Ryan White CARE Act: Implementation of the New Minority AIDS Initiative Provisions
Released: 2009-03-27T00:00:00

Letter

Background

MAI, a component of the CARE Act, provides for funds to eligible grantees with the goal of reducing HIV-related health disparities among minority populations. HRSA awards MAI grants to Part A, B, C, D, and F grantees through a competitive process. HRSA provides oversight of these grantees, while the grantees provide oversight of their service providers.

HRSA Administration of CARE Act Funding

HRSA primarily awards CARE Act funds to grantees for core medical services, support services, and education through five primary sections of the legislation—Parts A, B, C, D, and F. In fiscal year 2007, 22 EMAs and 34 TGAs received grants under Part A; all 50 states, the District of Columbia, Puerto Rico, and 7 U.S. territories received grants under Part B; 354 public and private organizations that provide services directly to individuals with HIV received grants under Part C; and 90 public and private organizations that provide services to families in which at least one member is HIV positive received grants under Part D. For Parts A, B, C, and D, programs funded by the CARE Act are the payers of last resort for care. In addition, some Part B funds are used to provide medication for HIV/AIDS treatment through the AIDS Drug Assistance Program (ADAP) when annual appropriation laws provide funds exclusively for this purpose. Fifteen AIDS education and training centers (AETC), which provide HIV/AIDS education to health professionals such as nurses and physicians, received funding under Part F. For all parts of the CARE Act, grantees may use CARE Act funds to engage service providers that provide HIV/AIDS services to individuals.

CARE Act funding for metropolitan areas, states, and territories is distributed in the form of base, supplemental, and MAI grants. CARE Act grant funding totaled approximately $2.1 billion in fiscal year 2007; $131.2 million of that amount was MAI grants, representing 6 percent of overall CARE Act grants. Grantees under Parts A, B, and C must spend at least 75 percent of their grants for core medical services, while no more than 25 percent of these funds can be spent for support services. Table 1 lists core medical service and support service categories.

In administering the CARE Act, HRSA issues guidance for applying for and spending MAI grants. HRSA requires MAI grantees to submit reports as a condition of their grant awards. The reports MAI grantees submit to HRSA summarize grantees’ MAI activities and include data on individuals served, services offered, budget allocations, and expenditures. For all parts of the CARE Act, HRSA provides oversight of grantees but expects grantees to provide oversight of service providers. (See fig. 1 for HRSA’s role in the administration and oversight of MAI funds.) focused on women, children, nd yoth multiple CARE Act parts.

Sometimes MAI grantees also function as service providers.

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

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

Service providers are organizations with which grantees contract or award subgrants to provide services or arrange to have another organization to provide services.

Reporting Requirements for CARE Act Grantees

Federal grantees are required to comply with certain audit requirements based upon their total expenditures of federal funding and to submit certain reports at a frequency determined by the agency awarding the grant. HRSA requires CARE Act grantees to submit the following reports: quarterly payment management reports, which include grantee spending for the previous 3-month period, and a financial status report, which is required within 90 days of the end of each grant year and accounts for expenditures under the project that year.

Additionally, HRSA has grant-specific reporting requirements. For example, Part A and B grantees are required to submit the annual Ryan White HIV/AIDS Program Data Report, which requires grantees and their service providers to provide information on the number of clients who have received services and demographic information about these clients, the services provided by the grantees’ service providers, the number of clients who received HIV counseling and testing, and medical information about the clients who received services.

There are also MAI-specific reporting requirements. Each MAI grantee is required to submit the Minority AIDS Initiative Report, which includes the final annual MAI plan due within 90 days of the budget start date each year and the annual progress report.

Grantees that receive Part A and B MAI grants have some additional reporting requirements since the enactment of RWTMA. Since the enactment of RWTMA, Part A and B MAI grantees have been required to submit separate sets of the payment management reports and financial status reports for their base and supplemental funding.

MAI Changes Resulting from RWTMA

MAI grants were first distributed in conjunction with CARE Act funding in fiscal year 1999. RWTMA added provisions on MAI funding to the CARE Act, authorizing specific amounts for the purpose of carrying out activities to evaluate and address the disproportionate impact of HIV/AIDS on, and the disparities in access, treatment, care, and outcomes for, racial and ethnic minorities. The amount of CARE Act funds used for MAI grants has increased from $24 million in fiscal year 1999 to $131 million in fiscal year 2007.

