistance to Support the Adoption of CDC’s Recommendation for HIV Testing in HealthCare Settings (August 2008). 

Page 16 GAO-09-985 HIV/AIDS Testing and Care
training sessions to more than 40,000 health care providers on the 

recommendations. 

HRSA provided for training during CDC-funded strategic planning 

workshops on routine HIV testing for hospital staff. CDC officials said that 

in 2007, the agency allocated over $900,000 for workshops in eight regions 

across the country on implementing routine HIV testing in emergency 

departments. CDC reported that 748 attendees from 165 hospitals 

participated in these workshops. HRSA-funded AETCs from each of the 

eight regions provided information on services they offer hospitals as they 

prepare to implement routine HIV testing, and also served as facilitators 

during the development of hospital-specific strategic plans. 

In addition, HRSA provided for training as part of a CDC-funded pilot 

project to integrate routine HIV testing into primary care at community 

health centers. HRSA officials said that their primary role in this project, 

called “Routine HIV Screening within Primary Care in Six Southeastern 

Community Health Centers,” was to provide for training on routine HIV 

testing and to ensure that HIV-positive individuals were connected to care, 

and that CDC provided all funding for the project. CDC officials told us 

that the first phase of the project funded routine HIV testing in two sites in 

Mississippi, two sites in South Carolina, and two sites in North Carolina. 

The CDC officials said that in 2008 four sites in Ohio were added and that 

these sites are receiving funding through CDC’s Expanded HIV Testing 

initiative. CDC officials said that they plan to start a second phase of the 

project with additional testing sites. 

CDC Has Taken Other 

Steps to Encourage 

Routine HIV Testing 

CDC has taken other steps to encourage routine HIV testing by funding 

special initiatives that focus on certain populations. In 2007, CDC initiated 

a 3-year project for state and local health departments called the 

“Expanded and Integrated Human Immunodeficiency Virus (HIV) Testing 

for Populations Disproportionately Affected by HIV, Primarily African 

Americans” initiative or the Expanded HIV Testing initiative. In the first 

year of the initiative, CDC awarded just under $35 million to 23 state and 

local health departments that had an estimated 140 or more AIDS cases 

diagnosed among African Americans in 2005. Individual awards were 

proportionately based on the number of cases, with amounts to each 

jurisdiction ranging from about $700,000 to over $5 million. Funding after 

the first year of the initiative was to be awarded to these same health 

Page 17 GAO-09-985 HIV/AIDS Testing and Care
departments on a noncompetitive basis assuming availability of funds and 

satisfactory performance.45 Funding for the second year of the initiative 

was just over $36 million and included funding for 2 additional health 

departments, bringing the total number of funded departments to 25. 

CDC asked health departments participating in the Expanded HIV Testing 

initiative to develop innovative pilot programs to expand testing 

opportunities for populations disproportionately affected by HIV—

primarily African Americans—who are unaware of their status. CDC 

required health departments to spend all funding on HIV testing and 

related activities, including the purchase of HIV rapid tests and connecting 

HIV-positive individuals to care. CDC strongly encouraged applicants to 

focus at least 80 percent of their pilot program activities on health care 

settings, including settings to which CDC had not previously awarded 

funding for HIV testing, such as emergency rooms, inpatient medical units, 

and urgent care clinics. Additionally, CDC required that programs in health 

care settings follow the agency’s 2006 routine HIV testing 

recommendations to the extent permitted by law. Programs in non-health 

care settings were to have a demonstrated history of at least a 2 percent 

rate of HIV-positive test results. 

The 2006 reauthorization of CARE Act programs included a provision for 

the Early Diagnosis Grant program under which CDC would make HIV 

prevention funding for each of fiscal years 2007 through 2009 available to 

states that had implemented policies related to routine HIV testing for 

certain populations.46 These policies were (1) voluntary opt-out testing of 

all pregnant women and universal testing of newborns or (2) voluntary 

opt-out testing of patients at STD clinics and substance abuse treatment 

centers.47 CDC’s fiscal year 2007 appropriation prohibited it from using 

funding for Early Diagnosis grants. In fiscal year 2008, CDC’s 

appropriation provided up to $30 million for the grants. CDC officials told 

us that in 2008, the agency awarded $4.5 million to the six states that had 

implemented at least one of the two specified policies as of December 31, 

 

45CDC plans to hold a new competition for the Expanded HIV Testing initiative after the 

first 3-year funding cycle. CDC also plans to expand the initiative to better meet the needs 

of the Latino population and gay and bisexual men. 

46Pub. L. No. 109-415, § 209, 120 Stat. 2767, 2802-03 (codified at 42 U.S.C. § 300ff-33). 

47Opt-out testing is a type of routine testing where a patient is notified that testing will be 

performed unless the patient elects to decline testing and consent is inferred unless the 

patient declines. 

Page 18 GAO-09-985 HIV/AIDS Testing and Care
2007. In fiscal year 2009, CDC’s appropriation provided up to $15 million 

for grants to states newly eligible for the program.48 CDC officials said that 

in 2009, one state received funding for implementing voluntary opt-out 

testing at STD clinics and substance abuse treatment centers.49 CDC 

officials also told us that they provided HRSA with information on how the 

Early Diagnosis Grant program would be implemented, but have not 

coordinated with the agency on administration of the program. 

Officials from just over half of the state and local health departments we 

interviewed said that their departments had implemented routine HIV 

testing in their jurisdictions, but that they generally did so in a limited 

number of sites. Officials from most of the health departments we 

interviewed and other sources knowledgeable about HIV have identified 

barriers to routine HIV testing, including lack of funding. 

Most Selected State 

and Local Health 

Departments 

Reported Not Widely 

Implementing Routine 

HIV Testing in Their 

Jurisdictions and 

Barriers Exist to Its 

Implementation 

 

48Appropriations in 2008 and 2009 limited the amount that could be made available to any 

one state to $1 million. 

49States that received funding for implementing a policy in 2008 could not receive funding 

for that same policy in 2009. For example, if a state received funding for implementing 

voluntary opt-out testing of patients at STD clinics and substance abuse treatment centers 

in 2008 it could not receive funding for having implemented this policy in 2009. 

Page 19 GAO-09-985 HIV/AIDS Testing and Care
Officials from 9 of the 14 state and local health departments we 

interviewed said that their departments had implemented routine HIV 

testing, but 7 said that they did so in a limited number of sites. Specifically, 

officials from 5 of the state health departments we interviewed said that 

their departments had implemented routine HIV testing in anywhere from 

one to nine sites and officials from 2 of the local health departments said 

that their departments had implemented it in two and four sites, 

respectively. Officials from all but 1 of these 7 departments said that their 

departments used funding from CDC’s Expanded HIV Testing initiative to 

implement routine HIV testing.50 CDC’s goal for its Expanded HIV Testing 

initiative is to test 1.5 million individuals for HIV in areas 

disproportionately affected by the disease and identify 20,000 HIV-infected 

persons who are unaware of their status per year. During the first year of 

the initiative,51 health departments that received funding under the CDC 

initiative reported conducting just under 450,000 HIV tests and identifying 

approximately 4,000 new HIV-positive results.52

Over Half of the Selected 

State and Local Health 

Departments Reported 

Implementing Routine HIV 

Testing in Their 

Jurisdictions, but 

Generally Did So in a 

Limited Number of Sites 

The two other health departments that had implemented routine HIV 

testing—one state health department and one local health department 

located in a large city—had been able to implement routine HIV testing 

more broadly. These departments had implemented routine HIV testing 

prior to receiving funding through the Expanded HIV testing initiative, and 

used the additional funding to expand the number of sites where it was 

implemented. For example, the local health department had started an 

initiative to achieve universal knowledge of HIV status among residents in 

an area of the city highly affected by HIV. The department used funding 

from the Expanded HIV Testing initiative and other funding sources to 

implement routine HIV testing in this area and other sites throughout the 

 

50Officials from one health department said that they funded routine HIV testing through 

the Early Intervention Services portion of their CARE Act Part A grant. 

