Minority AIDS Initiative: Consolidation of Fragmented HIV/AIDS Funding Could Reduce Administrative Challenges
Published: 2013-11-22T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: According to CDC data, racial and ethnic minorities in the United States--particularly Blacks/African-Americans and Hispanics/Latinos--have been disproportionately affected by HIV/AIDS, representing 72 percent of new HIV infections and 74 percent of all AIDS diagnoses in 2011. In addition to core funding programs through CDC and HRSA that are intended to provide services to all qualifying individuals affected by HIV/AIDS, MAI seeks to improve HIV-related health outcomes and reduce health disparities for minority communities through the provision of grant funds. MAI grants are distributed to a variety of entities.
The Ryan White HIV/AIDS Treatment Extension Act of 2009 required GAO to (1) examine the services provided, population served, and administrative challenges faced by MAI grantees, and (2) describe the best practices identified by grantees and other stakeholders for community outreach and capacity building. GAO conducted a review of services reported in fiscal year 2011 MAI grantee annual reports from a generalizable sample of 100 grantees, and interviewed agency officials and other stakeholders. GAO also reviewed grant administrative requirements, and data on MAI grant amounts and populations served.
section_title: What GAO Found
paragraphs: Minority AIDS Initiative (MAI) grantees reported providing services similar to the medical services, support services, and HIV testing and prevention services provided with core HIV/AIDS funding, which is provided by the Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC) to grantees. In addition, MAI grantees faced administrative challenges managing HIV/AIDS funding that was fragmented across several grants. Various agencies within the Department of Health and Human Services (HHS) awarded MAI grants to grantees. The agencies included CDC, HRSA, the Substance Abuse and Mental Health Services Administration, and seven other offices within HHS. The MAI grantees in GAO's sample reported providing mostly support services with their MAI grants, similar to the types of support services grantees provided with core HIV/AIDS funding from CDC and HRSA. These support services included community outreach and education, and staff or provider training. Twenty percent of the grantees also reported providing medical services to their clients. According to the limited data HHS agencies and offices maintain on the demographics of the population served with MAI grants, the majority of recipients of MAI services were from racial and ethnic minority groups, as is also the case with recipients of services provided with core HIV/AIDS funds. MAI grantees faced administrative challenges because the fragmented nature of MAI and core HIV/AIDS funding required them to manage funding from several sources, each of which required them to complete multiple application and reporting requirements. For example, one city received nine HHS grants to provide HIV/AIDS services - six MAI grants and three core HIV/AIDS grants - and for each of these grants, that city had to complete separate administrative requirements. In this case, while HHS is funding all of the services, it is doing so across multiple funding streams, which raises the possibility of inefficiencies and requires unnecessarily duplicative application and reporting requirements of grantees that could otherwise be using their resources to provide needed services. Additionally, according to HRSA officials, these administrative challenges discouraged some grantees from applying for MAI grants. HRSA officials stated that some of the states receiving core HIV/AIDS grants chose not to request MAI grants because the grants' small size did not justify the additional reporting or other administrative requirements that would accompany them.
MAI grantee reports that GAO reviewed, as well as stakeholder organizations GAO interviewed, described a variety of best practices for community outreach and capacity building that at times led to improved client recruitment and improved capacity of community based organizations to serve communities disproportionately affected by HIV/AIDS. For instance, MAI grantees reported targeting specific communities, broadening outreach strategies, utilizing social media forums, and using various HIV testing strategies as best practices for community outreach that at times led to improved recruitment for HIV testing and other services. Grantees and some of the stakeholders reported that upgrading technology and providing training to grantee staff were the best methods to improve capacity to serve clients.
section_title: What GAO Recommends
paragraphs: To enhance HIV/AIDS services to minority populations, HHS should consolidate MAI funding into core HIV/AIDS funding and seek legislation as necessary to achieve a consolidated approach. HHS stated that GAO's recommendations align with the National HIV/AIDS Strategy.

section_title: Letter
paragraphs: An estimated 1.2 million people in the United States were living with  human immunodeficiency virus (HIV) infections in 2012, and  approximately 50,000 new infections occur annually. Since the first cases  of acquired immunodeficiency syndrome (AIDS) were reported in June  1981, more than 600,000 people with AIDS have died. Racial and ethnic  minorities in the United States —particularly African-Americans and  Hispanics/Latinos—have been disproportionately affected by HIV/AIDS.  According to the most recent data from the Centers for Disease Control  and Prevention (CDC), part of the Department of Health and Human  Services (HHS), racial and ethnic minorities represented 72 percent of  new HIV infections and 74 percent of all AIDS diagnoses in 2011.
Two agencies within HHS, the Health Resources and Services  Administration (HRSA) and CDC, administer grant programs that provide  core HIV/AIDS funding for HIV/AIDS services. HRSA awards core  HIV/AIDS grants pursuant to the Ryan White Comprehensive AIDS  Resources Emergency Act of 1990 (CARE Act), which was enacted to  address the treatment needs of uninsured and underinsured persons  living with HIV/AIDS.Act programs for HIV/AIDS treatment through the provision of medical  services, support services, and education was approximately $2.1 billion.
In fiscal year 2011, HRSA’s budget for core CARE  Independent of HRSA’s core grant programs under the CARE Act, CDC’s  Division of HIV/AIDS Policy awards core HIV/AIDS grants for prevention  programs, research and evaluation, surveillance, and policy development  to reduce the impact of HIV/AIDS. In fiscal year 2011, CDC’s budget for  its core HIV/AIDS programs was approximately $666.4 million. Goals for  CDC’s core HIV/AIDS funding in fiscal year 2011 included decreasing  annual HIV incidence, decreasing the HIV transmission rate, increasing  the proportion of HIV-infected people in the United States who know they  are infected, improving HIV/AIDS surveillance, and ensuring that all  persons diagnosed with HIV are linked to care.
In addition to the core HIV/AIDS grant programs, CDC, HRSA, and  numerous other HHS agencies and offices award grants to implement the  Minority AIDS Initiative (MAI). First known as the Congressional Black  Caucus Initiative, MAI originated in 1998 in response to provisions in a  house conference report accompanying the Omnibus Consolidated and  Emergency Supplemental Appropriations Act, 1999. The conference  report instructed HRSA to target funds to reduce HIV-related treatment  outcome disparities in communities of color, noting that this funding  should be used to complement existing and previously planned targeted  HIV/AIDS minority activities.
