This is the accessible text file for GAO report number GAO-14-84 
entitled 'Minority AIDS Initiative: Consolidation of Fragmented 
HIV/AIDS Funding Could Reduce Administrative Challenges' which was 
released on November 22, 2013. 

This text file was formatted by the U.S. Government Accountability 
Office (GAO) to be accessible to users with visual impairments, as 
part of a longer term project to improve GAO products' accessibility. 
Every attempt has been made to maintain the structural and data 
integrity of the original printed product. Accessibility features, 
such as text descriptions of tables, consecutively numbered footnotes 
placed at the end of the file, and the text of agency comment letters, 
are provided but may not exactly duplicate the presentation or format 
of the printed version. The portable document format (PDF) file is an 
exact electronic replica of the printed version. We welcome your 
feedback. Please E-mail your comments regarding the contents or 
accessibility features of this document to Webmaster@gao.gov. 

This is a work of the U.S. government and is not subject to copyright 
protection in the United States. It may be reproduced and distributed 
in its entirety without further permission from GAO. Because this work 
may contain copyrighted images or other material, permission from the 
copyright holder may be necessary if you wish to reproduce this 
material separately. 

United States Government Accountability Office: 
GAO: 

Report to Congressional Committees: 

November 2013: 

Minority AIDS Initiative: 

Consolidation of Fragmented HIV/AIDS Funding Could Reduce 
Administrative Challenges: 

GAO-14-84: 

GAO Highlights: 

Highlights of GAO-14-84, a report to congressional committees. 

Why GAO Did This Study: 

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. 

What GAO Found: 

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. 

What GAO Recommends: 

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. 

View GAO-14-84. For more information, contact Marcia Crosse at (202) 
512-7114 or crossem@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

Fragmented Funding for Similar Services to Similar Populations 
Resulted in Administrative Challenges for MAI Grantees: 

MAI Grantees and Stakeholder Organizations Reported a Variety of Best 
Practices for Community Outreach and Capacity Building: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments: 

Appendix I: Minority AIDS Initiative (MAI) Funding, Activities, and 
Grantees Funded, Fiscal Years 1999-2011: 

Appendix II: Methodology for Review of Minority AIDS Initiative (MAI) 
Services from Sample of MAI Annual Grantee Reports: 

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

Appendix IV: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Minority AIDS Initiative (MAI) Funding Allocations for 
Department of Health and Human Services (HHS) Agencies and Offices (in 
Millions of Dollars), Fiscal Year 2011: 

Table 2: The City of Chicago's MAI and Core HIV/AIDS Grant 
Administrative Requirements, Fiscal Year 2012: 

Table 3: Department of Health and Human Services (HHS) Minority AIDS 
Initiative (MAI) Funding (in Millions of Dollars), Fiscal Years 1999-
2011: 

Table 4: Secretary's Minority AIDS Fund (SMAIF) Funding to HHS Offices 
(in Millions of Dollars), Fiscal Years 1999-2011: 

Table 5: Health Resources and Services Administration (HRSA) Minority 
AIDS Initiative Funding (in Millions of Dollars) and Number of 
Grantees, by Part, Fiscal Years 2007-2011: 

Table 6: Centers for Disease Control and Prevention (CDC) Minority 
AIDS Initiative (MAI) Funding (in Millions of Dollars) and Number of 
Grantees, Fiscal Years 2007-2011: 

Table 7: Substance Abuse and Mental Health Services Administration 
(SAMHSA) Minority AIDS Initiative (MAI) Funding (in Millions of 
Dollars) and Number of Grantees, Fiscal Years 2007-2011: 

Table 8: Indian Health Service (IHS) Secretary's Minority AIDS 
Initiative Funding (in Millions of Dollars) and Number of Grantees, 
Fiscal Years 2007-2011: 

Table 9: Office of HIV/AIDS and Infectious Disease Policy (OHAIDP) 
Secretary's Minority AIDS Initiative Funding (in Millions of Dollars) 
and Number of Grantees, Fiscal Years 2007-2011: 

Table 10: Office of Minority Health (OMH) Secretary's Minority AIDS 
Initiative Funding (in Millions of Dollars) and Number of Grantees, 
Fiscal Years 2007-2011: 

Table 11: Office of Population Affairs (OPA) Secretary's Minority AIDS 
Initiative Funding (in Millions of Dollars) and Number of Grantees, 
Fiscal Years 2007-2011: 

Table 12: Office on Women's Health (OWH) Secretary's Minority AIDS 
Initiative Funding (in Millions of Dollars) and Number of Grantees, 
Fiscal Years 2007-2011: 

Table 13: Regional Health Administrators (RHA) Secretary's Minority 
AIDS Initiative Funding (in Millions of Dollars) and Number of 
Grantees, Fiscal Years 2007-2011: 

Table 14: Categories of Services and Best Practices Identified in MAI 
Annual Grantee Reports: 

Abbreviations: 

AIDS: acquired immunodeficiency syndrome: 

CARE Act: Ryan White Comprehensive AIDS Resources Emergency Act of 
1990: 

CBO: community-based organization: 

CDC: Centers for Disease Control and Prevention: 

HHS: Department of Health and Human Services: 

HIV: human immunodeficiency virus: 

HRSA: Health Resources and Services Administration: 

IHS: Indian Health Service: 

MAI: Minority AIDS Initiative: 

OAH: Office of Adolescent Health: 

OHAIDP: HHS Office of HIV/AIDS and Infectious Disease Policy: 

OMH: Office of Minority Health: 

OPA: Office of Population Affairs: 

OWH: Office on Women's Health: 

RHA: Regional Health Administrators: 

SAMHSA: Substance Abuse and Mental Health Services Administration: 

SMAIF: Secretary's Minority AIDS Initiative Fund: 

[End of section] 

GAO:
United States Government Accountability Office: 
441 G St. N.W. 
Washington, DC 20548: 

November 22, 2013: 

The Honorable Tom Harkin: 
Chairman: 
The Honorable Lamar Alexander: 
Ranking Member: 
Committee on Health, Education, Labor and Pensions: 
United States Senate: 

The Honorable Fred Upton: 
Chairman: 
The Honorable Henry Waxman: 
Ranking Member: 
Committee on Energy and Commerce: 
House of Representatives: 

An estimated 1.2 million people in the United States were living with 
human immunodeficiency virus (HIV) infections in 2012, and 
approximately 50,000 new infections occur annually. Since the first 
cases of acquired immunodeficiency syndrome (AIDS) were reported in 
June 1981, more than 600,000 people with AIDS have died. Racial and 
ethnic minorities in the United States--particularly African-Americans 
and Hispanics/Latinos--have been disproportionately affected by 
HIV/AIDS.[Footnote 1] According to the most recent data from the 
Centers for Disease Control and Prevention (CDC), part of the 
Department of Health and Human Services (HHS), racial and ethnic 
minorities represented 72 percent of new HIV infections and 74 percent 
of all AIDS diagnoses in 2011.[Footnote 2] 

Two agencies within HHS, the Health Resources and Services 
Administration (HRSA) and CDC, administer grant programs that provide 
core HIV/AIDS funding for HIV/AIDS services.[Footnote 3] HRSA awards 
core HIV/AIDS grants pursuant to the Ryan White Comprehensive AIDS 
Resources Emergency Act of 1990 (CARE Act), which was enacted to 
address the treatment needs of uninsured and underinsured persons 
living with HIV/AIDS.[Footnote 4] In fiscal year 2011, HRSA's budget 
for core CARE Act programs for HIV/AIDS treatment through the 
provision of medical services, support services, and education was 
approximately $2.1 billion. 

Independent of HRSA's core grant programs under the CARE Act, CDC's 
Division of HIV/AIDS Policy awards core HIV/AIDS grants for prevention 
programs, research and evaluation, surveillance, and policy 
development to reduce the impact of HIV/AIDS. In fiscal year 2011, 
CDC's budget for its core HIV/AIDS programs was approximately $666.4 
million. Goals for CDC's core HIV/AIDS funding in fiscal year 2011 
included decreasing annual HIV incidence, decreasing the HIV 
transmission rate, increasing the proportion of HIV-infected people in 
the United States who know they are infected, improving HIV/AIDS 
surveillance, and ensuring that all persons diagnosed with HIV are 
linked to care. 

In addition to the core HIV/AIDS grant programs, CDC, HRSA, and 
numerous other HHS agencies and offices award grants to implement the 
Minority AIDS Initiative (MAI). First known as the Congressional Black 
Caucus Initiative, MAI originated in 1998 in response to provisions in 
a house conference report accompanying the Omnibus Consolidated and 
Emergency Supplemental Appropriations Act, 1999.[Footnote 5] The 
conference report instructed HRSA to target funds to reduce HIV-
related treatment outcome disparities in communities of color, noting 
that this funding should be used to complement existing and previously 
planned targeted HIV/AIDS minority activities.[Footnote 6] 

In the context of HIV/AIDS grants, applicants may be eligible to 
receive core HIV/AIDS grants and/or MAI grants. These grant programs 
carry different administrative requirements that grantees must observe 
for each of the separate grants they may receive. Agencies and offices 
that administer grants maintain these requirements to ensure that the 
funds are being used in the way intended by the grant program. 

