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 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. 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 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 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 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 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.