In the context of HIV/AIDS grants, applicants may be eligible to receive  core HIV/AIDS grants and/or MAI grants. These grant programs carry  different administrative requirements that grantees must observe for each  of the separate grants they may receive. Agencies and offices that  administer grants maintain these requirements to ensure that the funds  are being used in the way intended by the grant program.
The Ryan White HIV/AIDS Treatment Extension Act of 2009 required us  to report on MAI and related issues.services provided, population served, and administrative challenges faced  by MAI grantees, and (2) describe the best practices identified by  grantees and other stakeholders for community outreach and capacity  building of CBOs serving the communities that are disproportionately  affected by HIV/AIDS. The Ryan White HIV/AIDS Treatment Extension  Act of 2009 also requires us to report on the history of MAI activities  within each relevant HHS agency and office to provide a description of  activities conducted and types of grantees funded. We provide  information from prior years on MAI funding, activities, and grantees in  appendix I.
In this report, we (1) examine the  To examine the services provided, population served, and administrative  challenges faced by MAI grantees, we interviewed all ten HHS agencies  and offices that awarded MAI grants in fiscal year 2011. These HHS  agencies and offices include HRSA, the primary federal agency for  improving access to health care services for uninsured, isolated or  medically vulnerable individuals; the Substance Abuse and Mental Health  Services Administration (SAMHSA), which leads public health efforts to  advance the behavioral health of the nation; CDC, which seeks to protect  health and promote quality of life through the prevention and control of  disease, injury, and disability; the Indian Health Service (IHS), which  provides federal health services to American Indians and Alaska Natives;  the Office of Population Affairs (OPA), which aims to be the leader in  family planning and reproductive health care services, training and  research; the Office of Minority Health (OMH); which aims to improve the  health of racial and ethnic minority populations through the development  of health policies and programs; the Office of HIV/AIDS and Infectious  Disease Policy (OHAIDP), which advises HHS officials on the  implementation and development of policies, programs, and activities  related to HIV/AIDS and other infectious diseases; the Office on Women’s  Health (OWH), which seeks to improve the health and sense of well-being  of women and girls; the Regional Health Administrators (RHA), which  seeks to perform essential functions for HHS in prevention,  preparedness, and agency-wide coordination; and the Office of  Adolescent Health (OAH), which seeks to improve the health and well  being of adolescents. We also interviewed staff from six stakeholder  organizations, including national HIV/AIDS organizations that represent  MAI grantees: the Black AIDS Institute, Latino Commission on AIDS,  National Alliance of State and Territorial AIDS Directors, National Council  of Urban Indian Health, National Minority AIDS Council, and National  Native American AIDS Prevention Center. In addition, we interviewed the  Kaiser Family Foundation, a subject matter expert. We interviewed these  organizations to obtain their perspectives on MAI. Information we  obtained from these interviews is not generalizable. We conducted a  review of MAI services reported in MAI annual grantee reports from a  generalizable sample of 100 MAI grantees from fiscal year 2011. To  select our sample, we created a list of all MAI grantees from the ten HHS  agencies and offices that awarded MAI grants in fiscal year 2011 and  then selected a generalizable sample of 100 grantees from these  agencies and offices. We then obtained MAI annual grantee reports for  these grantees from the respective agencies and offices and used NVivo  software to identify the types of MAI services in these reports (app. II  provides more detail on our sample design.).provided and population served from this sample are generalizable to the  population of MAI grantees. We summarize the statistical precision of our  estimates using a 95 percent confidence interval, which is the interval that  would contain the population value in 95 percent of the samples we could  have drawn. Since the size of the confidence intervals varies widely  across the estimates, we specify these intervals where we refer to the  estimates. We categorized MAI services described in the grantee reports  into six categories. We then analyzed and compared the services  identified in these categories by HHS agency and office, grant amount,  source of grant, and organizational type. We also reviewed agency  guidance on which services grantees are expected to provide with their  MAI and core HIV/AIDS grants.
In addition, to identify the population served by MAI, we obtained and  reviewed the available demographic data on the race and ethnicity of the  clients served with MAI grants as well as aggregate historical funding  data that we requested and obtained from HHS agencies and offices for  fiscal years 2007-2012. Some agencies and offices could not provide  demographic data on their clients, but we assessed the reliability of the  demographic data that the agencies and offices could provide by  interviewing agency officials about how their demographic data was  collected, and we also discussed any inconsistencies we found in the  data. We found the data provided to be sufficiently reliable for presenting  information about the race and ethnicity of MAI grantee populations. We  also obtained, reviewed, and analyzed the core HIV/AIDS grant amounts  that MAI grantees in our sample were awarded in order to understand the  total amount of HIV/AIDS funding that MAI grantees received. We then  compared the core HIV/AIDS grant amounts to their MAI grant amounts.  To determine core HIV/AIDS grant amounts, we used CDC and HRSA  funding data in addition to publicly available funding data. We compared  publically available data to data provided to us, and confirmed the data  with the agencies where there were discrepancies. We found these data  to be reliable for our purposes.
Furthermore, to assist us in reviewing the administrative challenges faced  by MAI grantees, we evaluated grantee administrative requirements  including applications and reporting requirements for MAI and core  HIV/AIDS grants, and considered our past work on federal programs or  activities government-wide that have evidence of fragmentation, overlap,  or duplication. In that work, we found that the presence of fragmentation  can lead to instances of overlap and duplication among government  agencies or programs that have similar goals or activities.
To describe the best practices identified by grantees for community  outreach and capacity building of CBOs serving communities  disproportionately affected by HIV/AIDS, we conducted a review of MAI  annual grantee reports from our generalizable sample of 100 MAI  grantees using NVivo software in order to identify and categorize what  grantees considered to be best practices. Specifically, we identified and  analyzed MAI services that grantees considered were best practices,  which included best practices for community outreach or capacity building  of CBOs that serve communities disproportionally affected by HIV/AIDS.  We defined the term best practices to include any successes, lessons  learned, or challenges overcome by grantees regarding their MAI  activities. Because grantees generally were not required to discuss best  practices in their MAI annual grantee reports, we cannot estimate the  proportion of grantees identifying such practices. Instead, we can simply  count the number of best practices reported in our sample that we  identified using our definition of best practices. As a result, our estimates  are not generalizable for this purpose, unlike our estimates of services  provided. In addition, we also obtained information on best practices for  community outreach and capacity building from the six stakeholder  organizations and one subject matter expert we interviewed.