The Ryan White HIV/AIDS Treatment Extension Act of 2009 required us to 
report on MAI and related issues.[Footnote 7] In this report, we (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 of CBOs serving the communities that are 
disproportionately affected by HIV/AIDS. The Ryan White HIV/AIDS 
Treatment Extension Act of 2009 also requires us to report on the 
history of MAI activities within each relevant HHS agency and office 
to provide a description of activities conducted and types of grantees 
funded. We provide information from prior years on MAI funding, 
activities, and grantees in appendix I. 

To examine the services provided, population served, and 
administrative challenges faced by MAI grantees, we interviewed all 
ten HHS agencies and offices that awarded MAI grants in fiscal year 
2011. These HHS agencies and offices include HRSA, the primary federal 
agency for improving access to health care services for uninsured, 
isolated or medically vulnerable individuals; the Substance Abuse and 
Mental Health Services Administration (SAMHSA), which leads public 
health efforts to advance the behavioral health of the nation; CDC, 
which seeks to protect health and promote quality of life through the 
prevention and control of disease, injury, and disability; the Indian 
Health Service (IHS), which provides federal health services to 
American Indians and Alaska Natives; the Office of Population Affairs 
(OPA), which aims to be the leader in family planning and reproductive 
health care services, training and research; the Office of Minority 
Health (OMH); which aims to improve the health of racial and ethnic 
minority populations through the development of health policies and 
programs; the Office of HIV/AIDS and Infectious Disease Policy 
(OHAIDP), which advises HHS officials on the implementation and 
development of policies, programs, and activities related to HIV/AIDS 
and other infectious diseases; the Office on Women's Health (OWH), 
which seeks to improve the health and sense of well-being of women and 
girls; the Regional Health Administrators (RHA), which seeks to 
perform essential functions for HHS in prevention, preparedness, and 
agency-wide coordination; and the Office of Adolescent Health (OAH), 
which seeks to improve the health and well being of adolescents. We 
also interviewed staff from six stakeholder organizations, including 
national HIV/AIDS organizations that represent MAI grantees: the Black 
AIDS Institute, Latino Commission on AIDS, National Alliance of State 
and Territorial AIDS Directors, National Council of Urban Indian 
Health, National Minority AIDS Council, and National Native American 
AIDS Prevention Center. In addition, we interviewed the Kaiser Family 
Foundation, a subject matter expert. We interviewed these 
organizations to obtain their perspectives on MAI. Information we 
obtained from these interviews is not generalizable. We conducted a 
review of MAI services reported in MAI annual grantee reports from a 
generalizable sample of 100 MAI grantees from fiscal year 2011. 
[Footnote 8] To select our sample, we created a list of all MAI 
grantees from the ten HHS agencies and offices that awarded MAI grants 
in fiscal year 2011 and then selected a generalizable sample of 100 
grantees from these agencies and offices.[Footnote 9] We then obtained 
MAI annual grantee reports for these grantees from the respective 
agencies and offices and used NVivo software to identify the types of 
MAI services in these reports (appendix II provides more detail on our 
sample design.).[Footnote 10] 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. We categorized MAI services 
described in the grantee reports into six categories. We then analyzed 
and compared the services identified in these categories by HHS agency 
and office, grant amount, source of grant, and organizational type. We 
also reviewed agency guidance on which services grantees are expected 
to provide with their MAI and core HIV/AIDS grants. 

In addition, to identify the population served by MAI, we obtained and 
reviewed the available demographic data on the race and ethnicity of 
the clients served with MAI grants as well as aggregate historical 
funding data that we requested and obtained from HHS agencies and 
offices for fiscal years 2007-2012. Some agencies and offices could 
not provide demographic data on their clients, but we assessed the 
reliability of the demographic data that the agencies and offices 
could provide by interviewing agency officials about how their 
demographic data was collected, and we also discussed any 
inconsistencies we found in the data. We found the data provided to be 
sufficiently reliable for presenting information about the race and 
ethnicity of MAI grantee populations. We also obtained, reviewed, and 
analyzed the core HIV/AIDS grant amounts that MAI grantees in our 
sample were awarded in order to understand the total amount of 
HIV/AIDS funding that MAI grantees received. We then compared the core 
HIV/AIDS grant amounts to their MAI grant amounts. To determine core 
HIV/AIDS grant amounts, we used CDC and HRSA funding data in addition 
to publicly available funding data. We compared publicly available 
data to data provided to us, and confirmed the data with the agencies 
where there were discrepancies. We found these data to be reliable for 
our purposes. 

Furthermore, to assist us in reviewing the administrative challenges 
faced by MAI grantees, we evaluated grantee administrative 
requirements including applications and reporting requirements for MAI 
and core HIV/AIDS grants, and considered our past work on federal 
programs or activities government-wide that have evidence of 
fragmentation, overlap, or duplication.[Footnote 11] In that work, we 
found that the presence of fragmentation can lead to instances of 
overlap and duplication among government agencies or programs that 
have similar goals or activities. 

To describe the best practices identified by grantees for community 
outreach and capacity building of CBOs serving communities 
disproportionately affected by HIV/AIDS, we conducted a review of MAI 
annual grantee reports from our generalizable sample of 100 MAI 
grantees using NVivo software in order to identify and categorize what 
grantees considered to be best practices. Specifically, we identified 
and analyzed MAI services that grantees considered were best 
practices, which included best practices for community outreach or 
capacity building of CBOs that serve communities disproportionally 
affected by HIV/AIDS. We defined the term best practices to include 
any successes, lessons learned, or challenges overcome by grantees 
regarding their MAI activities. Because grantees generally were not 
required to discuss best practices in their MAI annual grantee 
reports, we cannot estimate the proportion of grantees identifying 
such practices. Instead, we can simply count the number of best 
practices reported in our sample that we identified using our 
definition of best practices. As a result, our estimates are not 
generalizable for this purpose, unlike our estimates of services 
provided. In addition, we also obtained information on best practices 
for community outreach and capacity building from the six stakeholder 
organizations and one subject matter expert we interviewed. 

We conducted this performance audit from October 2012 to November 2013 
in accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe 
that the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our audit objectives. 

Background: 

History of MAI: 

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.[Footnote 12] 

HRSA's MAI program was codified into law as part of the 2006 
reauthorization of the CARE Act.[Footnote 13] To be eligible for MAI 
grants under the CARE Act, grantees must also have received CARE Act 
grants under Parts A through D or F, these MAI grants provide funding 
in addition to core HIV/AIDs grants awarded by HRSA under other 
provisions of the CARE Act.[Footnote 14] 

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. 

MAI Funding Allocations In Fiscal Year 2011: 

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.[Footnote 15] 
In addition, the 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 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.) 

Table 1: Minority AIDS Initiative (MAI) Funding Allocations for 
Department of Health and Human Services (HHS) Agencies and Offices, 
Fiscal Year 2011: 

HHS Agency or Office: Health Resources and Services Administration 
(HRSA); 
Agency MAI Allocations[A]: $153.4 million; 
HHS Allocation of MAI (SMAIF) Appropriation[B]: $7.7 million. 

HHS Agency or Office: Substance Abuse and Mental Health Services 
Administration (SAMHSA); 
Agency MAI Allocations[A]: $116.7 million; 
HHS Allocation of MAI (SMAIF) Appropriation[B]: $5.9 million. 

HHS Agency or Office: Centers for Disease Control and Prevention (CDC); 
Agency MAI Allocations[A]: $93.6 million; 
HHS Allocation of MAI (SMAIF) Appropriation[B]: $10.4 million. 

HHS Agency or Office: Indian Health Service (IHS); 
HHS Allocation of MAI (SMAIF) Appropriation[B]: $4.2 million. 

HHS Agency or Office: Office of Population Affairs (OPA); 
HHS Allocation of MAI (SMAIF) Appropriation[B]: $7.2 million. 

HHS Agency or Office: Office of Minority Health (OMH); 
HHS Allocation of MAI (SMAIF) Appropriation[B]: $5.5 million. 

HHS Agency or Office: Office of HIV/AIDS and Infectious Disease Policy 
(OHAIDP); 
HHS Allocation of MAI (SMAIF) Appropriation[B]: $3.4 million. 

HHS Agency or Office: Office on Women's Health (OWH); 
HHS Allocation of MAI (SMAIF) Appropriation[B]: $3.4 million. 

HHS Agency or Office: Regional Health Administrators (RHA); 
HHS Allocation of MAI (SMAIF) Appropriation[B]: $2.0 million. 

HHS Agency or Office: Office of Adolescent Health (OAH); 
HHS Allocation of MAI (SMAIF) Appropriation[B]: $0.2 million. 

HHS Agency or Office: Total; 
Agency MAI Allocations[A]: $363.7 million; 
HHS Allocation of MAI (SMAIF) Appropriation[B]: $52.8 million[C]. 

Source: GAO analysis of HHS data. 

Note: Dollar amounts are rounded to one decimal point. 

[A] HRSA, SAMHSA, and CDC allocate MAI funds from their respective 
annual appropriations. 