51Under the Expanded HIV Testing initiative, CDC provided funding to 23 health 

departments in the first year of the initiative and 2 of these departments did not report data 

to CDC. Two additional health departments received funding in the second year of the 

initiative. 

52Though the initiative did not reach its goal in the first year, this could be related to the 

time it takes states and local areas to start up routine HIV testing. NASTAD officials we 

interviewed said that it takes time for states and local areas to build the capacity to 

conduct routine HIV testing, but that once the infrastructure is in place testing can increase 

quickly. According to CDC, the number of tests conducted during the second half of the 

first year of the Expanded HIV Testing initiative was more than four times the number 

conducted during the first half. 

Page 20 GAO-09-985 HIV/AIDS Testing and Care
city, including 20 emergency rooms. An official from the state health 

department said that while the department had already funded routine HIV 

testing in some settings, for example STD clinics and community health 

centers, funding from the Expanded HIV Testing initiative allowed them to 

fund routine HIV testing in other types of settings, for example emergency 

rooms. 

Officials from five health departments we interviewed said that their 

departments had not implemented routine HIV testing in their 

jurisdictions, including three state health departments and two local 

health departments. None of these health departments received funding 

through CDC’s Expanded HIV Testing initiative, and officials from two of 

the state health departments specifically cited this as a reason why they 

had not implemented routine HIV testing. Officials from all of the 

departments that had not implemented routine HIV testing said that their 

departments do routinely test certain populations for HIV, including 

pregnant women, injection drug users, and partners of individuals 

diagnosed with HIV. 

Officials from Selected 

State and Local Health 

Departments and Other 

Sources Have Identified 

Barriers That Exist to 

Implementing Routine HIV 

Testing 

Officials from 11 of the 14 state and local health departments we 

interviewed and other sources knowledgeable about HIV have identified 

barriers that exist to implementing routine HIV testing. Officials from 5 of 

the 11 health departments cited lack of funding as a barrier to routine HIV 

testing. For example, an official from 1 state health department told us 

that health care providers have said that they would do routine HIV testing 

if they could identify who would pay for the cost of the tests. The need for 

funding was corroborated by officials from an organization that contracts 

with state and local health departments to coordinate HIV-related care and 

services. These officials told us that they had often seen routine HIV 

testing end when funding streams dried up and noted that there has been 

little implementation of CDC’s 2006 routine HIV testing recommendations 

in their area outside of STD clinics and programs funded through the 

Expanded HIV Testing initiative. 

Officials from state and local health departments we interviewed and other 

sources also cited lack of insurance reimbursement as a barrier to routine 

HIV testing. When identifying lack of funding as a barrier to routine HIV 

testing, officials from two state health departments we interviewed 

explained that there is a general lack of insurance reimbursement for this 

purpose. Other organizations we interviewed and CDC also raised the lack 

of insurance reimbursement for routine HIV testing as a barrier. For 

example, one provider group that we spoke with said that many providers 

Page 21 GAO-09-985 HIV/AIDS Testing and Care
are hesitant to offer HIV tests without knowing whether they will be 

reimbursed for it. In a recent presentation, CDC reported that out of 11 

insurance companies, as of May 2009, all covered targeted HIV testing,53

but only 6 reimbursed for routine HIV testing.54 CDC also reported that as 

of this same date only one state required that insurers reimburse for HIV 

tests regardless of whether testing is related to the primary diagnosis.55

CDC noted that legislation similar to this state’s has been introduced, but 

not passed, in two other states as well as at the federal level. 

Medicare does not currently reimburse for routine HIV testing, though the 

Centers for Medicare & Medicaid Services initiated a national coverage 

analysis as the first step in determining whether Medicare should 

reimburse for this service.56 While federal law allows routine HIV testing as 

a covered service under Medicaid, individual states decide whether or not 

they will reimburse for routine HIV testing. According to one study, 

reimbursement for routine HIV testing has not been widely adopted by 

state Medicaid programs.57 Many insurers, including Medicare and 

Medicaid, base their reimbursement policies on the recommendations of 

the U.S. Preventive Services Task Force, which is the leading independent 

panel of private-sector experts in prevention and primary care.58 While the 

Task Force has recommended that clinicians conduct routine HIV testing 

when individuals are at increased risk of HIV infection and for all pregnant 

 

53HIV testing is targeted when it is based on an assessment of risk. 

54CDC, Update on HIV Testing (presentation given at the CDC-HRSA Advisory Committee 

meeting, Atlanta, GA: May 2009). 

55Requiring insurers to reimburse for HIV testing regardless of primary diagnosis means 

that plans have to cover HIV testing for individuals who are asymptomatic and for whom 

exposure to infection is uncertain. It also requires plans to cover testing done by an 

emergency or urgent care service provider, even if the testing is unrelated to the reason for 

the visit. 

56As a result of this analysis, on September 9, 2009, the Centers for Medicare & Medicaid 

Services issued a proposal to cover routine HIV testing for certain populations. 

57L. Cheever, et al., “Ensuring Access to Treatment for HIV Infection,” Clinical Infectious 

Diseases, Vol. 45, No. 4 (2007). 

58The U.S. Preventive Services Task Force was first convened by the U.S. Public Health 

Service in 1984. Since 1998, the Task Force has been sponsored by HHS’ Agency for 

Healthcare Research and Quality. According to the Agency for Health Care Research and 

Quality, the Task Force conducts rigorous, impartial assessments of the scientific evidence 

for the effectiveness of a broad range of clinical preventive services, including screening, 

counseling, and preventive medications. Its recommendations are considered the “gold 

standard” for clinical preventive services. 

Page 22 GAO-09-985 HIV/AIDS Testing and Care
women, it has not made a recommendation for routine HIV testing when 

individuals are not at increased risk, saying that the benefit in this case is 

too small relative to the potential harms.59

In addition, officials from three state health departments we interviewed 

discussed legal barriers to implementing routine testing. For example, 

officials from one department said that implementation of routine HIV 

testing would require a change in state law to eliminate the requirement 

for pretest counseling and written informed consent. Similarly, officials 

from another department said that while their department had been able 

to conduct routine testing through the Expanded HIV Testing initiative, 

expanding it further might require changing state law to no longer require 

written informed consent for HIV testing. The officials explained that 

while the initiative did have a written informed consent form, the 

department had been able to greatly reduce the information included on 

the form in this instance. The department is currently in the process of 

looking for ways to further expand HIV testing without having to obtain 

changes to state law. According to a study published in the Annals of 

Internal Medicine, as of September 2008, 35 states’ laws did not present a 

barrier to implementing routine HIV testing, though the 3 states discussed 

above were identified as having legal barriers.60

Officials from 3 of the state and local health departments we interviewed 

discussed operational barriers to integrating routine HIV testing with the 

policies and practices already in place in health care settings. For 

example, an official from a state health department said that the 

department tries to work past operational barriers to routine HIV testing, 

but if after 6 months the barriers prove too great in one site the 

department moves implementation of routine HIV testing to another site. 

An official from another state health department noted that in hospital 

settings it can take a long time to obtain approval for new protocols 

associated with routine HIV testing. NASTAD conducted a survey of the 25 

state and local health departments that received funding through the 

Expanded HIV Testing initiative and found that health departments 

 

59The U.S. Preventive Services Task Force defines increased risk for HIV infection as 

reporting one or more individual risk factors or receiving health care in a high-prevalence 

or high-risk clinical setting. 

60For more information on this study, see A. Mahajan, et al., “Consistency of State Statutes 

with the Centers for Disease Control and Prevention HIV Testing Recommendations for 

Health Care Settings,” Annals of Internal Medicine, Vol. 150, No. 4 (2009). 