According to HRSA officials, Part A and B MAI funds are to be used to expand the core medical and support services to minorities that might not otherwise be provided through the base funding. Part C, D, and F MAI funds are to be used to expand the number of individuals receiving services as these individuals may not otherwise be served by non-MAI funding.

Prior to the enactment of RWTMA, the MAI funds for Part A and B grantees were awarded according to a formula that solely reflected the number of living minority AIDS cases in the metropolitan area, state, or territory receiving funds. These data are referred to as case counts. RWTMA changed how case counts are defined for other CARE Act programs to include living HIV cases. For Part A and B MAI grants, HRSA changed the case counts from the number of living minority AIDS cases to the number of living minorities with HIV/AIDS for the most recent year available as reported to CDC.

The CARE Act requires HRSA to award Part A and B MAI grants using a competitive process. The Part A and B MAI applications, which are separate from Part A and B base and supplemental applications, require grantees to describe their local needs and the services they would provide using MAI funds. HRSA continues to use minority case counts in determining MAI grant awards, but now does so in combination with application scores. HRSA officials reported that the agency calculates Part A and B MAI grant awards based on both the grantee’s application scores and the minority case count in the metropolitan area, state, or territory. HRSA application guidance outlines the points awarded for each section of the application, and the impact of a grantee’s performance in its completion of the application is demonstrated in the MAI funding the grantee receives. The CARE Act does not specifically require Part C, D, and F MAI grants to be awarded on a competitive basis or to be awarded separately from base funds under those parts. HRSA awarded MAI grants under these parts competitively, as a component of the competitive grant award for the base Parts C, D, and F. HRSA did this prior to the enactment of RWTMA and continues to do so.

Barriers to Care

Barriers to HIV/AIDS care can delay or prevent individuals’ timely entrance into, or continuation of, core medical or support services, thus reducing the likely success of care. Research shows that minorities, in general, often receive a lower quality of health care and face barriers to obtaining health care, including services related to cancer screening, cardiovascular disease, diabetes, and HIV/AIDS. Barriers to HIV/AIDS care can include issues such as histories of substance abuse disorders or domestic violence. For example, research studies show that individuals living with HIV/AIDS who also have substance abuse disorders and are actively using substances are less likely to adhere to medical care. Barriers to care, such as lack of transportation to medical care or social stigma associated with HIV/AIDS, can also affect minority communities. For example, we have found in previous work that lack of transportation was found to delay, prevent, or interrupt HIV/AIDS treatment for American Indian and Alaska Native communities. HRSA required MAI applicants to describe barriers to care for minorities in their jurisdictions as part of their MAI applications. Eliminating or decreasing barriers is important to the delivery of comprehensive, integrated, quality HIV/AIDS services.

The New Competitive Process for Parts A and B Altered MAI Funding Amounts, Increased Administrative Requirements for Grantees, and Generally Funded the Same Initiatives

The new competitive process for Parts A and B resulted in changes in the amount of funding from what grantees would have received under the old formula-based process. Grantees that received MAI funding stated that the administrative requirements of the grant increased significantly in fiscal year 2007, and some grantees chose not to apply for MAI funds. Grantees continued funding existing initiatives to reduce health disparities for minorities rather than funding new initiatives, and grantees generally provided funding to the same service providers as they had in prior years.

The New Competitive Process Resulted in Changes in the Amount of Funding from What Grantees Would Have Received under the Old Formula-Based Process

The new MAI competitive process resulted in funding amounts that differed from what grantees would have received under the old formula- based process that based funding solely on minority case counts. All Part A and B grantees that applied for MAI funds in fiscal year 2007 received MAI funding. However, since RWTMA changed the process by which MAI funds were awarded, some grantees’ MAI grant amounts differed from what they would have been awarded under the previous formula-based process.

