HIV/AIDS: Changes Needed to Improve the Distribution of Ryan White CARE Act and Housing Funds

Highlights

Among federal efforts to address the HIV/AIDS epidemic are the CARE Act of 1990 and the Housing Opportunities for Persons with AIDS program (HOPWA) administered by the Departments of Health and Human Services (HHS) and Housing and Urban Development (HUD), respectively. Both use formulas based upon a grantee's number of AIDS cases, rather than HIV and AIDS cases, to distribute funds to metropolitan areas, states, and territories. HIV cases must be incorporated with AIDS cases in CARE Act formulas not later than fiscal year 2007. GAO was asked to examine (1) how CARE Act and HOPWA funds are allocated among types of services, (2) the extent of funding distribution differences among CARE Act and HOPWA grantees, and how funding formula provisions contribute to these differences, and (3) what distribution differences could result from incorporating HIV case counts in CARE Act and HOPWA funding formulas.

Recommendations

Matter for Congressional Consideration

Matter	Status	Comments
While only AIDS case counts are currently used for determining CARE Act formula funding, Congress has required that HIV case counts be incorporated into the funding formulas not later than fiscal year 2007. Regardless of when HIV case counts are incorporated, issues will still exist regarding how AIDS cases are used in the formulas and the effect various provisions have on funding. If Congress wishes CARE Act funding to more closely reflect the distribution of persons living with AIDS, and to more closely reflect the distribution of persons living with HIV/AIDS when HIV cases are incorporated into the funding formulas, it may wish to consider revising the funding formulas used to determine grantee eligibility and grant amounts using a measure of living AIDS cases that does not include deceased cases and reflects the longer lives of persons living with AIDS.	Closed – Not Implemented	In December 2006, the Ryan White HIV/AIDS Treatment Modernization Act of 2006 was enacted, thereby amending the Ryan White CARE Act. In the Modernization Act, Congress implemented part of our suggestion regarding how AIDS cases are counted. Congress changed how the number of living AIDS cases was counted for determining grantee amounts and, therefore, grant amount are now based on a better measure of the number of AIDS cases living in a jurisdiction. However, Congress retained or implemented new eligibility criteria for grants that do not necessarily reflect the number of persons living with AIDS in a jurisdiction. In October 2009, Congress again reauthorized the Ryan White CARE Act (Public Law 111-87). It did not make any additional changes in the methods used to determine eligibility for CARE Act grants.
While only AIDS case counts are currently used for determining CARE Act formula funding, Congress has required that HIV case counts be incorporated into the funding formulas not later than fiscal year 2007. Regardless of when HIV case counts are incorporated, issues will still exist regarding how AIDS cases are used in the formulas and the effect various provisions have on funding. If Congress wishes CARE Act funding to more closely reflect the distribution of persons living with AIDS, and to more closely reflect the distribution of persons living with HIV/AIDS when HIV cases are incorporated into the funding formulas, it may wish to consider eliminating the counting of cases in EMAs for Title I base grants and again for Title II base grants.	Closed – Implemented	In this report, we stated that if Congress wanted the Ryan White CARE Act funding to more closely reflect the distribution of persons living with AIDS, it should eliminate the counting of cases for both Title I grants to metropolitan areas and for Title II grants to states, the District of Columbia, and territories. This is referred to as double counting. In December 2006, the Ryan White HIV/AIDS Treatment Modernization Act of 2006 was enacted, thereby reauthorizing the CARE Act. In the reauthorization, Congress addressed double counting in two ways. First, Congress stipulated a new funding formula for CARE Act grants to states, the District of Columbia, and territories. This change partially reduced the impact of double counting by altering how funding was allocated among grantees. Second, Congress stated that the Secretary of Health and Human Services should develop a Severity of Need Index that, when ready, would replace the formula for determining funding to states, the District of Columbia, and territories.
While only AIDS case counts are currently used for determining CARE Act formula funding, Congress has required that HIV case counts be incorporated into the funding formulas not later than fiscal year 2007. Regardless of when HIV case counts are incorporated, issues will still exist regarding how AIDS cases are used in the formulas and the effect various provisions have on funding. If Congress wishes CARE Act funding to more closely reflect the distribution of persons living with AIDS, and to more closely reflect the distribution of persons living with HIV/AIDS when HIV cases are incorporated into the funding formulas, it may wish to consider modifying the hold-harmless provisions for Title I, Title II, and AIDS Drug Assistance Program base grants to reduce the extent to which they prevent funding from shifting to areas where the epidemic has been increasing.	Closed – Implemented	In December 2006, the Ryan White HIV/AIDS Treatment Modernization Act of 2006 was enacted, thereby amending the Ryan White CARE Act. In the Modernization Act, Congress eliminated the hold-harmless provision for one set of metropolitan areas, eliminated two hold-harmless provisions for states, territories, and the District of Columbia, and modified a third hold-harmless provision for states, territories, and the District of Columbia.
While only AIDS case counts are currently used for determining CARE Act formula funding, Congress has required that HIV case counts be incorporated into the funding formulas not later than fiscal year 2007. Regardless of when HIV case counts are incorporated, issues will still exist regarding how AIDS cases are used in the formulas and the effect various provisions have on funding. If Congress wishes CARE Act funding to more closely reflect the distribution of persons living with AIDS, and to more closely reflect the distribution of persons living with HIV/AIDS when HIV cases are incorporated into the funding formulas, it may wish to consider modifying the Title I grandfather clause, which protects the eligibility of metropolitan areas that no longer meet the eligibility criteria.	Closed – Implemented	In December 2006, the Ryan White HIV/AIDS Treatment Modernization Act of 2006 was enacted, thereby amending the Ryan White CARE Act. In the Modernization Act, the grandfather clause which protected the eligibility of metropolitan areas that no longer met the eligibility criteria was modified so that funding eligibility would end if for three consecutive years a metropolitan area does not meet specified criteria.
While only AIDS case counts are currently used for determining CARE Act formula funding, Congress has required that HIV case counts be incorporated into the funding formulas not later than fiscal year 2007. Regardless of when HIV case counts are incorporated, issues will still exist regarding how AIDS cases are used in the formulas and the effect various provisions have on funding. If Congress wishes CARE Act funding to more closely reflect the distribution of persons living with AIDS, and to more closely reflect the distribution of persons living with HIV/AIDS when HIV cases are incorporated into the funding formulas, it may wish to consider eliminating the two-tiered structure of the Emerging Communities program.	Closed – Implemented	In December 2006, the Ryan White HIV/AIDS Treatment Modernization Act of 2006 was enacted, thereby amending the Ryan White CARE Act. In the Modernization Act, the Emerging Communities provision was changed so that there was only one group of emerging communities rather than two.
If Congress wishes to preserve funding for the ADAP Severe Need grants, it may wish to consider revising the Title II hold-harmless provision that is funded with amounts set aside for ADAP Severe Need Grants.	Closed – Implemented	In December 2006, the Ryan White HIV/AIDS Treatment Modernization Act of 2006 was enacted, thereby amending the Ryan White CARE Act. In the Modernization Act, the provision that funded hold-harmless payments with amounts set aside for AIDS Drug Assistance Program severe need grants was eliminated. Instead, funding for hold-harmless payments would be come from a different source.
If Congress wishes HOPWA funding to more closely reflect the distribution of persons living with AIDS, it may wish to consider changing the program so that HOPWA formula grant eligibility, including for bonus grants, and base grant funding allocations are based on a measure of living AIDS cases.	Closed – Not Implemented	Congress has not taken action to change how AIDS cases are counted in the Department of Housing and Urban Development's Housing Opportunities for Persons with AIDS program.

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