Page 23 GAO-09-985 HIV/AIDS Testing and Care
reported some barriers in implementing routine HIV testing, including 

obtaining buy-in from staff in health care settings and providing adequate 

training, education, and technical assistance to this staff. Other barriers 

mentioned by officials from health departments we interviewed included 

health care providers not being comfortable testing everyone for HIV and 

the ability of providers to provide care for the increased number of people 

who might be diagnosed through expanded HIV testing. 

CDC officials estimated that approximately 30 percent of the agency’s 

annual HIV prevention funding is spent on HIV testing. For example, 

according to CDC officials, in fiscal year 2008 this would make the total 

amount spent on HIV testing about $200 million out of the $652.8 million 

CDC allocated for domestic HIV prevention to its Division of HIV/AIDS 

Prevention.61 Of the $200 million CDC officials estimated was spent on 

testing, CDC did report that, in fiscal year 2008, $51.1 million was spent on 

special HIV testing initiatives, such as the Expanded HIV testing initiative 

and the Early Diagnosis Grant program.62

CDC Officials 

Estimated That About 

30 Percent of the 

Agency’s Annual HIV 

Prevention Funding Is 

Spent on HIV Testing 

CDC officials said that, outside of special testing initiatives, they could not 

provide the exact amount CDC spent on HIV testing. CDC’s Division of 

HIV/AIDS Prevention spends the majority of its domestic HIV prevention 

budget in connection with cooperative agreements, grants, and contracts 

to state and local health departments and other funded entities. CDC 

officials explained that grantees submit reports to CDC on the activities 

they fund at the middle and end of the year. The officials said that while 

project officers check to see that these reports are consistent with how 

grantees planned to spend their funding, CDC does not routinely aggregate 

how much all grantees spent on a given activity, including HIV testing. In 

addition, outside of the Expanded HIV Testing initiative, CDC does not 

maintain data on how funds for HIV testing are distributed to different 

 

61According to CDC officials, in fiscal year 2008 CDC allocated approximately $79 million in 

domestic HIV prevention funding to other divisions in the agency, including the Division of 

Adolescent and School Health, the Division of STD Prevention, the Division of 

Reproductive Health, and the Division of TB Elimination. For the purposes of this report, 

we focus on the Division of HIV/AIDS Prevention because it received nearly 90 percent of 

CDC’s HIV prevention funding. 

62Other federal agencies have also provided funding for special HIV testing initiatives. For 

example, HHS’ Office of Population Affairs provided $10 million to 77 projects in 34 states 

to expand HIV testing in family planning projects over 2 years. The Substance Abuse and 

Mental Health Services Administration has committed $60 million from 2007-2012 to 

expand routine HIV testing in 22 states. 

Page 24 GAO-09-985 HIV/AIDS Testing and Care
settings within jurisdictions. For example, this would mean that CDC does 

not have data on how much money a state health department spends on 

testing in emergency rooms, versus how much money it spends on testing 

in community-based organizations. 

According to data from NHIS, nearly 70 percent of all HIV tests in the 

United States were conducted in a private doctor’s office, HMO, or 

hospital setting in 2007. Specifically, 50 percent of all HIV tests were 

conducted in a private doctor’s office or HMO and nearly 20 percent of all 

HIV tests were conducted in a hospital setting, including emergency 

departments. The remaining tests were conducted in a variety of settings, 

including public clinics and HIV counseling and testing sites. Less than 

1 percent of all HIV tests were conducted in a correctional facility, STD 

clinic, or a drug treatment facility. These data are similar to earlier data 

from NHIS. In 2002, NHIS found that 44 percent of all HIV tests were 

conducted in a private doctor’s office or HMO and 22 percent of all HIV 

tests were conducted in a hospital setting. 

Analysis of CDC surveillance data on the settings in which HIV-positive 

individuals are diagnosed suggests that approximately 40 percent of all 

HIV-positive results in the United States occurred in a private doctor’s 

office, HMO, or hospital setting in 2007,63 the most recent year for which 

data were available.64 These data also suggest that hospital inpatient 

settings account for a disproportionate number of HIV-positive results 

discovered late in the course of the disease. In 2007, hospital inpatient 

settings accounted for 16 percent of all HIV-positive results. Among HIV 

cases diagnosed in 2006, these same settings accounted for 31 percent of 

HIV-positive results that occurred within 1 year of an AIDS diagnosis. 

National Data Suggest 

That Most HIV Tests 

and Nearly Half of 

HIV-Positive Results 

Occur in a Private 

Doctor’s Office, HMO, 

or Hospital Setting, 

but the Data on 

Settings Where 

People Test Positive 

Have Limitations 

While CDC surveillance data can provide some indication of the types of 

settings where the greatest percentage of HIV-positive results occur, data 

limitations did not permit a more detailed analysis of HIV-positive results 

by setting type. Specifically, information on facility of diagnosis was 

 

63CDC officials noted that the settings where HIV diagnoses are reported can sometimes 

differ from the settings where individuals test positive for HIV. Specifically, they said that 

in the 2007 surveillance data, individuals who tested positive for HIV in the emergency 

room were included in the HIV diagnoses reported for hospital inpatient settings. 

64CDC surveillance data on the settings in which HIV-positive individuals were diagnosed in 

2007 are from the 34 states that had mature name-based HIV reporting systems that year. 

Page 25 GAO-09-985 HIV/AIDS Testing and Care
missing or unknown for nearly one out of every four HIV cases reported 

through the surveillance system in 2007.65 CDC officials told us that in the 

past the agency used data from the Supplement to HIV/AIDS Surveillance 

project to examine the types of settings where individuals test positive for 

HIV, but this project ended in 2004.66 CDC reported that in place of the 

Supplement to HIV/AIDS Surveillance project, the agency has 

implemented the Medical Monitoring Project.67 However, data from the 

Medical Monitoring Project were not available at the time of our analysis.68

 

65CDC surveillance data also exclude states that do not have mature name-based HIV 

reporting systems. In 2007, 16 states and the District of Columbia did not have a mature 

name-based HIV reporting system, including some large states such as California and 

Massachusetts. In addition, name-based data do not include individuals taking an 

anonymous HIV test. As of April 2008, 41 states and 4 territories and associated 

jurisdictions offered anonymous testing. 

66The Supplement to HIV/AIDS Surveillance project was a collaborative effort between 

CDC and 19 state and local areas that conducted cross-sectional interviews with 

individuals with HIV from 1990 to 2004. 

67The Medical Monitoring Project is conducted in 23 participating project areas that are 

estimated to include over 80 percent of the total HIV cases in the United States. 

68Data from the first year of CDC’s Expanded HIV Testing initiative can also provide 

information on the types of settings where HIV-positive results occur. For example, these 

data suggest that HIV testing in emergency rooms may yield a disproportionate number of 

positive results per HIV test conducted. However, data from this initiative are not 

generalizable, because the types of settings funded through the initiative are not 

representative of the types of settings where HIV testing is conducted in the United States. 

Page 26 GAO-09-985 HIV/AIDS Testing and Care
CDC has calculated a national estimate of more than 200,000 undiagnosed 

HIV-positive individuals—that is, individuals who were unaware they are 

HIV positive and were therefore not receiving care for HIV. CDC estimated 

that 232,700 individuals, or 21 percent of the 1.1 million people living with 

HIV at the end of 2006, were unaware that they were HIV positive.69

CDC does not have a national estimate of the total number of diagnosed 

individuals not receiving care, but CDC has calculated a national estimate 

of more than 12,000 diagnosed HIV-positive individuals who did not 

receive care within a year after they were diagnosed with HIV in 2003. 