Prior to RWTMA, a Part A or B grantee’s MAI funding was based on its share of minority AIDS cases relative to the total number of minority AIDS cases in all metropolitan areas or states and territories eligible for funds, and a competitive application was not required. For example, if a Part A grantee’s minority case count accounted for 4 percent of the total number of minority AIDS cases in all eligible metropolitan areas, that grantee would receive 4 percent of the total available Part A MAI funds. The new competitive MAI process, as implemented by HRSA, considers the minority case count in determining a grantee’s MAI award, but does so in conjunction with the grantee’s MAI application score. Because a grantee’s MAI application score is considered along with the number of HIV/AIDS cases in the metropolitan area, state, or territory, there is no longer a one- to-one relationship between an applicant’s proportion of cases and its proportion of MAI grant funding. As a result, we found differences between the amounts many grantees would have received under the old formula-based process and the amounts they received under the new competitive process. For example, in fiscal year 2007, Phoenix received $127,578 (39.8 percent) less than it would have received under the old formula, while Houston received $154,018 (10.9 percent) more. In addition, in some cases we found that grantees with a lower number of HIV/AIDS cases received more funding under MAI than grantees with a higher number of HIV/AIDS cases because of their competitive scores. Table 2 shows Part A MAI grantees’ fiscal year 2007 funding levels under the competitive process, and an estimate of what each grantee’s funding level would have been under the old formula-based process. For Part A MAI, 30 of the 56 grantees received lower funding amounts under the new competitive process than they would have under the old formula-based process. The median difference for all Part A grantees between the actual fiscal year 2007 funding and the estimated funding based on the old formula-based process was a loss of $3,053. Because of their competitive scores, 20 Part A grantees experienced changes of greater than 10 percent of what they would have received under the old formula-based process.

Table 3 shows Part B MAI grantees’ fiscal year 2007 funding levels under the competitive process and an estimate of what each grantee’s funding level would have been under the old formula-based process. For Part B MAI, 20 of the 29 grantees that applied for funding received higher funding amounts under the new competitive process than they would have under the old formula-based process. For these Part B grantees, the median difference between the actual fiscal year 2007 funding and the estimated funding based on the old formula-based process was a gain of $2,779. (See app. III for a comparison of the fiscal year 2006 and fiscal year 2007 Part A and B MAI funding amounts and MAI as a proportion of total funding.) Because of their competitive scores, 20 Part B grantees experienced changes of greater than 10 percent of what they would have received under the old formula-based process.

The New Competitive Process Increased the Administrative Requirements for Grantees, and Some Grantees Chose Not to Apply for MAI Funds

Many MAI grantees said that the new competitive process increased their administrative requirements. Part A and B grantees that applied for MAI grants in fiscal year 2007 reported that the new MAI grant application and reporting requirements are time-consuming and duplicative of the requirements for the Part A and Part B base and supplemental funding. Prior to the implementation of the MAI competitive process, grantees answered a few MAI-related questions on their base and supplemental applications. However, the amount of funding a grantee received was based on the grantee’s number of AIDS cases relative to the overall number of AIDS cases among all grantees, not its responses to these questions.

Several grantees we interviewed that did apply and received MAI grants stated that the administrative requirements increased significantly with the new competitive process. Grantees explained that integrating the Part A and Part B base funding program activities with MAI activities has become difficult because under the new process, these activities must be reported separately. Reporting on MAI activities has also been made substantially more difficult because of HRSA’s designation of different fiscal years for different CARE Act grant programs. The fiscal year for Part A base and supplemental funding is March 1 to February 28. For Part B base and supplemental funding the fiscal year is April 1 to March 31. The Part A and Part B MAI fiscal year is August 1 to July 31. Some grantees said that the separate fiscal years increased their administrative requirements. For example, one grantee told us that the separate reporting and different fiscal years act as an “artificial separation” of funding for services to the same client population. While grant guidance states that “HRSA expects grantees to implement and administer MAI-funded services and activities in a manner that is consistent with the Part A and Part B programs,” some grantees stated that the different funding cycles make such integration difficult. Many grantees also explained that the separate applications and different funding cycles complicated the contracting process, thus requiring them to write more contracts, file more reports, and conduct additional monitoring without extra funding for this added administration.

In addition, HRSA officials explained that some states and territories did not apply for MAI funding because in past years they had received relatively small amounts of funding, and would have to undergo increased requirements because of the new competitive application process to receive that funding in fiscal year 2007. In total, 22 states and territories that were Part B grantees in fiscal year 2006 chose not to apply for MAI in fiscal year 2007. Grantees that chose to apply in fiscal year 2007 received MAI funding that amounted to less than 1 percent of their total Part B funding (see app. III for funding tables for total CARE Act awards for Part B grantees). Moreover, some grantees explained that they only had about a month to complete the MAI application after new application guidance was issued, which they did not consider to be enough time to prepare the application. In addition, one grantee we interviewed also explained that the narrow scope of Part B MAI funding, that is, that it could only be used for ADAP-related outreach and education services, also made it less likely to apply. As indicated in table 3, because there was a fixed amount of funding and fewer applications were received, there were more MAI funds available to each grantee that submitted an application.