We conducted this performance audit from October 2012 to November  2013 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
subsections: section_title: History of MAI
paragraphs: MAI was established in 1998 in response to growing concern about the  impact of HIV/AIDS on racial and ethnic minorities in the United States.  According to the most recent CDC data, there were an estimated 23,734  AIDS diagnoses in 2011 among persons of minority races/ethnicities,  accounting for 74 percent of total AIDS diagnoses in the United States  and dependent areas; these data reflect an overall trend present since  1994. National HIV/AIDS data indicate that since 1994 minorities have  become a significant majority of persons with HIV/AIDS. In 2011,  Blacks/African-Americans accounted for 13 percent of the U.S.  population, but accounted for 49 percent of AIDS diagnoses;  Hispanics/Latinos accounted for 17 percent of the population, but  accounted for 21 percent of AIDS diagnoses; and Caucasians/Whites  accounted for 74 percent of the population, but accounted for 26 percent  of AIDS diagnoses.
Pub. L. No. 109-415, § 603, 120 Stat. 2767, 2818 (codified at 300ff-121). core HIV/AIDs grants awarded by HRSA under other provisions of the  CARE Act.
Other HHS agencies and offices, including HRSA, continue to carry out  MAI grant programs separate from the statutory MAI program that HRSA  implements under the CARE Act. In particular, CDC, SAMHSA, and the  Office of the Secretary also award MAI grants to provide services for  communities disproportionally affected by HIV/AIDS. CDC and SAMHSA  award MAI grants directly to grantees. In contrast, MAI funds  administered by the Office of the Secretary, referred to as the Secretary’s  MAI Fund (SMAIF), are distributed by the Office of HIV/AIDS and  Infectious Disease Policy (OHAIDP) to HRSA, CDC, SAMHSA, and  seven other HHS agencies and offices. These agencies and offices, in  turn, award SMAIF grants. MAI and SMAIF funding are often provided to  the same grantees that receive core HIV/AIDS funding.
section_title: MAI Funding Allocations in Fiscal Year 2011
paragraphs: Three HHS agencies, HRSA, SAMSHA, and CDC, allocate a portion of  their respective annual appropriations to carry out MAI programs. In fiscal  year 2011, CDC, HRSA, and SAMHSA allocated approximately   $363.7 million of their respective appropriations for MAI programs. CDC,  HRSA, and SAMHSA use this funding to award grants for the provision of  services to racial and ethnic minorities with HIV/AIDS.Office of the Secretary receives an annual line item MAI appropriation,  which it calls SMAIF. The Office of the Secretary received a $52.8 million  appropriation for SMAIF funding in fiscal year 2011. OHAIDP distributed  this funding on behalf of the Office of the Secretary to ten HHS agencies  and offices within HHS, including HRSA, CDC, and SAMHSA, for a   In addition, the  variety of activities to address HIV/AIDS in racial and ethnic minority  communities. In turn, these agencies and offices awarded SMAIF grants  and cooperative agreements to the same types of organizations and  entities that receive other MAI funding to provide services. HRSA’s  SMAIF funding is in addition to the amounts it receives in order to make  MAI grants under the CARE Act. (See table 1 for fiscal year 2011 MAI  funding.)
MAI grantees include a wide variety of organizations. MAI grantees  include health departments, state and local governments, tribal  governments, community health centers, hospitals and medical centers,  CBOs, colleges and universities, AIDS Education and Training Centers,  and national HIV/AIDS organizations such as the National Minority AIDS  Council.that are awarded contracts to conduct evaluations of MAI programs.  Some MAI grantees also receive core HIV/AIDS funding. Where this is  the case, MAI grants generally account for a small percentage of the  grantee’s funding to provide HIV/AIDS services.
section_title: Core HIV/AIDS and MAI Budget Request and Allocation Process
paragraphs: As part of the federal budget process, HHS requests core HIV/AIDS  funding and MAI funding, which Congress provides under different  appropriations provisions. After its annual budget is enacted, HHS  exercises discretion in allocating core HIV/AIDS funding and MAI funding  to the extent authorized by law.
With respect to the CARE Act, annual appropriations acts provide an  amount for all CARE Act programs, as well as requirements to make  certain sums available for implementing specific parts of the CARE Act  such as Parts A and B. Annual CARE Act appropriations have not  directed specific amounts for the MAI program, although the authorizing  legislation provides a schedule of amounts to be reserved for  supplemental MAI grants from any amounts appropriated for the MAI  program. HRSA derives its annual MAI budget allocation based on the  schedule of amounts provided in the authorizing legislation.
Congress has not enacted specific appropriations provisions applicable to  core HIV/AIDS programs administered by CDC or the separate MAI  programs administered by CDC and SAMSHA. As a result, these  agencies exercise discretion in making allocation decisions for their  respective programs, which may be influenced by any applicable  committee report language accompanying their annual appropriations  acts.
During the budget request process, HHS also requests general  departmental management funds for the Office of the Secretary, including  an amount for prevention and treatment activities known as SMAIF.  Congress has provided an annual line item appropriation to the Office of  the Secretary for this purpose, without specifying how HHS is to allocate  these funds. As a result, HHS exercises discretion in allocating this  funding to numerous agencies and offices to implement separate MAI  grant programs.
section_title: MAI Administrative Requirements
paragraphs: About three-quarters of MAI grantees submit applications, and about a  quarter are not required to submit an application. The application process  generally consists of an application or request for funding that includes a  written description of the services the grantee plans to provide using the  MAI grant. For example, SAMHSA grantees are required to submit  applications which provide details on how grantees plan to spend their  MAI grants on programs related to substance abuse and mental health  services. Agencies and offices that award MAI grants evaluate whether to  fund grantees based upon whether or not their planned services are  consistent with MAI. However, grant amounts may be determined by a  formula that considers the number of racial and ethnic minorities reported  to have HIV that live in the area the grantee serves. About a quarter of  MAI grantees receive core HIV/AIDS funding and are not required to  submit any application for MAI grants. In these instances, the amount of  the MAI grant is also based upon a formula that considers the number of  racial and ethnic minorities reported to have HIV that live in areas served  by the grantee.