CDC reported that the estimated proportion of individuals with HIV who 

did not receive care within a year of diagnosis—which CDC measures by 

the number of HIV-positive individuals who did not have a reported CD4 

or viral load test within this time—was 32.4 percent, or 12,285 of the 

37,880 individuals who were diagnosed with HIV in 2003.70 Since this 

estimate is based on the number of HIV-positive individuals who did not 

receive care within a year of diagnosis, this estimate does not include all 

individuals diagnosed with HIV who are not receiving care. For example, 

an individual may receive care within a year of diagnosis, but subsequently 

drop out of care 2 years later. Or an individual may receive care 2 years 

after diagnosis. In these examples, the individuals’ change in status as 

receiving care or not receiving care is not included in CDC’s estimate of 

the proportion of diagnosed individuals not receiving care. 

A National Estimate 

of the Number of 

Undiagnosed HIVPositive Individuals Is 

Available, but an 

Estimate Is Not 

Available for the Total 

Number of Diagnosed 

Individuals Not 

Receiving Care 

Nationally and 

Neither Estimate Is 

Available at the State 

Level 

Although CDC has published these estimates, the agency has noted 

limitations to the data used to calculate the number of diagnosed HIVpositive individuals not receiving care for HIV. First, not all states require 

laboratories to report all CD4 and viral load test results; without this 

information being reported, CDC’s estimates may overstate the number of 

 

69CDC uses a statistical method to calculate these estimates. For more information on this 

method, see CDC, “HIV Prevalence Estimates—United States,” 2006, Morbidity and 

Mortality Weekly Report, Vol. 57, No. 39 (2008). 

70These estimates are based on the 33 states with mature confidential name-based HIV 

reporting used in CDC’s 2005 surveillance report. These states have had name-based HIV 

reporting systems in place since at least 2000. See CDC, “Reported CD4+ T-lymphocyte 

results for adults and adolescents with HIV/AIDS—33 states, 2005,” HIV/AIDS Surveillance 

Supplemental Report, Vol. 11, No. 2 (2005). 

Page 27 GAO-09-985 HIV/AIDS Testing and Care
individuals who did not enter into care within 1 year of HIV diagnosis.71

Additionally, in the past, CDC only required jurisdictions to report an 

individual’s first CD4 or viral load test, which did not allow CDC to 

provide an estimate of all HIV-positive individuals who are not receiving 

care for HIV after the first year. CDC is currently disseminating updated 

data collection software which will permit the collection and reporting of 

all results collected by states. However, CDC officials told us that this 

software is still going through quality control checks. 

While CDC calculates national estimates of the number of undiagnosed 

HIV-positive individuals not receiving care for HIV and the number of 

diagnosed HIV-positive individuals who did not receive care within a year 

of diagnosis, the agency does not calculate these estimates at the state 

level. CDC officials said that these estimates are not available at the state 

level because not all states have mature name-based HIV reporting 

systems.72 CDC officials said that the agency is determining what it will 

need to estimate the number of undiagnosed individuals at the state level 

once all states have mature HIV reporting systems. CDC officials also said 

that once the new data collection software to collect CD4 and viral load 

test results from states is ready, data on all diagnosed HIV-positive 

individuals not receiving care may be available at the state level for those 

states with mature name-based HIV reporting systems with laboratory 

reporting requirements.73

 

71According to CDC, not all states require laboratories to report CD4 and viral load results 

at all levels. Individuals whose tests are not reported are included in the number of HIVpositive individuals not receiving care for HIV because CDC has no indication that theses 

individuals are in care. As of December 2008, 26 states, the District of Columbia, and 

Puerto Rico required laboratory reporting of all CD4 and viral load test results. 

72Even though all states are collecting AIDS cases by name, some states are transitioning 

their reporting systems for cases of HIV that have not progressed to AIDS from code- to 

name-based. Due to the differences in reporting and CDC’s use of these data, when we 

refer to name-based HIV reporting systems or the data collected through those systems, we 

are referring to cases of HIV that have not progressed to AIDS. Although all states and 

territories and associates jurisdictions, with the exception of the Federated States of 

Micronesia, Palau, and the Republic of the Marshall Islands, have switched to a name-based 

HIV reporting system, not all systems are mature. Systems are required to be mature in 

order to be used in CDC’s surveillance estimates. All systems in which name-based HIV 

counts are being collected will be mature by 2012 and case counts will be available in 2014. 

73CDC officials noted that underreporting of CD4 and viral load test results may continue to 

occur under the new data collection software, and additional study may be required to 

provide estimates of the number of diagnosed HIV-positive individuals not receiving care at 

the state level. 

Page 28 GAO-09-985 HIV/AIDS Testing and Care
HRSA also collects states’ estimates of the number of diagnosed HIVpositive individuals not receiving care for HIV, but data are not 

consistently collected or reported by states, and therefore estimates are 

not available for comparison across all states. States report their estimates 

of the number of diagnosed HIV-positive individuals who are not receiving 

care as unmet need estimates to HRSA as a part of the states’ CARE Act 

Part B grant applications. However, these estimates have limitations and 

are not comparable across states. One limitation is that not all states 

require laboratory reporting of CD4 and viral load results for all 

individuals who receive the tests. States use reported CD4 and viral load 

test results to calculate their unmet need, and, according to HRSA, without 

data for all individuals who receive CD4 or viral load tests, a state may 

overestimate its unmet need. Another limitation is that the estimates 

submitted in the states’ fiscal year 2009 grant applications were calculated 

using differing time periods. For example, New Hampshire calculated its 

unmet need estimate using HIV cases collected as of December 31, 2004, 

while Colorado calculated its estimate using data collected as of June 30, 

2008. Additionally, not all states have access to information on the number 

of individuals receiving care through private insurance; therefore, these 

individuals are counted as part of the state’s unmet need. 

According to officials we interviewed, several barriers exist that could 

prevent HIV-positive individuals from receiving care. HRSA officials told 

us that structural barriers within the health care system, such as no or 

limited availability of services, inconvenient service locations and clinic 

hours, and long wait times for appointments can influence whether an 

individual is receiving care for HIV. Other barriers identified by HRSA 

officials are the quality of communication between the patient and 

provider, lack of or inadequate insurance, financial barriers, mental illness, 

and substance abuse. HRSA officials also noted that personal beliefs, 

attitudes, and cultural barriers such as racism, sexism, homophobia, and 

stigma can also have an impact on an individual’s decision to seek care. 

Officials from two states and one local health department we spoke with 

stated that transportation was a barrier, while officials from two state 

health departments stated that lack of housing was a barrier for access to 

care. Unstable housing can prevent individuals with HIV from accessing 

Officials We 

Interviewed Identified 

Barriers to Care That 

Exist for HIV, but 

Agencies Have 

Implemented 

Initiatives to Connect 

HIV-Positive 

Individuals to Care 

Page 29 GAO-09-985 HIV/AIDS Testing and Care
health care and adhering to complex HIV treatments because they must 

attend to the more immediate need of obtaining shelter.74

Agencies have implemented initiatives to connect diagnosed individuals to 

care for HIV. For example, part of CDC’s Expanded HIV Testing initiative 

focused on connecting individuals diagnosed with HIV to care. In the first 

year of the initiative, 84 percent of newly diagnosed patients received their 

HIV test results and 80 percent of those newly diagnosed were connected 

to care. CDC has also funded two studies that evaluated a case 

management intervention to connect HIV-positive individuals to care for 

HIV. In these studies, case management was conducted in state and local 

health departments and community-based organizations and included up 

to five visits with a case manager over a 3-month period. In one of these 

studies, 78 percent of individuals who participated in case management 

were still in care 6 months later. 

