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. 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. 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. 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. MAI grantees reported providing services similar to those provided with core HIV/AIDS grants. MAI and core HIV/AIDS grantees provided services primarily to minorities. MAI grants were often part of fragmented HIV/AIDS funding streams that carried separate administrative requirements that caused administrative challenges for MAI grantees. MAI grantees in our sample reported providing mostly support services, similar to the types of support services grantees provided with core HIV/AIDS grants. These support services included community outreach and education, and staff or provider training. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.) 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.) 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. 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. 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. 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. 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.) 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. 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.

Summary: 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. 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. 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.