According to HHS officials, MAI grantees are required to report to their  funding agency on how they use their MAI grants. These reports  generally include a description of the services they provided with the  grants and an accounting of the grants themselves. HHS officials stated  that MAI grantees are generally required to submit reports at least  annually, but some are required to submit reports more frequently. HHS  officials stated that some grantees report on their use of MAI grants as  part of their reporting on their use of core HIV/AIDS grants. HHS agencies  use these reports to evaluate whether the services grantees provided to  racial and ethnic minorities with HIV/AIDS met the objectives they  outlined in their applications.
section_title: Fragmented Funding for Similar Services to Similar Populations Resulted in Administrative Challenges for MAI Grantees
paragraphs: MAI grantees reported providing services similar to those provided with  core HIV/AIDS grants. MAI and core HIV/AIDS grantees provided  services primarily to minorities. MAI grants were often part of fragmented  HIV/AIDS funding streams that carried separate administrative  requirements that caused administrative challenges for MAI grantees.
subsections: section_title: MAI Grantees Provided Services Similar to Those Provided with Core HIV/AIDS Funding
paragraphs: MAI grantees in our sample reported providing mostly support services,  similar to the types of support services grantees provided with core  HIV/AIDS grants. These support services included community outreach  and education, and staff or provider training. A fraction of the grantees  reported providing medical services to their clients.
Based on our review of the annual reports submitted by 100 MAI grantees  in our sample, we found
Eighty-one percent of grantees reported providing community  outreach and education services for the purposes of recruiting and  retaining clients to HIV/AIDS services. For example, grantees  reported using social media platforms, including Facebook and  Twitter, to recruit and retain individuals into care and holding  community HIV/AIDS awareness events.
Seventy-two percent of grantees reported providing assistance to  clients including care coordination, case management, or referrals to  care. Activities also included assisting clients with social services such as housing, employment, and post-HIV test counseling.
Sixty-nine percent of grantees reported providing clients with  HIV/AIDS or other related illnesses testing services, such as rapid HIV  testing.
Fifty-eight percent of grantees reported providing or receiving training  for grantee staff, providers, or other organizations affiliated with the  grantee, such as training to keep providers informed about HIV  related clinical service guidelines.
Twenty percent of grantees reported using MAI grants to provide core   For example, grantees provided primary  medical services to clients. and outpatient medical care to HIV/AIDS-infected clients and  substance abuse treatment or counseling to clients. Two  stakeholders we interviewed believed MAI funds have not been  targeted to medical services, and are generally too small to support  providing medical services.
The services provided by MAI grantees were similar to those provided by  grantees awarded HRSA’s and CDC’s core HIV/AIDS funding. HRSA’s  fiscal year 2011 budget justification to Congress indicated that core  HIV/AIDS funds were used to provide clients with medical care such as  primary health care; assisting clients by providing early intervention  services; family support services; training for health care providers; and  other support services. CDC described using its core HIV/AIDS funding to  provide support services that included training clients by enhancing  prevention services among the most affected communities. The services  described included assisting clients by integrating and providing linkage  to care services and expanding HIV testing. CDC also described  community outreach and education services that included developing  social marketing campaigns.
The services that MAI grantees reported providing are consistent with  available guidance. Guidance for MAI grantees varied considerably  across the agencies and offices that receive MAI funding. However,  agency guidance generally instructed grantees to provide services similar  to those provided with core HIV/AIDS grants and instructed grantees to  ensure that they provided services within racial and ethnic minority  communities. Some agencies and offices that award MAI grants provide  specific guidance to grantees on how to use those grants, while others  provide guidance in the form of application and reporting instructions.
section_title: Available Data Suggest MAI and Core HIV/AIDS Grantees Provide Services Primarily to Minorities
paragraphs: The limited demographic information available from the HHS agencies  and offices that could provide data suggests that the majority of those  served with both MAI and core HIV/AIDS grants are racial and ethnic  minorities. This is consistent with the current distribution of HIV/AIDS in  the United States. HHS officials also said that the majority of clients  served by MAI grantees are minorities. However, the demographic data  are not consistently tracked. Agency officials said that HHS did not  require them to request and compile demographic data from MAI or core  HIV/AIDS grantees in fiscal year 2011. HHS agencies and offices were  only able to provide us data for 54 percent of MAI grantees in fiscal year  2011, representing 34 percent of all MAI funding. These data suggest that  HHS’s assessment is likely correct. SAMHSA data indicated that   70 percent of its MAI service recipients were minorities in fiscal year  2011. Available demographic data from three offices that receive SMAIF  funding— OPA, OMH, and OWH—indicated that over 80 percent of their  MAI service recipients were minorities. IHS data indicated it served a MAI  population that was 100 percent American Indian/Alaska Native.
CDC could not provide demographic data on the recipients of services funded by core  HIV/AIDS funds.
HIV/AIDS grants across HHS agencies and offices, indicate that   73 percent of the recipients were minority. Specifically, 47 percent were  African-Americans/Blacks, 22 percent identified as Hispanics, and   4 percent identified as either Asian, American Indian/Alaska Native,  Native Hawaiian/Pacific Islander or Multi-racial. This is consistent with  the overall demographics of the HIV-positive population in the United  States, in which racial and ethnic minorities represented 72 percent of  new HIV infections and 74 percent of all AIDS diagnoses in 2011.While  the data are insufficient to conclusively determine the extent to which  each program serves minority clients, the data suggest that both primarily  serve minority populations.
section_title: MAI Grantees Face Challenges Resulting from the Administrative Requirements of Fragmented Funding Streams
paragraphs: MAI and core HIV/AIDS funding is often fragmented across several  grants, sometimes from several different HHS offices or agencies. In past  work, we have concluded that funding is fragmented when more than one  agency or more than one organization within an agency provides funding  in the same broad areas of national need, and opportunities exist to  improve service delivery. In this work, we identified approaches that  agencies can take to improve efficiency. These approaches include  streamlining or consolidating management or operational processes to  make them more cost-effective. MAI and core HIV/AIDS funding is  fragmented because numerous agencies and offices in HHS receive it  and all provide services to respond to the same area of national need.  The National HIV/AIDS Strategy of 2010 noted this issue as one that  could complicate the coordination of HIV/AIDS programs. The Strategy  stated that “HIV service providers often receive funding from multiple  sources with different grant application processes and funding schedules,  and varied reporting requirements.”enacted specific appropriations provisions applicable to core HIV/AIDS  programs administered by CDC or the separate MAI programs  administered by CDC and SAMHSA. As a result, these agencies exercise  discretion in making allocation decisions for their respective core  HIV/AIDS and MAI programs, which may be influenced by applicable   As noted earlier, Congress has not  committee report language accompanying their annual appropriations  acts. Additionally, annual line item appropriations for SMAIF programs do  not specify how HHS is to allocate these funds to implement MAI. Thus,  HHS can exercise discretion to consolidate disparate MAI funding  streams. In addition, HHS could seek legislation to amend the CARE Act  or other law, as necessary, to enable HHS to further consolidate amounts  directed at MAI programs into core HIV/AIDs programs.