HRSA has developed two initiatives as Special Projects of National 

Significance.75 The first initiative, “Enhancing Access to and Retention in 

Quality HIV Care for Women of Color,” was developed to implement and 

evaluate the effectiveness of focused interventions designed to improve 

timely entry and retention into quality HIV care for women of color. The 

second initiative, the “Targeted HIV Outreach and Intervention Model 

Development” initiative, was a 5-year, 10-site project implemented to bring 

underserved HIV-positive individuals into care for HIV. According to 

HRSA, results of the initiative indicated that individuals are less likely to 

have a gap of 4 months or more of care when they have had nine or more 

contacts with an outreach program within the first 3 months of these 

programs. 

In collaboration with AIDS Action, an advocacy organization formed to 

develop policies for individuals with HIV, HRSA has also funded the 

“Connecting to Care” initiative. AIDS Action and HRSA developed the 

initiative to highlight successful methodologies to help connect or 

reconnect individuals living with HIV to appropriate and ongoing medical 

care. The methodologies were identified from cities across the country 

 

74See GAO, Ryan White CARE Act: Implementation of the New Minority AIDS Initiative 

Provisions, GAO-09-315 (Washington, D.C.: March 2009), 43-47. 

75Special Projects of National Significance grants are authorized by Part F of the CARE Act. 

These grants fund programs to quickly respond to emerging needs and programs to develop 

a standard electronic data system. 

Page 30 GAO-09-985 HIV/AIDS Testing and Care
and are being utilized in different settings. The initiative includes two 

publications with 42 interventions that have been reported to be 

successful in connecting HIV-positive individuals to care. The publications 

provide a description, logistics, strengths and difficulties, and outcomes of 

each intervention and focus specifically on homeless individuals, Native 

Americans, immigrant women, low-income individuals in urban and rural 

areas, and currently or formerly incarcerated individuals. AIDS Action has 

held training workshops that provided technical assistance to explain the 

interventions, including how to apply the best practices from successful 

programs. 

HRSA provides grants under Part C of the CARE Act to public and private 

nonprofit entities to provide early intervention services to HIV-positive 

individuals on an outpatient basis that can help connect people to care. 

Part C grantees are required to provide HIV medical care services that can 

include outpatient care, HIV counseling, testing, and referral, medical 

evaluation and clinical care, and referrals to other health services. These 

programs also provide services to improve the likelihood that undiagnosed 

individuals will be identified and connected to care, such as outreach 

services to individuals who are at risk of contracting HIV, patient 

education materials, translation services, patient transportation to medical 

services, and outreach to educate individuals on the benefits of early 

intervention. 

HRSA and CDC are currently collaborating on a clinic-based research 

study, “Increasing Retention in Care among Patients Being Treated for HIV 

Infection.” The study is designed to develop, implement, and test the 

efficacy of an intervention intended to increase appointment attendance 

among individuals at risk of missing scheduled appointments in HIV 

clinics. 

In addition to CDC and HRSA initiatives, officials we interviewed told us 

that state and local health departments have implemented their own 

initiatives to connect HIV-positive individuals to care. Officials from six 

states and five local health departments we spoke with stated that their 

departments use case management to assist HIV-positive individuals 

through the process of making appointments and to help address other 

needs of the individuals. For example, officials from one of these health 

departments explained that some case managers sign up qualified 

individuals for an AIDS Drug Assistance Program and others assist with 

locating housing or with substance abuse issues, which can also be 

barriers to staying in care. Case managers make sure individuals are 

staying in care by finding patients who have missed appointments or who 

Page 31 GAO-09-985 HIV/AIDS Testing and Care
providers have been unable to contact. In addition, officials from one state 

and four local health departments we spoke with told us that their 

departments use mental health professionals and officials from one state 

and three local health departments told us that their departments use 

substance abuse professionals to connect individuals to care, since 

individuals who need these services are at a high risk of dropping out of 

care. Officials from two health departments said that their departments 

use counseling and officials from one health department said that partner 

counseling is conducted when an individual is diagnosed with HIV. 

HHS provided technical comments on a draft of the report, which we 

incorporated as appropriate. Agency Comments 

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

Services. The report will be available at no charge on GAO’s Web site at 

http://www.gao.gov. 

If you or your staffs have any questions, please contact me at (202) 512-

7114 or crossem@gao.gov. Contact points for our Offices of Congressional 

Relations and Public Affairs may found on the last page of this report. 

Other staff who made major contributions to this report are listed in 

Marcia Crosse

appendix IV. 

Director, Health Care 

Page 32 GAO-09-985 HIV/AIDS Testing and Care
Appendix I: Information on Transitioning 

Prisoners with HIV to Care Upon Their Appendix I: Information on Transitioning Release 

Prisoners with HIV to Care Upon Their 

Release 

U.S. federal prisons have become a principal screening and treatment 

venue for thousands of individuals who are at high risk for human 

immunodeficiency virus (HIV) or who have HIV.1

 According to a 2008 

report by the Bureau of Justice Statistics, the overall rate of estimated 

confirmed acquired immune deficiency syndrome (AIDS) cases among the 

prison population (.46 percent) was more than 2.5 times the rate of the 

general U.S. population at the end of calendar year 2006.2

 The Bureau of 

Justice Statistics also reported that 1.6 percent of male inmates and 

2.4 percent of female inmates in state and federal prisons were known to 

be HIV positive. To ensure that infected individuals are aware of their 

HIV-positive status and to ensure that they receive care while in prison, 21 

states tested all inmates for HIV at admission or at some point during their 

incarceration. Forty-seven states and all federal prisons tested inmates if 

they had HIV-related symptoms or if they requested an HIV test. 

The Ryan White Comprehensive AIDS Resources Emergency Act of 1990 

(CARE Act) was enacted to address the needs of jurisdictions, health care 

providers, and people with HIV and their family members.3

 CARE Act 

programs have been reauthorized three times (1996, 2000, and 2006) and 

are scheduled to be reauthorized again in 2009.4

 The CARE Act 

Amendments of 2000 required the Health Resources and Services 

Administration (HRSA) to consult with the Department of Justice and 

others to develop a plan for the medical case management and provision 

of support services to individuals with HIV when they are released from 

the custody of federal and state prisons. The plan was to be submitted to 

Congress no later than 2 years after the date of enactment of the CARE Act 

Amendments of 2000. 

 

1

HIV is the virus that causes acquired immune deficiency syndrome (AIDS). In this report, 

except where noted, we use the term HIV to refer to HIV disease, inclusive of cases that 

have and have not progressed to AIDS. When we use the term AIDS alone it refers 

exclusively to HIV disease that has progressed to AIDS. 

2

Calendar year 2006 data were the most recent data available at the time of this report. U.S. 

Department of Justice, Bureau of Justice Statistics, HIV in Prisons, 2006 (Washington, 

D.C.: 2008). http://www.ojp.usdoj.gov/bjs/pub/htm1/hivp/2006/hivp06.htm. 

3

Pub. L. No. 101-381, 104 Stat. 576 (codified as amended at 42 U.S.C. §§ 300ff through 300ff121). The 1990 CARE Act added title XXVI to the Public Health Service Act. Unless 

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

4

CARE Act programs were previously 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), and the Ryan White HIV/AIDS 

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

Page 33 GAO-09-985 HIV/AIDS Testing and Care 
Appendix I: Information on Transitioning 

Prisoners with HIV to Care Upon Their 

Release 

You asked us to review the implementation status of the plan and to 

determine the extent of any continued coordination between HRSA and 

the Department of Justice to transition prisoners with HIV to CARE Act 

programs. However, HRSA officials told us that they did not create this 

plan or coordinate with the Department of Justice to create this plan. 

Additionally, the requirement for this plan was eliminated by the 2006 

Ryan White Treatment Modernization Act. We are therefore providing 

information related to other steps that HRSA has taken to address the 

provision of HIV prevention and care for incarcerated persons with HIV 

transitioning back to the community and into CARE Act funded programs. 