[B] The HHS Office of the Secretary receives an annual MAI 
appropriation which is referred to as the Secretary's Minority AIDS 
Fund (SMAIF), that it distributes to ten HHS agencies, which include 
HRSA, SAMHSA, and CDC. 

[C] According to agency officials, the expenses associated with the 
administration of SMAIF funding were $2.9M in fiscal year 2011 which 
we include in the HHS Allocation of MAI (SMAIF) Appropriation. 

[End of table] 

MAI grantees include a wide variety of organizations.[Footnote 16] 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.[Footnote 17] MAI grantees also include 
commercial vendors and businesses 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. 

Core HIV/AIDS and MAI Budget Request and Allocation Process: 

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.[Footnote 18] 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.[Footnote 19] 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. 

[MAI Administrative Requirements: 

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. 

Fragmented Funding for Similar Services to Similar Populations 
Resulted in Administrative Challenges for MAI Grantees: 

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 Provided Services Similar To Those Provided With Core 
HIV/AIDS Funding: 

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.[Footnote 20] 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.[Footnote 21] 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.[Footnote 22] 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.[Footnote 23] 

* 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.[Footnote 24] 

* Twenty percent of grantees reported using MAI grants to provide core 
medical services to clients.[Footnote 25] For example, grantees 
provided primary and outpatient medical care to HIV/AIDS-infected 
clients and substance abuse treatment or counseling to clients. 
[Footnote 26] 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. 

Available Data Suggest MAI and CORE HIV/AIDS Grantees Provide Services 
Primarily to Minorities: 

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.[Footnote 27] 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. 

HRSA is the only agency that could provide demographic data on the 
recipients of services funded by core HIV/AIDS grants but these data 
combined recipients of services funded by core HIV/AIDS grants with 
recipients of services funded by MAI grants. Although the data 
included recipients of services from MAI grants, they provide a good 
indication of the demographics of recipients of services from core 
HIV/AIDS grants because MAI grants only amount to 7 percent of core 
HIV/AIDS funding.[Footnote 28] The data provided by HRSA, which 
accounted for 76 percent of core 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.[Footnote 29] 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 Grantees Face Challenges Resulting From The Administrative 
Requirements Of Fragmented Funding Streams: 

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.[Footnote 30] 
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." [Footnote 31] As noted earlier, 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 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 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. 

Table 2: The City of Chicago's MAI and Core HIV/AIDS Grant 
Administrative Requirements, Fiscal Year 2012: 

Administrative Requirement: Targeted Capacity Expansion Grant 
Application; 
The grant application is required for the 12 Metropolitan Statistical 
Areas and Metropolitan Divisions most impacted by HIV/AIDS. Award 
amounts vary based on the size of the population most at risk for or 
living with HIV in the jurisdiction, but grantees are required to 
submit documentation of intent to provide required services, ability 
to collect data and measure performance, and budget information; 
Due Date, Fiscal Year 2012: June 13, 2011[A]; 
Source of Grant Type of Grant: SAMHSA; MAI. 

Administrative Requirement: Minority AIDS Initiative Annual Plan; 
The primary purpose of the Part A MAI Annual Plan is to ensure grants 
are used to link minority clients to HIV care services. The plan is to 
include a planned timeframe for delivering services; a description of 
service goals and objectives; the racial and ethnic communities to be 
served, and the number of service units to be provided during the 
reporting period; 
Due Date, Fiscal Year 2012: October 17, 2011; 
Source of Grant Type of Grant: HRSA; MAI, Part A. 

Administrative Requirement: CARE Act Part A Grant Application; 
The CARE Act application is required for all 52 CARE Act Part A 
grantees. The application requires grantees to report information on 
current and new program initiatives. The application also outlines the 
reporting requirements and other documentation required from grantees; 
Due Date, Fiscal Year 2012: November 1, 2011; 
Source of Grant Type of Grant: HRSA; Core HIV/AIDS funding, CARE Act 
Part A. 

Administrative Requirement: Maintenance of Effort Expenditures Report; 
The maintenance of effort expenditures report is used to ensure 
grantees have maintained level expenditures for two consecutive grant 
years. The expenditures must be based on the local budget items; 
Due Date, Fiscal Year 2012: December 5, 2011; 
Source of Grant Type of Grant: HRSA; Core HIV/AIDS funding, CARE Act 
Part A. 

Administrative Requirement: Program Terms Report; 
The program terms report includes a planned allocation report, budget 
and budget justification narrative, an implementation plan, the 
Consolidated List of Contractors, and the Contract Review 
Certification[B]; 
Due Date, Fiscal Year 2012: December 5, 2011; 
Source of Grant Type of Grant: HRSA; Core HIV/AIDS funding, CARE Act 
Part A. 

Administrative Requirement: Unobligated Balance Estimate and Carryover 
Request; 
The CARE Act provides that base and supplemental grant funds were 
available for obligation by the grantee for a 1-year period beginning 
on the first day of the grant year. It also requires HRSA to cancel 
any unobligated balances not subject to a waiver at the end of the 
grant year, recover funds that had been disbursed to grantees, and 
redistribute these funds to grantees in need as supplemental grants. 
Grantees must estimate their unobligated balances during the grant 
year and provide final amounts in their federal financial report. 
Grantees may request to carryover funds for one additional grant year; 
Due Date, Fiscal Year 2012: January 1, 2012; 
Source of Grant Type of Grant: HRSA; Core HIV/AIDS funding, CARE Act 
Part A. 

Administrative Requirement: CARE Act HIV/AIDS Program Services Report; 
The CARE Act HIV/AIDS program services report provides information on 
services provided by grantees and service providers to HRSA. 
Additionally, grantees and service providers use this report to 
provide information on clients, including their demographic status, 
services received and HIV clinical information; 
Due Date, Fiscal Year 2012: March 15, 2012; 
Source of Grant Type of Grant: HRSA; Core HIV/AIDS funding, CARE Act 
Part A. 

Administrative Requirement: CARE Act Part A Comprehensive Plan; 
The comprehensive plan is a requirement that is due every 3 years at 
the beginning of the grant year. The plan is to be used as a "road 
map" for the maintenance and improvement of the grantee's system of 
care. Grantees are required to include appropriate strategies, goals, 
and timelines; 
Due Date, Fiscal Year 2012: May 21, 2012; 
Source of Grant Type of Grant: HRSA; Core HIV/AIDS funding, CARE Act 
Part A. 

Administrative Requirement: Final Expenditure Table, including MAI 
Expenditures; 
This expenditure table serves as a monitoring tool to identify the use 
of grants at the end of the grant period. It identifies service 
categories that have been delivered, the use of carry-over grants, and 
identifies trends in the amount of CARE Act grants being used to 
deliver these services; 
Due Date, Fiscal Year 2012: June 28, 2012; 
Source of Grant Type of Grant: HRSA; Core HIV/AIDS funding, CARE Act 
Part A. 

Administrative Requirement: Annual Progress Report; 
The Annual Progress Report is to inform HRSA of the progress made in 
the administration of Ryan White programs; to identify accomplishments 
and challenges in meeting established goals and objectives; and to 
address grantees' need for technical assistance; 
Due Date, Fiscal Year 2012: June 28, 2012[C]; 
Source of Grant Type of Grant: HRSA; Core HIV/AIDS funding, CARE Act 
Part A. 

Administrative Requirement: Report on Expenditures for Women, Infants, 
Children and Youth; 
The report on expenditures for Women, Infants, Children and Youth is a 
requirement used to determine that a grantee allocates resources for 
women, infants, children, and youth at no less than the percentage 
constituted by the ratio of the population of women, infants, 
children, and youth with HIV/AIDS to the general populations with 
HIV/AIDS; 
Due Date, Fiscal Year 2012: July 28, 2012; 
Source of Grant Type of Grant: HRSA; Core HIV/AIDS funding, CARE Act 
Part A. 

Administrative Requirement: Federal Financial Report; 
The Federal Financial Report outlines the grantee's outlays, 
unliquidated obligations, total federal share, and final unobligated 
balance; 
Due Date, Fiscal Year 2012: July 30, 2012; 
Source of Grant Type of Grant: HRSA; Core HIV/AIDS funding, CARE Act 
Part A. 

Administrative Requirement: Minority AIDS Initiative Annual Report; 
CARE Act Part A grantees receiving MAI funds must submit two 
components of the MAI Report annually: (1) the MAI Annual Plan for the 
use of these funds, and (2) the year-end MAI Annual Report documenting 
program outcomes. Each MAI Report has two parts: (1) Web forms for 
standardized quantitative and qualitative information and (2) an 
accompanying narrative providing background information to explain the 
data submitted and a summary of program accomplishments, challenges, 
and lessons; 
Due Date, Fiscal Year 2012: January 31, 2013; 
Source of Grant Type of Grant: HRSA; MAI, Part A. 

Administrative Requirement: CARE Act Part C Grant Application; 
The application requires CARE Act Part C grantees to provide 
information on the comprehensive continuum of outpatient HIV primary 
care services in the targeted area that they will provide with CARE 
Act and MAI funds. The application also outlines the reporting 
requirements and other documentation required from grantees; 
Due Date, Fiscal Year 2012: October 14, 2011; 
Source of Grant Type of Grant: HRSA; Core HIV/AIDS Funding, CARE Act 
Part C. 