The New Competitive Process Generally Resulted in the Funding of the Same Initiatives

Some Part A and B grantees reported that they have continued to fund the same initiatives to reduce minority health disparities that they did prior to the implementation of the new MAI competitive process. Grantees we interviewed whose fiscal year 2007 MAI funding increased from the previous year stated that they funded their service providers to continue funding existing initiatives to reduce health disparities for minorities. Some grantees whose fiscal year 2007 MAI funding decreased from the prior year reported to us that they reduced or eliminated the amount of funding they awarded to service providers. One grantee reported that a service provider the grantee had intended to fund declined to provide services because the service provider lacked the resources needed to comply with MAI reporting requirements.

Part A grantees generally used the same request for proposal (RFP) process to select service providers under the new MAI competitive process as they had used before. Of the 43 Part A grantees that responded to our survey, 33 stated that they used an RFP selection process to choose service providers in the first year under the new competitive process, and 35 stated that they used an RFP prior to RWTMA. Of the 8 grantees that did not use an RFP process, 5 generally stated that they did not need RFPs in the first year of the change to the new competitive process because they used an RFP process in an earlier year to select service providers and awarded multiple-year contracts.

Most of the Part B grantees that responded to our survey changed how they selected service providers after the switch to a competitive process. While 20 out of 44 Part B survey respondents that received MAI funding before the change to the new competitive process used an RFP to select service providers, only 7 out of 26 Part B survey respondents that received MAI funding after the change used an RFP process to select service providers. Some grantees stated that they provided funding to one or two organizations with which they were familiar, applied the funds to existing contracts, or used the funds themselves, instead of issuing an RFP.

Grantees Fund a Range of Core Medical and Support Services under MAI

MAI grantees under all parts of the CARE Act reported funding a range of core medical and support services using MAI funds. These services can be provided either directly by the grantees or through service providers. We found that Part A grantees generally used MAI funds to fund services similar to those funded through base or supplemental grants. This is in accordance with HRSA’s guidance, which states that it is appropriate to implement similar types of services using MAI and base and supplemental Part A funds. Only rarely did Part A grantees use MAI funds exclusively to fund a specific type of service, such as outreach to minority individuals or nonmedical case management not otherwise supported with CARE Act funds. Some Part A grantees reported that they take a coordinated approach to the prioritization and expenditure of base, supplemental, and MAI funds.

Part A grantees reported funding a range of core medical and support services under MAI. According to our survey, four of the top five services most commonly funded in fiscal year 2007 were categorized as core medical services—medical case management, outpatient and ambulatory health services, substance abuse outpatient care, and mental health services. (See table 4.) Outreach was the only support service among the top five most commonly funded services. In addition, nine Part A grantees responded that they funded a range of services other than those listed in our survey, including early intervention services, residential substance abuse treatment, and psychosocial support.

Similar to Part A grantees, Part C and D grantees used MAI funding for a range of core medical and support services, while Part B and F grantees used MAI funding for specific services designated by the MAI provisions in the CARE Act. In interviews, Part C and D MAI grantees generally reported funding core medical and support services based on their clients’ needs as well as their organizational missions. For example, five Part D MAI grantees reported focusing their services on the needs of women and youth, including offering child care services and targeted case management. The CARE Act restricts the use of Part B MAI funds to efforts related to increasing the number of minorities in ADAP. Part F MAI grantees told us that they use MAI funds for education efforts targeting health care professionals who are from, or primarily serve, minority communities. These education efforts are similar to services they fund using other CARE Act grants.

Some MAI grantees reported changing the mix of services they funded from fiscal year 2005 through fiscal year 2007. Grantees we interviewed said that they changed the mix of services they funded to comply with the requirement added by RWTMA that at least 75 percent of grant funding be spent for core medical services. Among the 43 respondents to our survey of Part A grantees, the number of MAI grantees funding medical case management more than doubled from fiscal year 2005 through fiscal year 2007, while the number funding nonmedical case management decreased by a third. In addition, Part A grantees indicated changes in the types of support services they funded from fiscal year 2005 through fiscal year 2007. Survey results showed increases in the number of grantees providing referrals to health care services and transportation services and a decrease in the number providing outreach services. Some Part A grantees reported that since the enactment of RWTMA, they have had to curtail support services such as housing, emergency financial assistance, and client advocacy as well as capacity building in historically underrepresented communities. Furthermore, in interviews, some grantees reported changing the types of services they funded as a result of RWTMA’s enactment. For example, two grantees, one Part A and one Part B, reported changing existing case management services to fit within the medical case management definition, which includes, for example, the coordination and follow-up of medical treatments.