Additionally, we provide information on steps taken by the Centers for 

Disease Control and Prevention (CDC) and states to address this issue.5

To provide information related to the steps that CDC and HRSA have 

taken to address the provision of HIV prevention and care for incarcerated 

persons, we interviewed CDC and HRSA officials. We also interviewed 

officials from nine state health departments about their programs for 

incarcerated persons with HIV transitioning back to the community and 

into CARE Act-funded programs, and the limitations of these programs.6

From these nine state health departments, officials from eight states 

provided responses about their programs. The remaining state did not 

have a transition program in place. Our sample is not generalizable to all 

state and local health departments. 

The U.S. prison system has been the focus of many studies on HIV testing 

for prisoners and care for those with HIV while in prison and upon their 

release. Studies have been conducted to determine the number of 

individuals who are accessing HIV testing and treatment for the first time 

upon their incarceration. Studies have also been conducted to evaluate 

how infected prisoners fare in their HIV treatment upon release from 

prison, as inmates often encounter social and economic changes including 

the need to secure employment and housing, establish connections with 

family, and manage mental health and substance abuse disorders. For 

example, one recent study of the Texas state prison system published in 

Background 

 

5

CDC provides funding to state and local health departments for HIV prevention, including 

counseling, testing, and referral services, primarily through cooperative agreements and 

grants. 

6

We interviewed officials from the following state health departments: California, Florida, 

Hawaii, Indiana, Missouri, North Carolina, Pennsylvania, Rhode Island, and Washington. 

Page 34 GAO-09-985 HIV/AIDS Testing and Care
Appendix I: Information on Transitioning 

Prisoners with HIV to Care Upon Their 

Release 

the Journal of the American Medical Association discussed an evaluation 

of the proportion of infected individuals who filled a highly active 

antiretroviral therapy (HAART) prescription within 10, 30, and 60 days 

after their release from prison, respectively.7

 The study found that 90 

percent of recently released inmates did not fill a prescription for HAART 

therapy soon enough to avoid a treatment interruption (10 days) and more 

than 80 percent did not fill a prescription within 30 days of release. Only 

30 percent of those released filled a prescription within 60 days. 

Individuals on parole and those who received assistance in completing a 

Texas AIDS Drug Assistance Program application were more likely to fill a 

prescription within 30 and 60 days.8

 Because those who discontinue 

HAART are at increased risk of developing a higher viral burden (resulting 

in greater infectiousness and higher levels of drug resistance), it is 

important for public health that HIV-positive prisoners continue their 

HAART treatment upon release from prison. CDC, HRSA, and several 

states we interviewed have implemented programs to aid in the transition 

of HIV-positive persons from prison to the community with emphasis on 

their continued care and treatment. 

CDC and HRSA have funded demonstration projects to address HIV 

prevention and care for prisoners with HIV upon their release from 

incarceration. Selected state health departments and their respective state 

departments of corrections have coordinated to help HIV-positive 

prisoners in their transition back to the community. 

CDC, HRSA, and 

States Have Taken 

Steps to Address the 

Provision of HIV 

Prevention and Care 

for Prisoners with HIV 

Upon Their Release 

 

7

Highly active antiretroviral therapy (HAART) means any combination of three or more 

antiretroviral drugs. While HAART has greatly improved survival rates of individuals living 

with HIV/AIDS, there is currently no cure for the disease. 

8

J. Bailargeon, et al., “Accessing Antiretroviral Therapy Following Release from Prison,” 

Journal of the American Medical Association, Vol. 301, No. 8 (2009). 

Page 35 GAO-09-985 HIV/AIDS Testing and Care
Appendix I: Information on Transitioning 

Prisoners with HIV to Care Upon Their 

Release 

CDC and HRSA have funded various projects to address the provision of 

HIV prevention and care for prisoners with HIV upon their release from 

incarceration. CDC and HRSA have also provided guidance to states 

regarding HIV-related programs. The list below describes the projects and 

guidance. 

• CDC and HRSA jointly funded a national corrections demonstration 

project in seven states (California, Florida, Georgia, Illinois, 

Massachusetts, New Jersey, and New York). This demonstration project 

was funded from 1999 to 2004. The goal of the demonstration project was 

to increase access to health care and improve the health status of 

incarcerated and at-risk populations disproportionately affected by the 

HIV epidemic. The “HIV/AIDS Intervention, Prevention, and Community of 

Care Demonstration Project for Incarcerated Individuals within 

Correctional Settings and the Community” involved jail, prison, and 

juvenile detention settings. The project targeted inmates with HIV, but also 

those with hepatitis B and hepatitis C, tuberculosis, substance abuse, and 

sexually transmitted diseases (STD). According to a HRSA report, the 

project was able to enhance existing programs in facilities, and develop 

new programs both within facilities and outside of them.9

 Many states 

integrated lessons learned through the project at varying levels throughout 

their state. 

CDC and HRSA Have 

Funded Demonstration 

Projects to Address HIV 

Prevention and Care for 

Prisoners with HIV and 

Provided Guidance to 

States Regarding HIVRelated Programs 

• CDC funded Project START to develop an HIV, STD, and hepatitis 

prevention program for young men aged 18-29 who were leaving prison in 

2001. The goal of this project was to test the effectiveness of the Project 

START interventions in reducing sexually risky behaviors for prisoners 

transitioning back to the community. State prisons in California, 

Mississippi, Rhode Island, and Wisconsin were selected. A study 

describing the Project START interventions indicated a multi-session 

community re-entry intervention can lead to a reduction in sexually risky 

behavior in recently released prisoners.10

 

9

Department of Health and Human Services, Health Services and Resources 

Administration, Opening Doors: The HRSA-CDC Corrections Demonstration Project for 

People Living with HIV/AIDS (Washington, D.C.: 2007). http://hab.hrsa.gov/tools/ 

openingdoors/index.htm. 

10R. J. Wolitski, et al., “Relative Efficacy of a Multisession Sexual Risk–Reduction 

Intervention for Young Men Released from Prisons in 4 States,” American Journal of 

Public Health, Vol. 96, No. 10 (2006). 

Page 36 GAO-09-985 HIV/AIDS Testing and Care
Appendix I: Information on Transitioning 

Prisoners with HIV to Care Upon Their 

Release 

• CDC funded a demonstration project at multiple sites in four states 

(Florida, Louisiana, New York, and Wisconsin) where prisoners in shortterm jail facilities were offered routine rapid initial testing and appropriate 

referral to care, treatment, and prevention services within the facility or 

outside of it. From December 2003 through June 2004, more than 5,000 

persons had been tested for HIV, and according to a CDC report, 108 

(2.1 percent) had received confirmed positive results.11

• CDC officials told us that CDC is currently completing three pilot studies 

which began in September 2006. These studies were conducted to develop 

interventions for HIV-positive persons being released from several prisons 

or halfway houses in three states: California (prisons), Connecticut 

(prisons), and Pennsylvania (halfway houses). 

• CDC officials explained that CDC has established a Corrections 

Workgroup within the National Center for HIV/AIDS, Viral Hepatitis, STD, 

and Tuberculosis Prevention. In March of 2009, the workgroup hosted a 

Corrections and Public Health Consultation: “Expanding the Reach of 

Prevention.” This forum provided an opportunity for subject matter 

experts in the fields of corrections and academia as well as 

representatives from health departments and community-based 

organizations to develop effective prevention strategies for their 

correctional systems. 