Administrative Requirement: Federal Financial Report; 
The Federal Financial Report is an accounting of expenditures under 
the project that year; 
Due Date, Fiscal Year 2012: Required within 90 days of the end of the 
budget period; 
Source of Grant Type of Grant: HRSA; Core HIV/AIDS Funding, CARE Act 
Part C. 

Administrative Requirement: Allocation and Expenditure Reports; 
These reports are an accounting of the allocation and expenditure of 
all grant funds according to the specific core medical services, 
support services, clinical quality management, and administration 
provided; 
Due Date, Fiscal Year 2012: Allocation report: Required 60 days after 
the start of the budget period; Expenditure report: Required 90 days 
after the end of the budget period; 
Source of Grant Type of Grant: HRSA; Core HIV/AIDS Funding, CARE Act 
Part C. 

Administrative Requirement: Final Report; 
The final report collects program-specific goals and progress on 
strategies; the overall impact of the project; the degree to which the 
grantee achieved the mission; and any barriers the grantee 
encountered, among other things; 
Due Date, Fiscal Year 2012: Required 90 days after the end of the 
project period; 
Source of Grant Type of Grant: HRSA; Core HIV/AIDS Funding, CARE Act 
Part C. 

Administrative Requirement: Interim Progress Report; 
The interim Progress report includes information on the grantee's 
budget, project narrative, and any additional information requested by 
CDC; 
Due Date, Fiscal Year 2012: Due no less than 90 days after the end of 
the budget period; 
Source of Grant Type of Grant: CDC; Core HIV/AIDS Funding. 

Administrative Requirement: Annual Progress Report; 
The Annual Progress Report includes information on the progress the 
grantee has made in achieving the target levels for each grant 
objective, information on the current budget, and any other additional 
information CDC requests; 
Due Date, Fiscal Year 2012: Due 90 days after the end of the budget 
period; 
Source of Grant Type of Grant: CDC; Core HIV/AIDS funding. 

Administrative Requirement: Financial Status Report; 
The Financial Status Report includes a final performance report and a 
financial status report; 
Due Date, Fiscal Year 2012: Due 90 days after the end of the grant; 
Source of Grant Type of Grant: CDC; Core HIV/AIDS funding. 

Administrative Requirement: Final Progress Report; 
Due Date, Fiscal Year 2012: Due 90 days after the end of the grant or 
no cost extension; 
Source of Grant Type of Grant: SAMHSA; MAI. 

Administrative Requirement: Final Financial Status Report; 
Due Date, Fiscal Year 2012: Due 90 days after the end of the grant; 
Source of Grant Type of Grant: SAMHSA; MAI. 

Source: GAO analysis of HHS information. 

[A] The Targeted Capacity Expansion Grant Application was due on June 
13, 2011, which was in federal fiscal year 2011. 

[B] The allocation report serves as a monitoring tool to track and 
monitor the use of grants. It identifies categories of services that 
are being delivered, changes in the type of services being provided 
over time and trends in the amount of CARE Act grants being used to 
deliver these services. The budget and budget justification narrative 
serve as monitoring tools to track and monitor the use of CARE Act 
grants. The implementation plan serves as a monitoring tool to verify 
implementation of approved medical and support services for the 
current grant year. The plan should include all the services and 
priorities reflected in the allocations report. All funded services 
must be included in the implementation plan. The Consolidated List of 
Contractors serves as a list of all subgrantees for the current grant 
year. The Contract Review Certification requires the grantee to 
certify that all subgrantees for the current grant year comply with 
CARE Act program requirements and federal grants requirements. 

[C] The Minority AIDS Initiative Annual Report for Part A grantees was 
due on January 31, 2013, which is in federal fiscal year 2013. 

[End of table] 

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 
sizable 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.[Footnote 
32] 

MAI Grantees and Stakeholder Organizations Reported a Variety of Best 
Practices for Community Outreach and Capacity Building: 

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.[Footnote 33] 

MAI Grantees and Stakeholder Organizations Reported Best Practices for 
Community Outreach to Improve Client Recruitment: 

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 and Stakeholder Organizations Reported Capacity Building 
Best Practices to Improve 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 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.[Footnote 34] 

* 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. 

Conclusions: 

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. 

Recommendations for Executive Action: 

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. 

Agency Comments: 

We provided a copy of this report to HHS for its review and HHS 
provided written comments (see appendix 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 [hyperlink, 
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. 

Signed by: 

Marcia Crosse: 
Director, Health Care: 

[End of section] 

Appendix I: Minority AIDS Initiative (MAI) Funding, Activities, and 
Grantees Funded, Fiscal Years 1999-2011: 

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).[Footnote 35] 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. 

Table 3: Department of Health and Human Services (HHS) Minority AIDS 
Initiative (MAI) Funding, Fiscal Years 1999-2011: 

Fiscal Year: 1999; 
Health Resources and Services Administration (HRSA): 
MAI: $22.3 million; 
SMAIF[A]: $5.8 million; 
Centers for Disease Control and Prevention (CDC): 
MAI: $46.9 million; 
SMAIF: N/A; 
Substance Abuse and Mental Health Services Administration (SAMHSA): 
MAI: $37.1 million; 
SMAIF: $12.5 million. 

Fiscal Year: 2000; 
Health Resources and Services Administration (HRSA): 
MAI: $73.1 million; 
SMAIF[A]: $5.0 million; 
Centers for Disease Control and Prevention (CDC): 
MAI: $58.7 million; 
SMAIF: N/A; 
Substance Abuse and Mental Health Services Administration (SAMHSA): 
MAI: $55.6 million; 
SMAIF: $12.0 million. 

Fiscal Year: 2001; 
Health Resources and Services Administration (HRSA): 
MAI: $109.2 million; 
SMAIF[A]: $6.1 million; 
Centers for Disease Control and Prevention (CDC): 
MAI: $84.4 million; 
SMAIF: N/A; 
Substance Abuse and Mental Health Services Administration (SAMHSA): 
MAI: $100.2 million; 
SMAIF: $11.4 million. 

Fiscal Year: 2002; 
Health Resources and Services Administration (HRSA): 
MAI: $123.2 million; 
SMAIF[A]: $6.2 million; 
Centers for Disease Control and Prevention (CDC): 
MAI: $92.9 million; 
SMAIF: $15.0 million; 
Substance Abuse and Mental Health Services Administration (SAMHSA): 
MAI: $110.4 million; 
SMAIF: $11.9 million. 

Fiscal Year: 2003; 
Health Resources and Services Administration (HRSA): 
MAI: $131.2 million; 
SMAIF[A]: $5.6 million; 
Centers for Disease Control and Prevention (CDC): 
MAI: $97.1 million; 
SMAIF: $13.1 million; 
Substance Abuse and Mental Health Services Administration (SAMHSA): 
MAI: $112.1 million; 
SMAIF: $12.0 million. 

Fiscal Year: 2004; 
Health Resources and Services Administration (HRSA): 
MAI: $130.3 million; 
SMAIF[A]: $6.9 million; 
Centers for Disease Control and Prevention (CDC): 
MAI: $97.3 million; 
SMAIF: $10.2 million; 
Substance Abuse and Mental Health Services Administration (SAMHSA): 
MAI: $112.0 million; 
SMAIF: $11.0 million. 

Fiscal Year: 2005; 
Health Resources and Services Administration (HRSA): 
MAI: $129.6 million; 
SMAIF[A]: $8.2 million; 
Centers for Disease Control and Prevention (CDC): 
MAI: $91.8 million; 
SMAIF: $9.7 million; 
Substance Abuse and Mental Health Services Administration (SAMHSA): 
MAI: $112.4 million; 
SMAIF: $11.3 million. 

Fiscal Year: 2006; 
Health Resources and Services Administration (HRSA): 
MAI: $128.6 million; 
SMAIF[A]: $8.6 million; 
Centers for Disease Control and Prevention (CDC): 
MAI: $96.1 million; 
SMAIF: $8.4 million; 
Substance Abuse and Mental Health Services Administration (SAMHSA): 
MAI: $111.5 million; 
SMAIF: $9.5 million. 

Fiscal Year: 2007; 
Health Resources and Services Administration (HRSA): 
MAI: $131.2 million; 
SMAIF[A]: $8.6 million; 
Centers for Disease Control and Prevention (CDC): 
MAI: $95.6 million; 
SMAIF: $7.7 million; 
Substance Abuse and Mental Health Services Administration (SAMHSA): 
MAI: $111.1 million; 
SMAIF: $10.2 million. 

Fiscal Year: 2008; 
Health Resources and Services Administration (HRSA): 
MAI: $135.1 million; 
SMAIF[A]: $7.2 million; 
Centers for Disease Control and Prevention (CDC): 
MAI: $94.0 million; 
SMAIF: $7.3 million; 
Substance Abuse and Mental Health Services Administration (SAMHSA): 
MAI: $111.7 million; 
SMAIF: $8.7 million. 