The fragmented nature of MAI and core HIV/AIDS funding caused  administrative challenges for grantees by often forcing grantees to  manage grants from several sources. These funding sources required  them to complete multiple administrative requirements. The duplication  and fragmentation of these requirements across the grant sources create  inefficiencies for the grantee that could be providing needed HIV/AIDS  services instead of using resources to complete multiple administrative  requirements. In fiscal year 2011, 56 percent, or 596, of the 1067 MAI  grantees received several HIV/AIDS grants, including at least one MAI  grant and one core HIV/AIDS grant. Of these 596 MAI grantees, 167  received a core HIV/AIDS grant from both CDC and HRSA.
For example, the city of Chicago received nine grants from HHS to  provide HIV/AIDS services. These include six MAI grants—one grant from  MAI Part A and one grant from MAI Part C, and four MAI grants from  CDC and SAMHSA, one from each agency’s MAI allocation and one from  each agency’s SMAIF funding. In addition, Chicago received three core  HIV/AIDS grants—one from CARE Act Part A, one from CARE Act   Part C, and one from CDC. Chicago is required to submit a report or  application for one of its HIV/AIDS grants in most months of the year and  in some months, they are required to produce multiple submissions.  While the specific services Chicago provided with the 9 grants varied, all  of the grants were used to provide HIV/AIDS treatment or prevention  services to residents of the city of Chicago. (See table 2.) Other cities with  a similar array of grants include Philadelphia, San Francisco, Los  Angeles, and New York City. MAI grantees face challenges in managing  the multiple administrative requirements for each of these grants.
Because of the administrative requirements associated with managing  multiple HIV/AIDS grants, some grantees decided not to apply for MAI  grants. In fiscal year 2011, according to information provided by HRSA,  37 percent of CARE Act Part B grantees chose not to apply for MAI  grants. Some grantees that chose not to apply were states with sizeable  minority populations. HRSA officials stated that several grantees reported  that their reasons for not applying for MAI funds were that the small size  of MAI grants did not provide enough funding to implement a program  and justify the additional administrative requirements. For grantees that  received several HIV/AIDS grants, including at least one MAI grant and  one core HIV/AIDS grant, the average MAI grant was $391,225, while the  average core HIV/AIDS grant was approximately $3,823,102. HRSA  officials stated that one Part B grantee declined an MAI grant because the  amount it received could not cover the cost of issuing a request for  proposals for subcontractors to conduct the MAI services. A stakeholder  that represents state health departments said that some states believe  that due to the small amount of MAI grants they receive, it is too  burdensome to justify the effort and expense to apply for and report on  these grants.
section_title: MAI Grantees and Stakeholder Organizations Reported a Variety of Best Practices for Community Outreach and Capacity Building
paragraphs: MAI grantees from our sample, as well as stakeholder organizations,  reported best practices for community outreach and capacity building that  at times led to improved client recruitment and improved capacity to  provide care.
subsections: section_title: MAI Grantees and Stakeholder Organizations Reported Best Practices for Community Outreach to Improve Client Recruitment
paragraphs: MAI grantees from our sample of 100 grantees, as well as some of the six  stakeholder organizations we interviewed, reported best practices for  community outreach that included targeting specific communities,  broadening outreach and education strategies, utilizing social media  forums, collaborating with other organizations, and using various HIV  testing strategies that at times led to increased recruitment for HIV testing  and other services to communities disproportionately affected by  HIV/AIDS.
23 grantees from our sample reported various community outreach  and education services that helped some grantees improve client  recruitment. For example, seven grantees offered individuals  incentives (e.g., prizes, food or gift-cards) that led to increased  participation in services such as testing and education. Four grantees  utilized social media forums (e.g., Facebook, Twitter, online  broadcasts, etc.) to conduct outreach and recruit individuals for  HIV/AIDS services. Additionally, three grantees broadened their  outreach and education strategies to focus on social issues that put  individuals at risk for HIV/AIDS, rather than focusing specifically on  HIV/AIDS, to overcome challenges with recruiting clients due to, for  example, social stigmas prevalent with HIV/AIDS. One stakeholder  organization we interviewed also reported tailoring outreach strategies  to match the needs of targeted communities as a best practice to  improve community outreach.
21 grantees from our sample reported strategies to target outreach  and education to improve outreach to communities disproportionately  affected by HIV/AIDS. For example, ten grantees conducted outreach  at venues in the communities where specific minority groups or  individuals at high risk for HIV/AIDS (e.g., men who have sex with  men, drug users, etc.) typically congregate.
17 grantees from our sample reported that collaborating with other  community organizations (e.g., HIV/AIDS organizations, medical  providers, youth centers, juvenile detention facilities, etc.) enhanced  the types of services offered to individuals. For example, six grantees  established memorandums of understanding with organizations to  help ensure individuals could seamlessly access services such as  medical care, testing for other sexually transmitted infections and  substance abuse services. Additionally, one stakeholder organization  reported working with community health centers to provide culturally  competent care and education to targeted minority communities.
15 grantees from our sample reported HIV testing strategies that they  found successful in increasing HIV testing rates. For example, three  grantees used rapid HIV testing methods that provided clients with  immediate test results, which one grantee reported prevented  potential transportation and scheduling challenges for clients to obtain  test results. Three grantees also provided HIV testing services in  mobile testing units, with one offering testing on evenings and  weekends to make testing more convenient and accessible to clients.  Additionally, one stakeholder organization reported providing HIV  testing at the same event annually to establish continuity and  reliability of access to HIV testing for individuals in the community.
section_title: MAI Grantees and Stakeholder Organizations Reported Capacity Building Best Practices To Improve Capacity to Provide Care
paragraphs: MAI grantees from our sample of 100 grantees, as well as some of the six  stakeholder organizations we interviewed, reported best practices for  capacity building, such as expanding infrastructure and providing training,  which at times improved their capacity to provide care to communities  disproportionately affected by HIV/AIDS.
Ten grantees from our sample reported activities such as training staff  and expanding infrastructure that improved their ability to provide  HIV/AIDS services to minority communities. For example, four  grantees from our sample reported planning or conducting trainings  on topics including cultural diversity which, for some grantees,  improved staff’s ability to provide care or conduct outreach to high-risk  populations or minority communities. Two grantees also cross-trained  staff to conduct different job tasks which helped to alleviate any  impacts of high staff turnover. Additionally, three grantees increased  their building space or service delivery areas to help expand the  services they offered to clients. Two grantees also developed or  enhanced their technology (e.g., databases) to track client services.