MAI Grantees Identified Multiple Barriers to Minorities’ Access to the Services Provided by HIV/AIDS Programs

MAI grantees identified multiple barriers that make it difficult for minorities to obtain services through HIV/AIDS programs. Similar to the barriers minorities face, in general, in obtaining health care, these barriers present challenges for individuals in obtaining HIV/AIDS services that may not only prevent or delay entry into care but could also decrease adherence to treatment. Barriers to minorities’ access to HIV/AIDS services are often interconnected and include issues such as a lack of transportation to HIV/AIDS services, mistrust of service providers, lacking or insufficient insurance, homelessness, poverty, and language issues. Language issues, for example, suggest the need for the linguistic services of an interpreter or translated materials to receive HIV/AIDS services. If a minority must overcome language issues in order to receive HIV/AIDS services and cannot do so, then these issues become a barrier to obtaining HIV/AIDS services. Complications for care, such as comorbidities, also were reported as barriers to minorities obtaining HIV/AIDS services.

We found that Part A and B grantees generally identified similar barriers in their MAI applications. Table 5 shows the 10 barriers to minorities obtaining HIV/AIDS services most frequently identified by Part A and B MAI grantees. They identified co-morbidities, housing issues, and poverty as the top three barriers to care, with at least 8 out of 10 grantees identifying each barrier. Co-morbidities can include hypertension, mental illness, sexually transmitted infections/diseases, and tuberculosis. Unstable housing can prevent minorities with HIV/AIDS from accessing health care and adhering to complex HIV/AIDS treatments because they often must attend to more immediate needs, such as obtaining food and shelter. Poverty, defined by the federal government according to income thresholds that vary by family size and composition, can have similar implications. Appendix IV provides descriptions and a more complete list of barriers identified by Part A and B grantees in their fiscal year 2007 MAI competitive grant applications.

In our interviews, grantees under Parts C, D, and F also described many of the issues in table 5 as barriers to minorities obtaining HIV/AIDS services. Grantees explained that HIV/AIDS care may not be the primary issue on an individual’s list of needs or concerns. Without overall programs to support these competing needs, minorities will experience barriers to obtaining HIV/AIDS medical services. For example, some grantees discussed barriers related to language issues within some minority communities. A Part C grantee identified the lack of bilingual health care providers as a major barrier to care for minorities served by the grantee. The director of a Part C grantee explained that stigma associated with HIV/AIDS is a barrier for some minorities because they are less likely to seek services within their communities for fear of revealing that they have HIV/AIDS. Part F grantees we interviewed stated that the barriers to care included the lack of specialty care, mistrust of health systems by patients, and the lack of insurance.

Agency Comments and Our Evaluation

HHS provided comments on a draft of this report. The comments are reprinted in appendix V. In its comments, HHS suggested that we identify the law authorizing Ryan White programs as either Title XXVI of the Public Health Service Act or the Ryan White HIV/AIDS program. Consistent with our previous work, we continue to refer to the law authorizing Ryan White programs as the CARE Act. As noted in the report, the current program is authorized under the CARE Act, as amended. We have added the Public Health Service Act title to our footnote providing the legal citation to the statute. In addition, HHS provided technical comments on the report draft, which we have incorporated as appropriate.

We are sending a copy of this report to the Acting Secretary of Health and Human Services. The report is also available at no charge on GAO’s Web site at http://www.gao.gov.

If you or your staff have any questions about this report, please contact me at (202) 512-7114 or crossem@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. Other staff who made major contributions to this report are listed in appendix VI.