• According to a Special Projects of National Significance program update, 

HRSA’s “Enhancing Linkages to HIV Primary Care and Services in Jail 

Settings” initiative seeks to develop innovative methods for providing care 

and treatment to HIV-positive inmates who are reentering the 

community.12 This 4-year project, which began in September 2007, is 

different from the “HIV/AIDS Intervention, Prevention, and Co

Care Demonstration Project for Incarcerated Individuals within 

Correctional Settings and in the Community” in that it focuses entirely on

jails. HRSA defines jails as locally operated facilities whose inmates ar

typically sentenced for 1 year or less or are awaiting trial or sentencing 

mmunity of 

e 

 

11CDC, Demonstration Projects for State and Local Health Departments: Routine Rapid 

HIV Testing of Inmates in Short-Stay Correctional Facilities (Atlanta, GA: 2004). 

http://www.cdc.gov/hiv/topics/prev_prog/ahp/resources/factsheets/Correctional_Facilities.

htm. 

12Department of Health and Human Services, Health Resources and Services 

Administration HIV/AIDS Bureau, What’s Going on @ SPNS. Enhancing Linkages: 

Opening Doors for Jail Inmates (Washington, D.C.: 2008). http://hab.hrsa.gov/special/ 

products2g.htm. 

Page 37 GAO-09-985 HIV/AIDS Testing and Care
Appendix I: Information on Transitioning 

Prisoners with HIV to Care Upon Their 

Release 

following trial. Under the initiative, HRSA has awarded grants to 10 

demonstration projects in the following areas: Atlanta, Georgia; Chester, 

Pennsylvania; Chicago, Illinois; Cleveland, Ohio; Columbia, South 

Carolina; New Haven, Connecticut; New York, New York; Philad

Pennsylvania; Providence, Rhode Island; and Springfield, M

elphia, 

assachusetts. 

 

Besides funding demonstration projects and creating workgroups, HRSA 

and CDC have issued guidance to states. HRSA issued guidance in 

September 2007 explaining allowable expenditures under CARE Act 

programs for incarcerated persons.13 The guidance states that 

expenditures under the CARE Act are only allowable to help prisoners 

achieve immediate connections to community-based care and treatment 

services upon release from custody, where no other services exist for 

these prisoners, or where these services are not the responsibility of the 

correctional system. The guidance provides for the use of funds for 

transitional social services including medical case management and social 

support services. CARE Act grantees can provide these transitional 

primary services by delivering the services directly or through the use of 

contracts. Grantees must also develop a mechanism to report to HRSA on 

the use of funds to provide transitional social services in correctional 

settings. In 2009, CDC issued HIV Testing Implementation Guidance for 

Correctional Settings.

14 This guidance recommended routine opt-out HIV 

testing for correctional settings and made suggestions for how HIV 

services should be provided and how prisoners should be linked to 

services.15 The guidance also addressed challenges that may arise for 

prison administrators and health care providers who wish to implement 

the guidelines in their correctional facilities. 

13Department of Health and Human Services, Health Resources and Services 

Administration HIV/AIDS Bureau, Policy Notice 07-04: The Use of Ryan White HIV/AIDS 

Program Funds for Transitional Social Support and Primary Care Services for 

Incarcerated Persons (Washington, D.C.: 2007). http://hab.hrsa.gov/law/0704.htm. 

14CDC, HIV Testing Implementation Guidance for Correctional Settings (Atlanta, GA: 

2009). http://www.cdc.gov/hiv/topics/testing/resources/guidelines/correctionalsettings/index.htm. 

15Opt-out testing is when a patient is notified that testing is a routine part of medical care 

and will be performed unless the patient declines. 

Page 38 GAO-09-985 HIV/AIDS Testing and Care
Appendix I: Information on Transitioning 

Prisoners with HIV to Care Upon Their 

Release 

Selected State Health 

Departments Have 

Coordinated with Their 

Respective State 

Departments of 

Corrections on HIVPositive Prisoner 

Transition Programs 

Of the eight state health departments in our review that had HIV transition 

programs in place, several have implemented programs that coordinate 

with the state’s department of corrections to provide prisoners with 

support services to help them in their transition back to the community. 

We provide examples of three of these programs below. 

• Officials from one state health department said that their department uses 

CARE Act and state funding to provide a prerelease program that uses the 

state’s department of corrections prerelease planners to make sure that 

prisoners with HIV are linked to care. Prisoners meet with their prerelease 

planner 60-90 days prior to release, and the planner links them to care 

services, has them sign up for the AIDS Drug Assistance Program and 

Medicaid, and follows up with them after their release to ensure that they 

remain in care. Additionally, the department of corrections provides 30 

days of medications to prisoners upon release. The state department of 

health has been working with the department of corrections to help them 

transition HIV-positive prisoners for the past 10 years. 

• According to officials from another state health department, their 

department uses state funds to provide transitional case management for 

HIV prisoners who are transitioning back into the community. Specialized 

medical case managers meet and counsel prisoners with HIV who are 

within 6 months of being released. Within 90 days of release, the prisoner 

and the medical case manager may meet several times to arrange housing, 

complete a Medicaid application, obtain referrals to HIV specialists and to 

the AIDS Drug Assistance Program, and provide the prisoner with 

assistance in obtaining a state identification card. Case managers will also 

work with the prisoner for 3 months after release so that the prisoner is 

stable in the community. After 90 days, the person can be transferred into 

another case management program or they can drop out. The client is kept 

on the AIDS Drug Assistance Program if they are not disabled. 

• According to officials from a third state health department, their 

department uses “Project Bridge,” a nationally recognized program to 

transition prisoners back into the community and into CARE Act 

programs. The Project Bridge program provides transition services to 

prisoners. Ninety-seven percent of the Project Bridge participants receive 

medical care during the first month of their release from prison. The state 

attributes the success of this program to the productive relationship 

between the state health department and the department of corrections. 

Project Bridge participants are involved in discharge planning with case 

managers starting 6 months before their discharge. Participants then 

receive intense case management for approximately 18-24 months after 

their release. During this period they are connected with medical and 

Page 39 GAO-09-985 HIV/AIDS Testing and Care
Appendix I: Information on Transitioning 

Prisoners with HIV to Care Upon Their 

Release 

social services. According to state officials, the program has also been 

effective in decreasing recidivism rates. 

Officials we interviewed from state health departments described several 

limitations to their departments’ programs. One state health department 

official explained that their department does not have the staff to 

coordinate services for all of the state’s 110 jails. Officials from two other 

state health departments explained that state budget cuts are threatening 

the continuation of their departments’ prisoner transition programs. One 

state health department official explained that finding the transitioning 

HIV-positive prisoner housing in the community is often very difficult. The 

lack of available housing has impacted their HIV care because they are so 

focused on finding housing that they are unable to focus on taking their 

medication or going to medical appointments. One state health department 

official explained that their department’s prisoners with HIV are 

sometimes not interested in being connected to care in the community. 

Another state health department official explained that the lack of funding 

for prisoner transition programs is a limitation of their program. 