Some stakeholder organizations that we interviewed also reported  conducting evaluations and providing training to improve the capacity  of organizations to provide services to minority communities. For  example, some stakeholders worked with organizations such as  CBOs to evaluate program needs or capacity levels in order to  improve and enhance their leadership capacity and infrastructure.  Additionally, some stakeholder organizations and an expert we  interviewed also cited the importance of providing training to build  staff skills and to build long-term capacity within organizations.
section_title: Conclusions
paragraphs: Since 1998, MAI grants have been awarded in addition to core HIV/AIDS  grants in order to improve HIV-related health outcomes and reduce HIV- related health disparities for racial and ethnic minority populations. Given  that the majority of individuals living with HIV/AIDS in the United States  today are racial and ethnic minorities, the populations eligible for the  services provided through both core HIV/AIDS grants and MAI grants are  primarily minority. In most cases, MAI grants not only have the same  purpose as core HIV/AIDS grants but MAI grants go to similar grantees to  provide similar services. Moreover, HHS agencies and offices are  required to manage separate, fragmented streams of funding that are  largely intended for the same purpose.
MAI grantees face a challenge in that they are often required to complete  duplicative administrative requirements for their HIV/AIDS funding. In past  work, GAO has determined that federal programs are duplicative when  they provide similar services to the same populations and fragmented  when numerous agencies or offices provide the same services. In this  case, a single department is funding the services, but it is doing so across  multiple agencies and offices with multiple funding streams. Such a  situation raises the possibility of inefficiencies and requires unnecessarily  duplicative administrative processes of grantees that could otherwise be  using their resources to provide needed services. Opportunities exist for  HHS to reduce unnecessarily fragmented funding streams through its  budget request and allocation process. For example, HHS can  consolidate disparate MAI funding streams when making discretionary  budget allocations, and it can restructure its annual budget requests to  concentrate funding in core HIV/AIDS programs. HHS can also seek  legislative solutions to achieve a more consolidated funding approach, for  example, by amendments to the CARE Act or other law, as necessary.
section_title: Recommendations for Executive Action
paragraphs: In order to reduce the administrative costs associated with a fragmented  MAI grant structure that diminishes the effective use of HHS’s limited  HIV/AIDS funding, and to enhance services to minority populations, HHS  should take the following two actions:
Consolidate disparate MAI funding streams into core HIV/AIDS  funding during its budget request and allocation process, and
Seek legislation to amend the CARE Act or other provisions of law, as  necessary, to achieve a consolidated approach.
section_title: Agency Comments
paragraphs: We provided a copy of this report to HHS for its review and HHS provided  written comments (see app. III). HHS stated that GAO’s  recommendations align with the National HIV/AIDS Strategy and federal  program accountability goals, but also stated that any restructuring of its  HIV/AIDS funding approach must ensure continued responsiveness to  minorities who are disproportionately affected by HIV/AIDS. HHS  welcomed an expanded discussion of strategies to more efficiently  administer MAI, reduce duplicative requirements for grantees, and more  effectively administer HIV/AIDS funding streams. HHS also described  some of its efforts to make SMAIF more efficient, responsive, and  accountable since the release of the National HIV/AIDS Strategy in July  2010.
HHS noted in its comments that it has several things to consider before it  moves to restructure its HIV/AIDS core funding streams and consolidate  MAI within core funding streams. HHS also noted that grantees’  administrative challenges are important but aren’t the only consideration  in assessing the merits of funding streams and the programs they  produce. HHS commented that any restructuring of core HIV/AIDS and  MAI funding streams and programs must ensure that HHS maintains its  responsiveness to the needs of communities and populations  disproportionately impacted by the HIV/AIDS epidemic. Our  recommendations that HHS take steps to consolidate disparate funding  streams provide HHS with discretion in defining grant eligibility  requirements or activities to address the issues HHS said it needs to  consider before restructuring funding streams. Consolidation can reduce  unnecessary, fragmented funding streams without compromising the  issues HHS needs to consider to ensure access to services for  disproportionately affected minorities.
HHS also provided technical comments, which we incorporated as  appropriate.
We are sending copies of this report to the Secretary of Health and  Human Services and interested congressional committees. In addition,  the report is available at no charge on the GAO website at  http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or crossem@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix IV.
section_title: Appendix I: Minority AIDS Initiative (MAI) Funding, Activities, and Grantees Funded, Fiscal Years 1999-2011
paragraphs: The Ryan White HIV/AIDS Treatment Extension Act of 2009 requires us  to report on the history of MAI program activities within each relevant  Department of Health and Human Services (HHS) agency and to provide  a description of activities conducted and types of grantees funded. To  provide this information, we requested data from each of the HHS  agencies and offices that have awarded MAI grants from 1999 through  2011 using either their own MAI program funding or transferred funding  from a department-level MAI account, known as the Secretary’s Minority  AIDS Fund (SMAIF). Three HHS agencies, the Centers for Disease  Control (CDC), the Health Resources and Services Administration  (HRSA), and the Substance Abuse and Mental Health Services  Administration (SAMHSA), reported using their own MAI program funds to  award grants to provide services in communities disproportionately  affected by human immunodeficiency virus/acquired immunodeficiency  syndrome (HIV/AIDS). In addition, the Office of HIV/AIDS and Infectious  Disease Policy (OHAIDP), acting on behalf of the HHS Office of the  Secretary, distributed SMAIF funding to HRSA, CDC, SAMHSA, and  seven other HHS agencies and offices which, in turn, awarded MAI grants  to provide services for communities disproportionally affected by  HIV/AIDS. For HRSA, CDC and SAMSHA, we report the total funding  level, by fiscal year, for their respective MAI programs as well as the total  SMAIF funding they received each fiscal year. For the other seven HHS  agencies, we report the total SMAIF funding they received each fiscal  year.
Tables 3 and 4 show annual MAI funding from 1999 to 2011.
HRSA’s MAI program was codified into law pursuant to the 2006  reauthorization of the Ryan White Comprehensive AIDS Resources  Emergency Act of 1990 (CARE Act). To be eligible for MAI grants under  the CARE Act, grantees must also have received grants under other  provisions of the CARE Act. HRSA reserves amounts from its annual  CARE Act appropriation for making supplemental MAI grants. There are  five primary sections of the CARE Act under which HRSA awards grants,  including MAI grants—Parts A, B, C, D and F. According to HRSA,
Part A MAI provides for grants to selected metropolitan areas—known  as eligible metropolitan areas and transitional grant areas—that have  been disproportionately affected by the HIV/AIDS epidemic.MAI grantees provide outpatient medical care, mental health and oral  health services, local pharmacy assistance, substance abuse  treatment, outreach, case management, early intervention services,  treatment adherence, and health education/risk reduction.