Fiscal Year: 2009; 
Health Resources and Services Administration (HRSA): 
MAI: $139.1 million; 
SMAIF[A]: $5.3 million; 
Centers for Disease Control and Prevention (CDC): 
MAI: $94.0 million; 
SMAIF: $1.8 million; 
Substance Abuse and Mental Health Services Administration (SAMHSA): 
MAI: $117.1 million; 
SMAIF: $9.6 million. 

Fiscal Year: 2010; 
Health Resources and Services Administration (HRSA): 
MAI: $146.1 million; 
SMAIF[A]: $5.3 million; 
Centers for Disease Control and Prevention (CDC): 
MAI: $94.0 million; 
SMAIF: $3.4 million; 
Substance Abuse and Mental Health Services Administration (SAMHSA): 
MAI: $116.6 million; 
SMAIF: $8.7 million. 

Fiscal Year: 2011; 
Health Resources and Services Administration (HRSA): 
MAI: $153.4 million; 
SMAIF[A]: $7.7 million; 
Centers for Disease Control and Prevention (CDC): 
MAI: $94.0 million; 
SMAIF: $10.4 million; 
Substance Abuse and Mental Health Services Administration (SAMHSA): 
MAI: $116.7 million; 
SMAIF: $5.9 million. 

Source: GAO analysis of Department of Health and Human Services (HHS) 
data. 

Note: Dollar amounts are rounded to one decimal point. 

[A] Secretary's Minority AIDS Initiative Fund. 

[End of table] 

Table 4: Secretary's Minority AIDS Fund (SMAIF) Funding to HHS 
Offices, Fiscal Years 1999-2011: 

Fiscal Year: 1999; 
Indian Health Service: $0; 
Office of Adolescent Health: $0; 
Office of HIV/AIDS and Infectious Disease Policy: $2.5 million; 
Office of Minority Health: $5.0 million; 
Office of Population Affairs: $0.5 million; 
Office on Women's Health: $0; 
Regional Health Administrators: $0. 

Fiscal Year: 2000; 
Indian Health Service: $0.8 million; 
Office of Adolescent Health: $0; 
Office of HIV/AIDS and Infectious Disease Policy: $3.0 million; 
Office of Minority Health: $6.5 million; 
Office of Population Affairs: $0.6 million; 
Office on Women's Health: $0.5 million; 
Regional Health Administrators: $0. 

Fiscal Year: 2001; 
Indian Health Service: $1.1 million; 
Office of Adolescent Health: $0; 
Office of HIV/AIDS and Infectious Disease Policy: $3.4 million; 
Office of Minority Health: $7.8 million; 
Office of Population Affairs: $3.0 million; 
Office on Women's Health: $0.5 million; 
Regional Health Administrators: $0. 

Fiscal Year: 2002; 
Indian Health Service: $1.5 million; 
Office of Adolescent Health: $0; 
Office of HIV/AIDS and Infectious Disease Policy: $3.2 million; 
Office of Minority Health: $7.9 million; 
Office of Population Affairs: $3.0 million; 
Office on Women's Health: $0.6 million; 
Regional Health Administrators: $0. 

Fiscal Year: 2003; 
Indian Health Service: $1.5 million; 
Office of Adolescent Health: $0; 
Office of HIV/AIDS and Infectious Disease Policy: $3.2 million; 
Office of Minority Health: $7.9 million; 
Office of Population Affairs: $3.0 million; 
Office on Women's Health: $0.6 million; 
Regional Health Administrators: $0. 

Fiscal Year: 2004; 
Indian Health Service: $1.5 million; 
Office of Adolescent Health: $0; 
Office of HIV/AIDS and Infectious Disease Policy: $3.2 million; 
Office of Minority Health: $7.7 million; 
Office of Population Affairs: $6.0 million; 
Office on Women's Health: $1.6 million; 
Regional Health Administrators: $0. 

Fiscal Year: 2005; 
Indian Health Service: $2.1 million; 
Office of Adolescent Health: $0; 
Office of HIV/AIDS and Infectious Disease Policy: $3.0 million; 
Office of Minority Health: $7.7 million; 
Office of Population Affairs: $6.0 million; 
Office on Women's Health: $3.1 million; 
Regional Health Administrators: $0. 

Fiscal Year: 2006; 
Indian Health Service: $2.0 million; 
Office of Adolescent Health: $0; 
Office of HIV/AIDS and Infectious Disease Policy: $6.0 million; 
Office of Minority Health: $7.0 million; 
Office of Population Affairs: $6.1 million; 
Office on Women's Health: $3.0 million; 
Regional Health Administrators: $0. 

Fiscal Year: 2007; 
Indian Health Service: $1.9 million; 
Office of Adolescent Health: $0; 
Office of HIV/AIDS and Infectious Disease Policy: $4.3 million; 
Office of Minority Health: $6.8 million; 
Office of Population Affairs: $6.0 million; 
Office on Women's Health: $4.0 million; 
Regional Health Administrators: $0. 

Fiscal Year: 2008; 
Indian Health Service: $2.3 million; 
Office of Adolescent Health: $0; 
Office of HIV/AIDS and Infectious Disease Policy: $2.2 million; 
Office of Minority Health: $8.8 million; 
Office of Population Affairs: $7.1 million; 
Office on Women's Health: $4.0 million; 
Regional Health Administrators: $1.3 million. 

Fiscal Year: 2009; 
Indian Health Service: $3.2 million; 
Office of Adolescent Health: $0; 
Office of HIV/AIDS and Infectious Disease Policy: $3.3 million; 
Office of Minority Health: $8.9 million; 
Office of Population Affairs: $8.1 million; 
Office on Women's Health: $6.1 million; 
Regional Health Administrators: $1.8 million. 

Fiscal Year: 2010; 
Indian Health Service: $4.4 million; 
Office of Adolescent Health: $0; 
Office of HIV/AIDS and Infectious Disease Policy: $3.7 million; 
Office of Minority Health: $8.9 million; 
Office of Population Affairs: $7.9 million; 
Office on Women's Health: $7.0 million; 
Regional Health Administrators: $1.7 million. 

Fiscal Year: 2011; 
Indian Health Service: $4.2 million; 
Office of Adolescent Health: $0.2 million; 
Office of HIV/AIDS and Infectious Disease Policy: $3.4 million; 
Office of Minority Health: $5.5 million; 
Office of Population Affairs: $7.2 million; 
Office on Women's Health: $3.4 million; 
Regional Health Administrators: $2.0 million. 

Source: GAO analysis of Department of Health and Human Services (HHS) 
data. 

Note: The National Institutes of Health is not listed in the chart 
above because it only received funding from the Secretary's Minority 
AIDS Initiative Fund in fiscal years 1999 and 2000. It received $2.7 
million in fiscal year 1999 and $1.2 million in fiscal year 2000. 
Dollar amounts are rounded to one decimal point. 

[End of table] 

HRSA: 

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).[Footnote 36] 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.[Footnote 
37] Part A 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.) 

Table 5: Health Resources and Services Administration (HRSA) Minority 
AIDS Initiative Funding (in Millions of Dollars) and Number of 
Grantees, by Part, Fiscal Years 2007-2011: 

Ryan White Part: Part A; 
2007: Funding: $43.8 million; 
2007: Number of Grantees: 56; 
2008: Funding: $45.4 million; 
2008: Number of Grantees: 56; 
2009: Funding: $47.1 million; 
2009: Number of Grantees: 56; 
2010: Funding: $46.7 million; 
2010: Number of Grantees: 56; 
2011: Funding: $49.1 million; 
2011: Number of Grantees: 52. 

Ryan White Part: Part B; 
2007: Funding: $7.0 million; 
2007: Number of Grantees: 30; 
2008: Funding: $7.3 million; 
2008: Number of Grantees: 26; 
2009: Funding: $7.5 million; 
2009: Number of Grantees: 26; 
2010: Funding: $8.8 million; 
2010: Number of Grantees: 36; 
2011: Funding: $9.2 million; 
2011: Number of Grantees: 36. 

Ryan White Part: Part C; 
2007: Funding: $53.4 million; 
2007: Number of Grantees: 206; 
2008: Funding: $55.4 million; 
2008: Number of Grantees: 208; 
2009: Funding: $57.4 million; 
2009: Number of Grantees: 204; 
2010: Funding: $61.3 million; 
2010: Number of Grantees: 203; 
2011: Funding: $64.4 million; 
2011: Number of Grantees: 212. 

Ryan White Part: Part D; 
2007: Funding: $17.1 million; 
2007: Number of Grantees: 57; 
2008: Funding: $17.1 million; 
2008: Number of Grantees: 55; 
2009: Funding: $17.2 million; 
2009: Number of Grantees: 58; 
2010: Funding: $18.9 million; 
2010: Number of Grantees: 58; 
2011: Funding: $20.0 million; 
2011: Number of Grantees: 61. 

Ryan White Part: Part D Youth; 
2007: Funding: $1.4 million; 
2007: Number of Grantees: 10; 
2008: Funding: $1.4 million; 
2008: Number of Grantees: 10; 
2009: Funding: $1.4 million; 
2009: Number of Grantees: 10; 
2010: Funding: $1.5 million; 
2010: Number of Grantees: 10; 
2011: Funding: $1.5 million; 
2011: Number of Grantees: 10. 