Page 40 GAO-09-985 HIV/AIDS Testing and Care
Appendix II: Part A Grantees’ Living 

HIV/AIDS Cases Used by HRSA to Determine 

Fiscal Year 2009 CARE Act Base Grants 

Part A Grantee HIV AIDS Total

Atlanta, Ga. 6,260 11,571 17,831

Austin, Tex. 1,630 2,458 4,088

Baltimore, Md. 11,901 9,488 21,389

Baton Rouge, La. 1,867 1,888 3,755

Bergen-Passaic, N.J. 1,858 2,190 4,048

Boston, Mass. 6,270 7,748 14,018

Caguas, P.R. 483 761 1,244

Charlotte-Gastonia, N.C.-S.C. 3,216 1,809 5,025

Chicago, Ill. 13,166 13,945 27,111

Cleveland, Ohio 2,020 2,158 4,178

Dallas, Tex. 6,589 8,346 14,935

Denver, Colo. 4,721 3,232 7,953

Detroit, Mich. 3,944 4,635 8,579

Dutchess County, N.Y. 452 803 1,255

Fort Lauderdale, Fla. 6,730 7,724 14,454

Fort Worth, Tex. 1,681 2,238 3,919

Hartford, Conn. 1,085 2,565 3,650

Houston, Tex. 8,047 10,809 18,856

Indianapolis, Ind. 1,825 1,990 3,815

Jacksonville, Fla. 2,169 2,970 5,139

Jersey City, N.J. 2,166 2,528 4,694

Kansas City, Mo. 1,953 2,390 4,343

Las Vegas, Nev. 2,968 2,763 5,731

Los Angeles, Calif. 15,106 22,431 37,537

Memphis, Tenn. 3,421 2,688 6,109

Miami, Fla. 10,877 12,988 23,865

Middlesex-Somerset-Hunterdon, N.J. 1,212 1,442 2,654

Minneapolis-St. Paul, Minn. 2,964 2,173 5,137

Nashville, Tenn. 2,036 2,215 4,251

Nassau-Suffolk, N.Y. 1,877 3,621 5,498

New Haven, Conn. 1,813 4,200 6,013

New Orleans, La. 3,397 4,006 7,403

New York, N.Y. 35,856 59,700 95,556

Newark, N.J. 6,237 6,669 12,906

Norfolk, Va. 3,329 2,353 5,682

Appendix II: Part A Grantees’ Living 

HIV/AIDS Cases Used by HRSA to Determine 

Fiscal Year 2009 CARE Act Base Grants 

Page 41 GAO-09-985 HIV/AIDS Testing and Care 
Appendix II: Part A Grantees’ Living 

HIV/AIDS Cases Used by HRSA to Determine 

Fiscal Year 2009 CARE Act Base Grants 

Part A Grantee HIV AIDS Total

Oakland, Calif. 2,431 4,173 6,604

Orange County, Calif. 2,370 3,662 6,032

Orlando, Fla. 3,953 4,550 8,503

Philadelphia, Pa. 9,070 13,596 22,666

Phoenix, Ariz. 4,528 3,775 8,303

Ponce, P.R. 627 1,371 1,998

Portland, Ore. 1,508 2,339 3,847

Riverside-San Bernardino, Calif. 3,167 4,686 7,853

Sacramento, Calif. 970 1,699 2,669

San Antonio, Tex. 1,711 2,568 4,279

San Diego, Calif. 5,161 6,403 11,564

San Francisco, Calif. 6,641 10,532 17,173

San Jose, Calif. 1,102 1,816 2,918

San Juan, P.R. 4,029 7,023 11,052

Santa Rosa, Calif. 415 844 1,259

Seattle, Wash. 3,099 3,914 7,013

St. Louis, Mo. 2,897 3,099 5,996

Tampa-St. Petersburg, Fla. 3,975 5,264 9,239

Vineland-Millville-Bridgeton, N.J. 375 461 836

Washington, D.C. 12,678 16,350 29,028

West Palm Beach, Fla. 2,881 4,513 7,394

Total 254,714 334,133 588,847

Source: HRSA. 

Note: Fourteen Part A grantees—Baltimore, Md.; Boston, Mass.; Chicago, Ill.; Los Angeles, Calif.; 

Oakland, Calif.; Orange County, Calif.; Portland, Ore.; Riverside-San Bernardino, Calif.; Sacramento, 

Calif.; San Diego, Calif.; San Francisco, Calif.; San Jose, Calif.; Santa Rosa, Calif.; and Washington, 

D.C.—submitted code-based HIV case counts to HRSA for the fiscal year 2009 funding formula and 

were assessed a 5 percent reduction in their HIV case counts in accordance with the CARE Act. For 

more information, see GAO-09-894, 8-10. 

Page 42 GAO-09-985 HIV/AIDS Testing and Care
Appendix III: Part B Grantees’ Living 

HIV/AIDS Cases Used by HRSA to Determine 

Fiscal Year 2009 CARE Act Base Grants 

Part B Grantee HIV AIDS Total

Alabama 5,702 4,164 9,866

Alaska 278 340 618

Arizona 5,949 5,180 11,129

Arkansas 2,388 2,296 4,684

California 41,730 63,187 104,917

Colorado 5,974 4,313 10,287

Connecticut 3,215 7,403 10,618

Delaware 1,259 1,813 3,072

District of Columbia 6,575 8,559 15,134

Florida 38,303 49,055 87,358

Georgia 10,883 17,447 28,330

Hawaii 845 1,251 2,096

Idaho 356 311 667

Illinois 15,447 16,513 31,960

Indiana 3,953 4,218 8,171

Iowa 637 912 1,549

Kansas 1,260 1,369 2,629

Kentucky 1,635 2,788 4,423

Louisiana 7,663 8,522 16,185

Maine 421 534 955

Maryland 15,793 15,029 30,822

Massachusetts 7,258 8,651 15,909

Michigan 6,177 6,900 13,077

Minnesota 3,370 2,457 5,827

Mississippi 4,575 3,570 8,145

Missouri 5,061 5,751 10,812

Montana 120 205 325

Nebraska 680 784 1,464

Nevada 3,447 3,214 6,661

New Hampshire 480 587 1,067

New Jersey 15,851 17,564 33,415

New Mexico 934 1,330 2,264

New York 44,973 73,879 118,852

North Carolina 12,812 8,718 21,530

North Dakota 83 78 161

Appendix III: Part B Grantees’ Living 

HIV/AIDS Cases Used by HRSA to Determine 

Fiscal Year 2009 CARE Act Base Grants 

Page 43 GAO-09-985 HIV/AIDS Testing and Care 
Appendix III: Part B Grantees’ Living 

HIV/AIDS Cases Used by HRSA to Determine 

Fiscal Year 2009 CARE Act Base Grants 

Part B Grantee HIV AIDS Total

Ohio 8,274 7,380 15,654

Oklahoma 2,259 2,333 4,592

Oregon 1,746 2,938 4,684

Pennsylvania 12,401 18,647 31,048

Puerto Rico 6,519 11,335 17,854

Rhode Island 985 1,346 2,331

South Carolina 6,591 7,604 14,195

South Dakota 209 144 353

Tennessee 7,032 6,822 13,854

Texas 25,894 34,734 60,628

Utah 932 1,206 2,138

Vermont 206 236 442

Virginia 10,092 8,573 18,665

Washington 4,420 5,734 10,154

West Virginia 662 786 1,448

Wisconsin 2,418 2,283 4,701

Wyoming 98 109 207

American Samoa 2 1 3

Commonwealth of the Northern Mariana Islands 3 3 6

Federated States of Micronesia 8 0 8

Guam 55 35 90

Palau 0 0 0

Republic of the Marshall Islands 0 1 1

U.S. Virgin Islands 235 335 570

Total 367,128 461,477 828,605

Source: HRSA. 

Note: Ten Part B grantees—California, the District of Columbia, Hawaii, Illinois, Maryland, 

Massachusetts, Oregon, Rhode Island, Vermont, and the Federated States of Micronesia—submitted 

code-based HIV case counts to HRSA for the fiscal year 2009 funding formula and were assessed a 

5 percent reduction in their HIV case counts in accordance with the CARE Act. For more information, 

see GAO-09-894, 8-10. 

Page 44 GAO-09-985 HIV/AIDS Testing and Care
Appendix IV: 

A

GAO Contact and Staff 

cknowledgments 

Page 45 GAO-09-985 

Appendix IV: GAO Contact and Staff 

Acknowledgments 

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

In addition to the contact above, Thomas Conahan, Assistant Director; 

Robert Copeland, Assistant Director; Leonard Brown; Romonda McKinney 

Bumpus; Cathleen Hamann; Sarah Resavy; Rachel Svoboda; and Jennifer 

Whitworth made key contributions to this report. 

HIV/AIDS Testing and Care 

GAO Contact 

Acknowledgments 

(290799) 
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