Part B MAI provides for grants to states and territories. Part B  grantees provide targeted outreach and educational activities to  increase minority participation in the AIDS Drug Assistance Program.
Part C MAI provides for grants to community health centers, health  departments, hospitals, medical centers and community-based  organizations (CBOs). Part C MAI grantees provide outpatient early  invention services including: primary medical care, oral health care,  mental health screening and treatment, substance abuse screening  and treatment, adherence counseling, nutritional services, and  specialty care.
Part D MAI provides for grants to state health departments, hospitals  or university based clinics, and other CBOs. Part D MAI grantees  provide family centered outpatient primary medical care, oral health  care, mental health screening and treatment, substance abuse,  screening and treatment, adherence counseling, nutritional services,  specialty care, pediatric care, women’s health, and access to clinical  trials.
Part D Youth MAI provides grants to hospitals, universities and other  CBOs. Part D Youth grantees identify HIV infected youth who are not  in care; enroll them in medical and supportive care; and retain them in  care. They also provide family centered outpatient primary medical  care, oral health care, mental health screening and treatment,  substance abuse screening and treatment, adherence counseling,  nutritional services, specialty care, and access to clinical trials.
Part F provides for grants to hospitals and universities. Part F MAI  grantees provide technical assistance, training, and education to other  MAI grantees.
HRSA reported that it also received SMAIF funding which it used for  grants for outreach to minority populations and training to HIV providers,  contracts promoting linkages to care for HIV/AIDS clients, and  cooperative agreements to support networks of HIV care by enhancing  primary medical care. HRSA’s SMAIF funding was also used in  connection with interagency agreements with CDC and its HIV/AIDS  Bureau. (See HRSA funding amounts and number of organizations  funded in table 5.)
In fiscal year 2007-2011 CDC reported that it awarded MAI funding  through cooperative agreements, contracts, interagency agreements, and  grants. Organizations that are awarded MAI funds by CDC include  business and commercial vendors, colleges and universities, CBOs,  federal agencies, hospitals, health departments, and national or regional  organizations. These organizations used MAI awards to provide capacity  building, evaluation, HIV prevention, demonstration projects, and  research activities to individuals disproportionately affected by HIV/AIDS.
CDC reported that it awarded SMAIF funding through contracts,  cooperative agreements and interagency agreements to a federal agency  and a national/regional organization, health departments, universities,  business/commercial vendors, and CBOs for capacity building,  evaluation, HIV prevention, surveillance, demonstration projects, and  research efforts. (See CDC funding amounts and number of organizations  funded in table 6.)
SAMHSA reported that they award MAI grants through three Centers: the  Center for Mental Health Services, the Center for Substance Abuse  Prevention, and the Center for Substance Abuse Treatment.
The Center for Mental Health Services reported that in fiscal years  2007-2010 it awarded cooperative agreements to domestic public  and private nonprofit entities. These cooperative agreements are  intended to enhance and expand the provision of effective, culturally  competent HIV/AIDS-related mental health services in minority  communities for persons living with HIV/AIDS and having a mental  health need. In fiscal year 2011, SAMHSA awarded funds to city and  state health departments in 11 cities, specifically among recipients of  the CDC’s Enhanced Comprehensive HIV Prevention Planning and  Implementation for Metropolitan Statistical Areas Most Affected by  HIV/AIDS grant program. According to agency documentation, these  entities intended to ensure that individuals that are either at high risk  for or have a mental or substance use disorder, and who are most at  risk for or are living with HIV/AIDS, had access to and received  appropriate behavioral health services (including prevention and  treatment), HIV/AIDS care, and medical treatment in integrated  behavioral health and primary care settings. Under this project,  activities were also targeted to integrate behavioral health and  primary care networks for HIV and medical treatment in minority  communities.
The Center for Substance Abuse Treatment reported that in fiscal  years 2007-2010 it awarded grants to CBOs, faith-based  organizations, national organizations, colleges and universities, clinics  and hospitals, research institutions, state and local government  agencies, and tribal entities to enhance and expand substance abuse  treatment and/or outreach and pretreatment services in conjunction  with HIV/AIDS services in African-American, Latino/Hispanic, and/or  other racial or ethnic communities highly affected by substance abuse  and HIV/AIDS. According to agency documentation, the Center also  awarded SMAIF grants to cohorts of organizations to expand the  capacity for providers to deliver rapid HIV testing, counseling and  referrals to care for fiscal year 2011.
The Center for Substance Abuse Prevention reported that in fiscal  years 2007-2011 it awarded cooperative agreements to CBOs  targeting at risk minority populations as well as colleges and  universities to provide a variety of activities including substance abuse  prevention services, HIV testing and outreach services; pre-post  counseling, reentry programs hepatitis education, and technical  assistance. Additionally, in this same timeframe contracts were  awarded for the review of grants, evaluation activity, technical  assistance to MAI grantees such as faith-based and community  organizations and the organization of grantee meetings. The Center  also awarded contracts to for-profit organizations and tribal  organizations with SMAIF funding during fiscal years 2007-2011. For  example, according to agency documentation, these organizations  provided training and technical assistance to coordinate substance  abuse education, HIV outreach and awareness, as well as testing on  college campuses and universities. (See SAMHSA funding and  number of grantees funded in Table 7.)
subsections: section_title: Indian Health Service (IHS)
paragraphs: IHS reported that it awarded SMAIF funding through grants, cooperative  agreements, contracts and interagency agreements in fiscal years 2007  through 2011. Specifically, the agency reported that Urban Indian Health  programs received grants to provide HIV screening services and IHS  established interagency agreements with federal sites for capacity  building and access to care services. Additionally, contractors provided  capacity building services, online HIV training for clinicians, and  educational videos. Cooperative agreements, grants, and interagency  agreements were made to increase HIV screening services. Lastly, grants  were used to provide effective behavioral interventions for tribal  communities. (See IHS MAI funding and number of grantees funded in  table 8.)
section_title: Office of Adolescent Health (OAH)
paragraphs: OAH reported that it received $200,000 in SMAIF funding in fiscal year  2011 that it used for a cooperative agreement with a university to provide  management of a resource center website and technical assistance. OAH  did not receive SMAIF funds prior to fiscal year 2011.