Ryan White Part: Part F; 
2007: Funding: $8.5 million; 
2007: Number of Grantees: 15; 
2008: Funding: $8.5 million; 
2008: Number of Grantees: 15; 
2009: Funding: $8.5 million; 
2009: Number of Grantees: 15; 
2010: Funding: $8.8 million; 
2010: Number of Grantees: 15; 
2011: Funding: $9.2 million; 
2011: Number of Grantees: 16. 

Ryan White Part: SMAIF[A]; 
2007: Funding: $8.6 million; 
2007: Number of Grantees: 24; 
2008: Funding: $7.2 million; 
2008: Number of Grantees: 20; 
2009: Funding: $5.3 million; 
2009: Number of Grantees: 26; 
2010: Funding: $5.3 million; 
2010: Number of Grantees: 19; 
2011: Funding: $7.7 million; 
2011: Number of Grantees: 33. 

Source: GAO analysis of HRSA and Office of HIV/AIDS and Infectious 
Disease Policy data. 

Note: Dollar amounts are rounded to one decimal point. 

[A] Secretary's Minority AIDS Initiative Fund. 

[End of table] 

CDC: 

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.) 

Table 6: Centers for Disease Control and Prevention (CDC) Minority 
AIDS Initiative (MAI) Funding and Number of Grantees, Fiscal Years 
2007-2011: 

Fiscal Year: 2007; 
MAI: $95.6 million; 
Number of Grantees: 239; 
SMAIF[A]: $7.7 million; 
Number of Grantees: 36. 

Fiscal Year: 2008; 
MAI: $94.0 million; 
Number of Grantees: 241; 
SMAIF[A]: $7.3 million; 
Number of Grantees: 27. 

Fiscal Year: 2009; 
MAI: $94.0 million; 
Number of Grantees: 252; 
SMAIF[A]: $1.8 million; 
Number of Grantees: 5. 

Fiscal Year: 2010; 
MAI: $94.0 million; 
Number of Grantees: 218; 
SMAIF[A]: $3.4 million; 
Number of Grantees: 29. 

Fiscal Year: 2011; 
MAI: $94.0 million; 
Number of Grantees: 217; 
SMAIF[A]: $10.4 million; 
Number of Grantees: 60. 

Source: GAO analysis of CDC and Office of HIV/AIDS and Infectious 
Disease Policy data. 

Note: Dollar amounts are rounded to one decimal point. 

[A] Secretary's Minority AIDS Initiative Fund. 

[End of table] 

SAMHSA: 

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.) 

Table 7: Substance Abuse and Mental Health Services Administration 
(SAMHSA) Minority AIDS Initiative (MAI) Funding and Number of 
Grantees, Fiscal Years 2007-2011: 

Fiscal Year: 2007; 
MAI: $111.1 million; 
Number of Grantees: 287; 
SMAIF[A]: $10.2 million; 
Number of Grantees[B]: 115. 

Fiscal Year: 2008; 
MAI: $111.7 million; 
Number of Grantees: 276; 
SMAIF[A]: $8.7 million; 
Number of Grantees[B]: 133. 

Fiscal Year: 2009; 
MAI: $117.1 million; 
Number of Grantees: 295; 
SMAIF[A]: $9.6 million; 
Number of Grantees[B]: 148. 

Fiscal Year: 2010; 
MAI: $116.6 million; 
Number of Grantees: 275; 
SMAIF[A]: $8.7 million; 
Number of Grantees[B]: 142. 

Fiscal Year: 2011; 
MAI: $116.7 million; 
Number of Grantees: 269; 
SMAIF[A]: $5.9 million; 
Number of Grantees[B]: 139. 

Source: GAO analysis of SAMHSA and Office of HIV/AIDS and Infectious 
Disease Policy data. 

Note: Dollar amounts are rounded to one decimal point. 

[A] Secretary's Minority AIDS Initiative Fund. 

[B] Some of SAMHSA's grants were funded with both MAI and SMAIF funds. 

[End of table] 

Indian Health Service (IHS): 

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.) 

Table 8: Indian Health Service (IHS) Secretary's Minority AIDS 
Initiative Funding and Number of Grantees, Fiscal Years 2007-2011: 

Fiscal Year: 2007; 
SMAIF[A]: $1.9; 
Number of Grantees: 11. 

Fiscal Year: 2008; 
SMAIF[A]: $2.3 million; 
Number of Grantees: 19. 

Fiscal Year: 2009; 
SMAIF[A]: $3.2 million; 
Number of Grantees: 42. 

Fiscal Year: 2010; 
SMAIF[A]: $4.4 million; 
Number of Grantees: 31. 

Fiscal Year: 2011; 
SMAIF[A]: $4.2 million; 
Number of Grantees: 46. 

Source: GAO analysis of Office of HIV/AIDS and Infectious Disease 
Policy and IHS data. 

Note: Dollar amounts are rounded to one decimal point. 

[A] Secretary's Minority AIDS Initiative Fund. 

[End of table] 

Office of Adolescent Health (OAH): 

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: 

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. 

Table 9: Office of HIV/AIDS and Infectious Disease Policy (OHAIDP) 
Secretary's Minority AIDS Initiative Funding and Number of Grantees, 
Fiscal Years 2007-2011: 

Fiscal Year: 2007; 
SMAIF[A]: $4.3 million; 
Number of Grantees: 6. 

Fiscal Year: 2008; 
SMAIF[A]: $2.2 million; 
Number of Grantees: 7. 

Fiscal Year: 2009; 
SMAIF[A]: $3.3 million; 
Number of Grantees: 11. 

Fiscal Year: 2010; 
SMAIF[A]: $3.7 million; 
Number of Grantees: 13. 

Fiscal Year: 2011; 
SMAIF[A]: $3.4 million; 
Number of Grantees: 12. 

Source: GAO analysis of OHAIDP data. 

Note: Dollar amounts are rounded to one decimal point. 

[A] Secretary's Minority AIDS Initiative Fund. 

[End of table] 

HHS Office of Minority Health (OMH): 

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. 

Table 10: Office of Minority Health (OMH) Secretary's Minority AIDS 
Initiative Funding and Number of Grantees, Fiscal Years 2007-2011: 

Fiscal Year: 2007; 
SMAIF[A]: $6.8 million; 
Number of Grantees: 24. 

Fiscal Year: 2008; 
SMAIF[A]: $8.8 million; 
Number of Grantees: 42. 

Fiscal Year: 2009; 
SMAIF[A]: $8.9 million; 
Number of Grantees: 51. 

Fiscal Year: 2010; 
SMAIF[A]: $8.9 million; 
Number of Grantees: 43. 

Fiscal Year: 2011; 
SMAIF[A]: $5.5 million; 
Number of Grantees: 34. 

Source: GAO analysis of Office of HIV/AIDS and Infectious Disease 
Policy and OMH data. 

Note: Dollar amounts are rounded to one decimal point. 

[A] Secretary's Minority AIDS Initiative Fund. 

[End of table] 

Office of Population Affairs (OPA): 

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. 

Table 11: Office of Population Affairs (OPA) Secretary's Minority AIDS 
Initiative Funding and Number of Grantees, Fiscal Years 2007-2011: 

Fiscal Year: 2007; 
SMAIF[A]: $6.0 million; 
Number of Grantees: 47. 

Fiscal Year: 2008; 
SMAIF[A]: $7.1 million; 
Number of Grantees: 50. 

Fiscal Year: 2009; 
SMAIF[A]: $8.1 million; 
Number of Grantees: 51. 

Fiscal Year: 2010; 
SMAIF[A]: $7.9 million; 
Number of Grantees: 54. 

Fiscal Year: 2011; 
SMAIF[A]: $7.2 million; 
Number of Grantees: 54. 

Source: GAO analysis of Office of HIV/AIDS and Infectious Disease 
Policy and OPA data. 

Note: Dollar amounts are rounded to one decimal point. 

[A] Secretary's Minority AIDS Initiative Fund. 

[End of table] 

Office on Women's Health (OWH): 

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. 

Table 12: Office on Women's Health (OWH) Secretary's Minority AIDS 
Initiative Funding and Number of Grantees, Fiscal Years 2007-2011: 

Fiscal Year: 2007; 
SMAIF[A]: $4.0 million; 
Number of Grantees: 36. 

Fiscal Year: 2008; 
SMAIF[A]: $4.0 million; 
Number of Grantees: 37. 

Fiscal Year: 2009; 
SMAIF[A]: $6.1 million; 
Number of Grantees: 50. 

Fiscal Year: 2010; 
SMAIF[A]: $7.0 million; 
Number of Grantees: 43. 

Fiscal Year: 2011; 
SMAIF[A]: $3.4 million; 
Number of Grantees: 30. 

Source: GAO analysis of Office of HIV/AIDS and Infectious Disease 
Policy and OWH data. 

Note: Dollar amounts are rounded to one decimal point. 

[A] Secretary's Minority AIDS Initiative Fund. 

[End of table] 

Regional Health Administrators (RHA): 

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.) 