Appendix I: Grantees Reported Few Challenges to Program Integration

The Ryan White Comprehensive AIDS Resources Emergency Act (CARE Act) requires us to report information on the challenges to human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) program integration experienced by CARE Act grantees. Challenges to program integration are issues that can prevent grantees and service providers from working together to coordinate HIV/AIDS service provision and can prevent clear communication between these organizations regarding funding and program requirements. To identify the challenges to HIV/AIDS program integration experienced by CARE Act grantees, we interviewed staff from selected Part A, B, C, D, and F grantees. To gather background information about the challenges to HIV/AIDS program integration experienced by CARE Act grantees, we interviewed officials from the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services and staff of the National Minority AIDS Council, Kaiser Family Foundation, the National Alliance of State and Territorial AIDS Directors, and the Communities Advocating Emergency AIDS Relief Coalition.

Grantees reported that few challenges exist to HIV/AIDS program integration. Many grantees and service providers funded under different parts of the CARE Act interact with other grantees, service providers, and federal and state HIV/AIDS programs to provide services. However, few problems were identified. For example, an official from a grantee told us that the organization promotes program integration by designing its services to create a “seamless flow” of care for individuals. This includes using targeted outreach programs to bring minorities into care and providing case management services. The service provider then follows up with minority individuals through case management services as well as mental health, substance abuse, and psychosocial support services, as needed.

Grantees reported few challenges to HIV/AIDS program integration even though they receive funding from multiple sources to provide HIV/AIDS services. Funding for HIV/AIDS programs to provide services can come from Medicaid, Medicare, Centers for Disease Control and Prevention (CDC) grants, Substance Abuse and Mental Health Services Administration (SAMHSA) grants, and state programs. Grantees we interviewed may receive funding from a variety of federal and state sources. However, CARE Act grants are designated as the “payer of last resort” and therefore pay for HIV/AIDS services that are not covered by other resources, such as Medicaid, Medicare, or private insurance. Some grantees reported in interviews that they have mechanisms in place to ensure that these CARE Act programs are the payers of last resort, which usually consists of closely tracking funding and expenditures on services rendered for individuals, and to identify the appropriate program to pay for HIV/AIDS services for individuals, including those with specific needs.

One challenge some grantees identified was a lack of uniform data collection and reporting requirements across the multiple parts of the CARE Act, even though the required data are similar. Some grantees we interviewed told us that differences in data collection and reporting systems are challenges to program integration across the multiple parts of the CARE Act.

Another challenge to achieving program integration is that definitions of services may differ between the CARE Act and other federal and state funding sources. Officials from a Part B grantee told us that differing definitions present challenges to collaboration and integration because grantees and service providers may be referencing different services despite using the same term. For example, the definition of “case management” is different depending on whether one uses the term in reference to the CARE Act or to another federally funded program, such as the Housing Opportunities for Persons with AIDS program.

Appendix II: Objectives, Scope, and Methodology

The CARE Act requires us to report on the Minority AIDS Initiative (MAI) and related issues. In this report, we are providing information on (1) the effect on grantees and service providers of the new competitive process for awarding Part A and B MAI funds, (2) the types of services grantees funded under MAI, and (3) barriers to minorities obtaining services from HIV/AIDS programs that were identified by grantees. The CARE Act also requires us to report on the challenges of integrating CARE Act–funded programs with HIV/AIDS programs funded from other sources such as Medicaid, Medicare, the Centers for Disease, Control and Prevention and SAMHSA. (See app. I for information on the challenges of HIV/AIDS program integration experienced by CARE Act grantees.)

To determine the effect of the new competitive process for awarding MAI funds on grantees and service providers, we conducted a Web-based survey of CARE Act grantees under Parts A and B. We obtained contact information for Part A and Part B grantee officials, including names and e-mail addresses, from HRSA. The survey questions focused on how grantees applied for MAI funds, distributed funds to service providers, and provided oversight, and what services they provided prior to and after the passage of the Ryan White HIV/AIDS Treatment Modernization Act of 2006 (RWTMA). We included in the survey Part B grantees that did not apply for MAI funding for fiscal year 2007 in order to obtain their reasons for not applying. The survey response rates were about 77 percent (43 out of 56) for Part A grantees and about 81 percent (48 out of 59) for Part B grantees.