OHAIDP reported that it used its SMAIF funding to award contracts to  national technology and health communications firms and consultants to  provide technical assistance, education, and outreach via AIDS.gov  during fiscal years 2007-2011. (See OHAIDP funding amounts and  number of organizations funded in table 9.) Additionally, CBOs and faith- based organizations, health departments, universities and colleges, and  training centers were awarded contracts by OHAIDP. These entities  provided outreach, education, technical assistance, HIV testing, and  capacity building for the Minority Serving Institutions HIV/AIDS Prevention  Demonstration Initiative. OHAIDP officials also reported that SMAIF funds  were used for the National HIV testing mobilization campaign, and to  coordinate for the National HIV/AIDS Strategy during this timeframe.
section_title: HHS Office of Minority Health (OMH)
paragraphs: OMH reported that it used its SMAIF funding to award grants and  cooperative agreements to CBOs and national organizations during fiscal  years 2007 through 2011. (See OMH funding amounts and number of  organizations funded in table 10.) Specifically, these funding mechanisms  provided capacity building, technical assistance, health promotion and  education, access to testing and care, counseling, peer education, and  links to social and support services.
section_title: Office of Population Affairs (OPA)
paragraphs: OPA reported that it used its SMAIF funding to award grants to health  departments, community health centers, Planned Parenthood, as well as  other organizations including non-profits, universities, hospitals, faith- based organizations, tribal health centers, and free-standing family  planning organizations during fiscal years 2007 through 2011. (See OPA  funding amounts and number of organizations funded in table 11.)  Specifically, these grants provided for expanded HIV testing, prevention  education, and referrals to care.
section_title: Office on Women’s Health (OWH)
paragraphs: OWH reported that it used its SMAIF funding in fiscal years 2007-2011 to  award grants for HIV prevention and education services for women,  including adolescents and youths at risk of HIV/AIDS. OWH reported that  SMAIF funds were used for contracts and cooperative agreements to  provide services to women living in the United States Virgin Islands,  Puerto Rico, and Native American women, as well as women sexually  involved with an incarcerated or recently released partner. (See OWH  funding and number of grantees funded in table 12.) Additionally, OWH  awarded grants for outreach and education services and events including  the National HIV/AIDS Awareness Day and the Young Women’s  Mobilization project.
section_title: Regional Health Administrators (RHA)
paragraphs: RHA reported that it used its SMAIF funding to contract with a for-profit,  publicly owned, and traded company to provide capacity building services  in fiscal years 2008-2011. (See RHA funding and number of grantees  funded in table 13.)
section_title: Appendix II: Methodology for Review of Minority AIDS Initiative (MAI) Services from Sample of MAI Annual Grantee Reports
paragraphs: To identify the types of services provided by grantees under MAI, we  selected a generalizable sample from 100 fiscal year 2011 grantees in  order to review their MAI annual grantee reports. To select our sample,  we created a list of all MAI grantees from the ten Department of Health  and Human Services (HHS) agencies and offices that awarded MAI  grants in fiscal year 2011. We selected a generalizable sample of 100  grantees that were approximately proportional to MAI funding amounts for  the respective agencies and offices. We then requested fiscal year 2011  MAI annual grantee reports for the 100 grantees from these agencies and   This sample is generalizable  offices and uploaded the reports into NVivo.to the whole population of MAI grantees. The sample was selected within  agency strata, with strata sample sizes defined to ensure that the  distribution of grantee spending for each agency was approximately  proportional to its distribution in the population of grantees. We calculated  sampling weights that reflected this design, which allowed us to  appropriately combine data across the agency strata and make estimates  that generalized to the whole population of MAI grantees.
We used NVivo to conduct a review of MAI services using the MAI annual  grantee reports we obtained from the generalizable sample of 100 MAI  grantees we selected. In order to identify the types of MAI services, we  categorized MAI services into six categories based on an initial review of  the reports: (1) administrative; (2) medical services; (3) client assistance;  (4) community outreach/education; (5) training; and (6) testing. We  created an additional category to identify best practices reported by  grantees to inform our second objective on best practices for community  outreach and capacity building of community-based organizations serving  communities that are disproportionately affected by human  immunodeficiency virus/acquired immunodeficiency syndrome  (HIV/AIDS). We defined the term best practices to include any successes,  lessons learned, or challenges overcome by grantees regarding their MAI  activities. We also created sub-categories for medical services and best  practices in order to obtain more detailed information on these categories  (see table 14 for the definitions of MAI categories and sub-categories).
We conducted a review of MAI services from the sample of 100 MAI  annual grantee reports in which three members of the team  independently coded a selection of reports to identify MAI services. We  reviewed each other’s coding to ensure its accuracy and resolved any  disagreements or inconsistencies in coding through a discussion between  team members to ensure mutual agreement that the services identified in  the annual grantee reports were consistent with the categories of services  listed in Table 14 above.
We identified the services provided in the 100 MAI annual grantee reports  through several rounds of NVivo coding and review. We then analyzed  our coding results in order to identify the types and frequency of MAI  services conducted by MAI grantees in our sample. We analyzed and  compared the MAI services identified in the six categories by grant  amount, HHS agency and office (e.g., the Health Resources and Services  Administration, Centers for Disease Control and Prevention, etc.), source  of grant (e.g., agency MAI allocation or funding from the Secretary’s MAI  Fund) and organization type (e.g., community-based organization, city,  etc). We also analyzed the output to identify best practices reported by  grantees that were associated with providing MAI services and/or in  serving communities disproportionally affected by HIV/AIDS. However,  because MAI grantees generally were not required to discuss best  practices in their annual grantee reports, we could not estimate the  proportion of grantees identifying such practices and, as a result, our  estimates are not generalizeable for this purpose.
Estimates of the services provided and population served from this  sample are generalizable to the population of MAI grantees. We  summarize the statistical precision of our estimates using a 95 percent  confidence interval, which is the interval that would contain the population  value in 95 percent of the samples we could have drawn. Since the size  of the confidence intervals varies widely across the estimates, we specify  these intervals where we refer to the estimates.
section_title: Appendix III: Comments from the Department of Health and Human Services
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the contact named above, key contributors to this report  were Tom Conahan, Assistant Director; Romonda McKinney Bumpus;  Cathleen Hamann; Seta Hovagimian; Jessica Morris; Steven Putansu;  Jeff Tessin; and Jennifer Whitworth.