Table 13: Regional Health Administrators (RHA) Secretary's Minority 
AIDS Initiative Funding and Number of Grantees, Fiscal Years 2007-2011: 

Fiscal Year: 2007; 
SMAIF[A]: $0; 
Number of Grantees: 0. 

Fiscal Year: 2008; 
SMAIF[A]: $1.3 million; 
Number of Grantees: 1. 

Fiscal Year: 2009; 
SMAIF[A]: $1.8 million; 
Number of Grantees: 1. 

Fiscal Year: 2010; 
SMAIF[A]: $1.7 million; 
Number of Grantees: 1. 

Fiscal Year: 2011; 
SMAIF[A]: $2.0 million; 
Number of Grantees: 1. 

Source: GAO analysis of Office of HIV/AIDS and Infectious Disease 
Policy and RHA data. 

Note: Dollar amounts are rounded to one decimal point. 

[A] Secretary's Minority AIDS Initiative Fund. 

[End of table] 

[End of section] 

Appendix II: Methodology for Review of Minority AIDS Initiative (MAI) 
Services from Sample of MAI Annual Grantee Reports: 

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.[Footnote 38] 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 offices and uploaded the 
reports into NVivo.[Footnote 39] This sample is generalizable 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.[Footnote 40],[Footnote 41] 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). 

Table 14: Categories of Services and Best Practices Identified in MAI 
Annual Grantee Reports: 

Category: Administrative; 
Definition: Grantee performs activities to help maintain its ability 
to conduct MAI activities, daily procedures and operation including 
assisting providers or other organizations in planning or implementing 
MAI activities, providing technical assistance, collaborating with 
organizations, etc. 

Category: Medical Services; 
Definition: Grantee provides or assists in providing direct medical 
services to clients, including dental, substance abuse, mental health, 
etc. 
Sub-categories: 
* HIV Primary and Outpatient Care: grantee provides primary care to 
clients in an inpatient or outpatient setting; 
* Substance Abuse Treatment/Counseling: grantee provides substance 
abuse treatment or care to clients in an inpatient or outpatient 
setting; 
* Mental Health Treatment/Counseling: grantee provides mental health 
treatment or counseling to clients in an inpatient or outpatient 
setting; 
* Screening/Testing for other sexually transmitted infections: grantee 
screens or tests clients for sexually transmitted diseases besides HIV; 
* Administrative/Collaboration: grantee assists or collaborates with 
providers who provide direct medical services. 

Category: Client Assistance; 
Definition: Grantee provides or assists providers in facilitating, 
referring or supporting client's care coordination, case management, 
counseling, as well as assisting clients with obtaining social 
services. 

Category: Community Outreach/Education; 
Definition: Grantee provides or assists in providing outreach and 
education services to clients and individuals with HIV/AIDS through 
social media, marketing, community events, training, etc. 

Category: Training; 
Definition: Grantee provides or receives training for grantee staff, 
providers, other organizations, etc. 

Category: Testing; 
Definition: Grantee directly provides or assists providers with 
clients testing services for HIV/AIDS, or other related illnesses. 

Category: Best Practices; 
Definition: Grantee cites any best practices, lessons learned and/or 
challenges overcome related to their MAI activities. 
Sub-categories: 
* Collaboration: grantee cites collaborating with other organizations 
that aided its ability to provide services to clients; 
* Targeted Community Outreach/Education: grantee cites activities that 
are specifically targeted to improve outreach to communities 
disproportionately affected by HIV/AIDS; 
* Community Outreach/Education: grantee cites activities to improve 
outreach and marketing to clients; 
* Client Assistance: grantee cites activities to help improve or 
facilitate linking clients to care, social support or medical services; 
* Testing: grantee cites activities to encourage clients to get tested 
for HIV/AIDS/other sexually transmitted infections; 
* Medical Services: grantee cites activities to improve their ability 
to provide or facilitate medical care for their clients; 
* Capacity Building: grantee cites activities to improve their 
infrastructure and expand their ability to provide services to clients; 
* Administrative: grantee cites activities to help maintain its 
ability to conduct MAI activities, daily procedures and operation. 

Source: GAO. 

[End of table] 

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. 

[End of section] 

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

Department of Health & Human Services: 
Office of The Secretary
Assistant Secretary for Legislation: 
Washington, DC 20201: 

November 4, 2013: 

Marcia Crosse: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street NW: 
Washington, DC 20548: 

Dear Ms. Crosse: 

Attached are comments on the U.S. Government Accountability Office's 
(GAO) report entitled, "Minority Aids Initiative: Consolidation of 
Fragmented HIV/AIDS Funding Could Reduce Administrative Challenges" 
(GAO-14-84). 

The Department appreciates the opportunity to review this report prior 
to publication. 

Sincerely, 

Signed by: 

Jim R. Esquea: 
Assistant Secretary for Legislation: 

Attachment: 

General Comments Of The Department Of Health And Human SERVICES (HHS) 
On The Government Accountability Office's (GAO) Draft Report Entitled. 
"Minority AIDS Initiative (MAI): Consolidation Of Fragmented Funding 
Could Reduce Administrative Challenges" (GAO-14-84): 

The Department appreciates the opportunity to review and comment on 
this draft report. 

HHS welcomes an expanded discussion on strategies to improve the 
administrative efficiencies of the Minority AIDS Initiative (MAI) 
including the Secretary's Minority AIDS Initiative Fund (SMAIF); 
reduce duplicative application, data collection and reporting 
requirements and burdens on grantees; reduce programmatic redundancy; 
and otherwise improve effective administration of HHS HIV/AIDS funding 
streams, both "core" and MAI. To address these administrative 
challenges, the GAO Report recommends that: (I) HHS "consolidate 
disparate MAI funding streams into core funding during its budget 
request and allocation process; and (2) seek legislation to amend the 
CARE Act or other provisions of law, as necessary to achieve a 
consolidated approach." These administrative improvements appear to be 
in alignment with the National HIV/AIDS Strategy and more overarching 
federal program accountability goals. However, before we move to 
restructure our HIV/AIDS core funding streams and consolidate the MAI 
within core funding streams, HHS would like to provide the following 
considerations. 

Any proposed restructuring of HIV/AIDS funding involving the 
elimination or consolidation of MAI, should take into account the 
original impetus and intent of the MAI including the acknowledgment 
that it was dissatisfaction with the use of "core HIV/AIDS funding" 
that prompted community leaders, members of Congress, and ultimately 
President Clinton to advocate for this racially and ethnically 
targeted funding. The original goals of the MAI are to improve HIV-
related health outcomes and improve HIV-related health disparities 
among racial and ethnic minorities by increasing capacity of 
indigenous minority community based organizations to more effectively 
serve their communities. Innovative and successful strategies targeted 
at the highest risk and hardest to serve populations were encouraged. 
The extent to which these goals remain viable and achievable in the 
absence of MAI funding should be considered. 

Related to the point above, administrative challenges are important 
but they aren't the only consideration in assessing the merits of 
funding streams and the programs they produce. Any restructuring of 
the core and MAI HIV/AIDS funding streams must ensure that HHS 
continues to be responsive to the HIV/AIDS needs of communities and 
populations disproportionately impacted by this epidemic. While all 
Americans should benefit from the broader public health programs, 
services, campaigns and activities that anchor "core HIV/AIDS 
funding," we must keep in mind that we don't have a generalized 
epidemic in the US. Certain racial and ethnic minority populations and 
specific sexual minority populations are at greater risk and have been 
disproportionately impacted. We should strive to be comprehensive and 
strategic in our reforms not simply efficient. The assessment of the 
administrative challenges says nothing about how responsive the 
programs are to the epidemic nor if the services or activities are 
appropriately prioritized, targeted and accountable. 

It should be noted that with the exception of CDC, HRSA and SAMHSA, 
the SMAIF is the primary or sole source of HIV funding for IHS and the 
6 OASH offices (OMIT, OWH, OHAIDP, OAR, OPA, & RHA). Consolidation to 
core HIV/AIDS funding will likely reduce the number of agencies or 
offices providing HIV/AIDS programming. The potential repercussions of 
this change on the Indian Health Service programming, our regional 
outreach and education efforts, the integration of HIV testing in our 
family planning clinics, and other MAI-funded programming must be 
considered. 

To illustrate the MAI fragmentation within a jurisdiction, the Report 
examines the city of Chicago and suggests that other cities like 
Philadelphia, San Francisco, Los Angeles and New York confront a 
similar array of fragmented grants with multiple administrative
requirements. The suggestion is that the grants all provide the same 
basic HIV/AIDS prevention and treatment services. We caution against 
assuming redundancy without a more comprehensive and nuanced review of 
what services arc actually being provided, for whom, where and
how. Chicago, like the other four cities is a geographically large, 
dense and diverse city. The racial, ethnic, cultural, and linguistic 
mix of residents needing HIV/AIDS programs and services could not be 
met with a one-size fits all approach. We must be vigilant to ensure 
that our efforts to improve administrative efficiency don't sacrifice 
a responsive, targeted approach. 