During the development of our survey, we conducted pretests with two Part A grantees (in Washington, D.C., and Baltimore, Maryland) and two Part B grantees (in Georgia and Pennsylvania). We opened the survey on May 15, 2008, and closed it on June 27, 2008. While the survey was open, we contacted each nonrespondent by e-mail to follow up and subsequently contacted any remaining nonrespondents by telephone to follow up as a way to address any problems and to encourage nonrespondents to complete the survey. Because this survey was conducted with all of the Part A and B grantees, it is not subject to sampling error. However, there are practical difficulties in conducting any survey that may introduce other types of errors, such as nonsampling errors. For example, nonsampling error may introduce unwanted variability or bias in the survey results and can result when survey respondents inconsistently interpret particular survey questions. We took steps to minimize nonsampling errors in developing the questionnaire and in data collection and analysis. While the response rates of 77 and 81 percent are high, if those not responding differed materially from those responding on any particular question we analyzed, our analysis may not accurately represent the group surveyed.

Therefore, our results are representative only of those responding to our survey and are not generalizable to a larger population.

In addition, we reviewed HRSA’s policies and reporting requirements for Parts A, B, C, D, and F. We interviewed HRSA officials and staff from selected grantees for Parts A and B to determine how funds were distributed to service providers.

We estimated funding amounts for Part A and B grantees based on the old formula-based process and analyzed the difference between these amounts and the actual funding for fiscal year 2007. To create these estimated funding amounts, we reviewed CARE Act MAI funding data for fiscal years 2006 and 2007, case counts of minorities living with AIDS for fiscal year 2006, and case counts of minorities living with HIV/AIDS for fiscal year 2007, all of which were provided by HRSA. To estimate funding amounts for each Part A and Part B grantee, we followed the old formula- based process, which used a proportion that represented the relationship between a grantee’s minority HIV/AIDS case count for fiscal year 2007 and the total minority HIV/AIDS case count for all jurisdictions, and then multiplied that proportion by the total amount of MAI funding available. This gave us the estimated amount of funding for each grantee. We then determined the difference between the actual funding the grantee received under the new competitive process for 2007 and our estimated funding amount to establish the impact of the change to the new competitive process. To assess the validity of the funding amounts, we compared data we received from HRSA to previously published funding amounts. To assess the reliability and validity of the computer-generated estimated funding amounts, we provided HRSA officials with a copy of our tables. They agreed with our methodology and were able to duplicate our funding amounts. We determined that the funding data and case count data were sufficiently reliable for the purposes of this report.

To identify the types of services grantees funded under MAI, we conducted a Web-based survey of Part A and B grantees, as described above, and interviewed selected Part A, B, C, D, and F grantees about services they provided under MAI prior to and after the passage of RWTMA. We interviewed HRSA officials and staff from six Part A and six Part B grantees to determine how funds were distributed. Although there was no change in the process for awarding funds under Parts C, D, and F, we interviewed grantees under those parts to learn about the services they funded. We interviewed staff from six Part C, six Part D, and three Part F grantees. We selected grantees to interview based on the amount of MAI funding they received and to ensure geographic diversity. All interviews were conducted over the telephone using a structured interview guide that was provided to the interviewees in advance. Question topics included the relationship between HRSA and the grantee and between the grantee and service providers, the services grantees funded, evaluation of services funded by grantees, barriers minorities with HIV/AIDS face in obtaining services through HIV/AIDS programs, and program integration barriers. We also interviewed staff of the National Minority AIDS Council, Kaiser Family Foundation, the National Alliance of State and Territorial AIDS Directors, and the Communities Advocating Emergency AIDS Relief Coalition.

To identify the barriers to minorities obtaining services from HIV/AIDS programs that were identified by grantees, we reviewed Part A MAI and Part B MAI competitive grant applications for fiscal year 2007, which included grantees’ responses regarding barriers minorities face in accessing HIV/AIDS services. We interviewed staff from selected Part A, B, C, D, and F grantees about barriers minorities with HIV/AIDS face in obtaining services through HIV/AIDS programs and budget allocations to different HIV/AIDS services. We requested and received from HRSA fiscal year 2007 MAI grant applications from all Part A and Part B applicants. We conducted content analyses on selected sections of the MAI applications in which grantees described barriers, co-morbidities, unmet needs, coordination of services, implementation plans, and impact of MAI services. During the content analyses, we collected information from the fiscal year 2007 Part A MAI and Part B MAI applications regarding barriers to HIV/AIDS services, co-morbidities for individuals with HIV/AIDS, and factors that were complications for care. We also interviewed staff from the organizations listed above.

We conducted our work from January 2008 to February 2009 in accordance with all sections of GAO’s Quality Assurance Framework that are relevant to our objectives. The framework requires that we plan and perform the engagement to obtain sufficient and appropriate evidence to meet our stated objectives and to discuss any limitations in our work. We believe that the information and data obtained, and the analysis conducted, provide a reasonable basis for any findings and conclusions.

Appendix III: Ryan White CARE Act Title I and II Funding for Fiscal Year 2006 and Part A and B Funding for Fiscal Year 2007

Table 6 shows funding for Title I grant awards for fiscal year 2006. Since the enactment of RWTMA, CARE Act Title I has been referred to as Part A. In fiscal year 2006, 51 Title I grantees received MAI funding, and the grant amounts ranged from $29,264 to $11,936,248. Overall, MAI grants accounted for 13 percent or less of a Title I grantee’s total CARE Act funding.

Table 7 shows Part A grant awards for fiscal year 2007. In addition, we provide information on the percentage change from fiscal year 2006 through fiscal year 2007 in Part A MAI grant awards. This change is based on several factors in addition to the new competitive process. (See pages 13-19 for our analysis of fiscal year 2007 funding that isolates the effect of this change.) The reasons for the changes in funding from fiscal year 2006 through fiscal year 2007 include the following: The addition of five Part A TGAs, which decreased the amount of individual funding for all Part A grantees.

Increases or decreases in grantees’ proportion of the total number of living minority HIV/AIDS cases, which is used as part of the determination of the demonstrated need for funding. From fiscal year 2006 through fiscal year 2007, HRSA changed the case count method from using the number of living minority AIDS cases to using the number of living minorities with HIV/AIDS for the most recent year available as reported to CDC.

Scoring of grantees’ competitive applications. The competitive process determines the funding level of each grantee partly by the score of its application.

In fiscal year 2007, 56 Part A grantees received MAI funding, and the grant amounts ranged from $50,000 to $9,347,777. Overall, MAI grants accounted for 10 percent or less of a Part A grantee’s total CARE Act funding in fiscal year 2007.

Table 8 shows funding for Title II grant awards for fiscal year 2006. Since the enactment of RWTMA, CARE Act Title II has been referred to as Part B. In fiscal year 2006, 51 Title II grantees received MAI funding, and funding amounts ranged from $415 to $1,606,289. Overall, MAI grants accounted for 1 percent or less of a Part B grantee’s total CARE Act funding.

Table 9 shows funding for Part B grant awards for fiscal year 2007. In addition, we provide information on the percentage change from fiscal year 2006 through fiscal year 2007 in Part B MAI grant awards. This change is based on several factors in addition to the new competitive process. (See pages 13-19 for our analysis of fiscal year 2007 funding that isolates the effect of this change.) The reasons for the changes in funding include the following: A decreased number of Part B MAI grantees applying for and accepting MAI funding, which increased the funds available to all Part B MAI grantees.

Increases or decreases in grantees’ proportion of the total number of living minority HIV/AIDS cases, which is a factor used as part of the determination of the demonstrated need for funding. From fiscal year 2006 through fiscal year 2007, HRSA changed the case count method from using the number of living minority AIDS cases to using the number of living minorities with HIV/AIDS for the most recent year available as reported to CDC.

Scoring of grantees’ competitive applications. The competitive process determines the funding level of each grantee partly by the score of its application.

In fiscal year 2007, 30 Part B grantees received MAI funding, and grant amounts ranged from $2,500 to $1,476,866. Overall, MAI grants accounted for 1 percent or less of a Part B grantee’s total CARE Act funding.

Appendix IV: Explanation of Barriers to Minorities Obtaining HIV/AIDS Services

We analyzed fiscal year 2007 Part A MAI and Part B MAI grant applications to identify the barriers to minorities obtaining HIV/AIDS services identified most frequently by grantees. Barriers are issues that can delay or prevent clients from receiving HIV/AIDS services on a timely basis, thus reducing the likely success of those services. Table 10 provides definitions for each barrier identified by Part A and B MAI grantees in their fiscal year 2007 MAI grant applications and the number of grantees from each part that identified the barrier.

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

Appendix VI: GAO Contact and Staff Acknowledgments

Acknowledgments

In addition to the contact named above, Tom Conahan, Assistant Director; Romonda McKinney Bumpus; Stefanie Bzdusek; Melanie Egorin; Jill Evancho; Cathleen Hamann; Martha Kelly; Justin Mausel; Deborah Miller; and Jennifer Whitworth made key contributions to this report.