Since the release of the NHAS in July 2010, several changes have been 
made in the administration of the SMAIF that have made the use of 
these funds more efficient, responsive and accountable. Over the last 
few years, OHAIDP has completed a restructuring on the administrative 
guidance and programmatic use of the SMAIF. These improvements include 
the development of a funding opportunity announcement (FOA) for use by 
the several agencies and offices that compete for SMAIF resources for 
their proposed projects. In addition to delineating priority project 
areas and targeted populations, the FOA outlines specific conditions 
of award that encourage cross-agency collaboration and require the 
integration of core indicators, data streamlining, and a reduction in 
reporting requirements as now expected with all HIV/AIDS programming. 
In addition, the use of larger scale, cross-agency demonstration 
initiatives such as the 12 Cities Demo, Care and Prevention of HIV in 
the US (CAPUS), and the soon to be released HIV Care Continuum Demo 
are all SMAIF-funded initiatives that specifically address concerns 
over multiple application, data collection and reporting requirements. 
Finally, due to a reassessment of their role in direct program and 
service delivery, OASH offices, including OMH, OWH and OHAIDP, have 
experienced a reduction in the number of HIV/AIDS projects funded over 
the last five years from the SMAIF. 

[End of section] 

Appendix IV: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Marcia Crosse, (202) 512-7114 or crossem@gao.gov: 

Acknowledgments: 

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. 

[End of section] 

Footnotes: 

[1] HIV is the virus that causes AIDS. We use the common term HIV/AIDS 
to refer to HIV disease, inclusive of cases that have progressed to 
AIDS. When we use these terms alone, HIV refers to the disease without 
the presence of AIDS, and AIDS refers exclusively to HIV disease that 
has progressed to AIDS. 

[2] CDC releases data on the number of diagnoses of HIV infection 
annually and the total number AIDS cases annually in its surveillance 
reports. Data from 2011 are the most recent available for these 
measures. 

[3] We use the term "core funding" to refer to those funding programs 
administered by CDC and HRSA that are intended to provide services to 
all qualifying individuals affected by HIV/AIDS, as opposed to 
targeted funding programs within HHS's Minority Aids Initiative. 

[4] Pub. L. No. 101-381, 104 Stat. 576 (codified, as amended, at 42 
U.S.C. §§ 300ff through 300ff-121). The 1990 CARE Act added title XXVI 
to the Public Health Service Act. Unless otherwise indicated, 
references to the CARE Act refer to current title XXVI. The CARE Act 
programs have been reauthorized by the Ryan White CARE Act Amendments 
of 1996 (Pub. L. No. 104-146, 110 Stat. 1346), the Ryan White CARE Act 
Amendments of 2000 (Pub. L. No. 106-345, 114 Stat. 1319), the Ryan 
White HIV/AIDS Treatment Modernization Act of 2006 (Pub. L. No. 109-
415, 120 Stat. 2767), and the Ryan White HIV/AIDS Treatment Extension 
Act of 2009 (Pub. L. No. 111-87, 123 Stat. 2885). 

[5] Pub. L. No. 105-277, 112 Stat. 2681 (1998). 

[6] H.R. Conf. Rep. No. 105-825, at 1265 (1998). 

[7] Pub. L. No. 111-87, § 2(g), 123 Stat. 2885, 2887 (codified at 42 
U.S.C. § 300ff-86). 

[8] We obtained fiscal year 2011 MAI annual grantee reports because 
this was the most recent information available for most agencies and 
offices. Some grantees had not yet submitted their fiscal year 2011 
reports at the time we did our work. Where this was the case, we used 
the fiscal year 2010 reports. MAI grantees submit annual grantee 
reports to the agency that awarded their MAI grants that typically 
include information on the types of services they provided with their 
MAI funds. Grantees that receive more than one MAI grant often have to 
submit a separate report to each agency from which they receive grants. 

[9] We identified a total of 1067 organizations awarded MAI grants by 
the ten HHS agencies and offices in fiscal year 2011. In addition to 
grants, some agencies may have awarded MAI funding to recipients 
through other mechanisms such as cooperative agreements, contracts, or 
interagency agreements. We have treated these recipients as "grantees" 
for purposes of this report regardless of the funding mechanism by 
which they received their funds. 

[10] NVivo is a qualitative data analysis software system that allows 
organization and analysis of information from a variety of sources 
including complex nonnumeric or unstructured data. 

[11] Fragmentation occurs when one or more federal agencies or agency 
organizations are involved in the same broad area of national need and 
opportunities exist to improve service delivery. Overlap occurs when 
multiple agencies or programs have similar goals, engage in similar 
activities or strategies to achieve them, or target similar 
beneficiaries. Duplication occurs when two or more agencies or 
programs are engaged in the same activities or provide the same 
services to the same beneficiaries. See GAO, 2013 Annual Report: 
Actions Needed to Reduce Fragmentation, Overlap, and Duplication and 
Achieve Other Financial Benefits, [hyperlink, 
http://www.gao.gov/products/GAO-13-279SP] (Washington, D.C.: Apr. 9, 
2013). 

[12] Those who identify as Hispanic or Latino may be any race, 
therefore CDC data on AIDS diagnoses may combine Hispanics/Latinos 
with other races. "Hispanic or Latino," as defined in the 2010 Census, 
refers to a person of Cuban, Mexican, Puerto Rican, South or Central 
American, or other Spanish culture or origin regardless of race. 
Additionally, Asian-Americans accounted for two percent of the AIDS 
diagnoses, and Native American/Alaskan Native/Native Hawaiian/other 
Pacific Islanders accounted for less than two percent of the AIDS 
diagnoses in 2011. 

[13] Pub. L. No. 109-415, § 603, 120 Stat. 2767, 2818 (codified at 
300ff-121). 

[14] HRSA awards core HIV/AIDS grants under Parts A through D and Part 
F of the CARE Act. Part A provides for grants to selected metropolitan 
areas that have been disproportionately affected by the HIV/AIDS 
epidemic. Part B provides for grants to states and territories to 
improve the quality, availability, and organization of HIV/AIDS 
services. Part C provides for grants to public and private nonprofit 
entities to provide early intervention services such as HIV testing 
and ambulatory care. Part D provides for grants to programs for family-
centered comprehensive care to children, youth, and women and their 
families. Part F provides for grants for demonstration and evaluation 
of innovative models of HIV/AIDS care delivery for hard-to-reach 
populations and training of health care providers. In addition to the 
core HIV/AIDs grants provided under Part F of the CARE Act, Part F 
also contains the provisions that form the statutory basis for 
supplemental MAI grants under the CARE Act, which are codified at 42 
U.S.C.§ 300ff-121. 

[15] CDC may also provide funds to grantees through cooperative 
agreements and contracts. We include these funds in our counts of 
grants. 

[16] When we use the term MAI grantees, we are referring to all 
grantees that receive MAI funding, including those that receive SMAIF 
funding. 

[17] Sixteen AIDS Education and Training Centers provide HIV/AIDS 
education to health professionals such as nurses and physicians. The 
AIDS Education and Training Centers are authorized by the CARE Act. 

[18] For example, see Department of Health and Human Services 
Appropriations Act, 2010, Pub. L. No. 111-117, div. D, title II, 123 
Stat. 3034, 3239-3240 (2009). 

[19] 42 U.S.C. § 300ff-121(b). 

[20] Grantees reported they either provided these services to clients 
directly or helped providers to deliver MAI services. 

[21] The 95 percent confidence interval of this estimate ranges from 
72 to 89 percent. 

[22] The 95 percent confidence interval of this estimate ranges from 
63 to 81 percent. 

[23] The 95 percent confidence interval of this estimate ranges from 
61 to 76 percent. 

[24] The 95 percent confidence interval of this estimate ranges from 
51 to 66 percent. 

[25] The 95 percent confidence interval of this estimate ranges from 
13 to 30 percent. 

[26] The maximum 95 percent confidence interval of these estimates is 
15 percent. 

[27] Those who identify as Hispanic or Latino may be any race, 
therefore agency data may combine Hispanics with other races when 
determining the number and percent of minorities served. "Hispanic or 
Latino," as defined in the 2010 Census, refers to a person of Cuban, 
Mexican, Puerto Rican, South or Central American, or other Spanish 
culture or origin regardless of race. 

[28] CDC could not provide demographic data on the recipients of 
services funded by core HIV/AIDS funds. 

[29] These data are based on CARE Act Parts A, B, C, and D data. 

[30] GAO, 2013 Annual Report: Actions Needed to Reduce Fragmentation, 
Overlap, and Duplication and Achieve Other Financial Benefits, 
[hyperlink, http://www.gao.gov/products/GAO-13-279SP] (Washington, 
D.C.: Apr. 9, 2013), 3. 

[31] The White House, National HIV/AIDS Strategy for the United States 
(July 2010), 42. 

[32] We found in 2009 that some Part B grantees did not apply for MAI 
grants because they did not think the level of funding justified the 
effort required to apply for and report on their use of the grants. 
Although MAI applications were required to be synchronized with other 
CARE Act grant applications in the 2009 reauthorization of the CARE 
Act, some Part B grantees have continued to not apply for MAI grants. 
GAO, Ryan White CARE Act: Implementation of the New Minority AIDS 
Initiative Provisions, [hyperlink, 
http://www.gao.gov/products/GAO-09-315] (Washington, D.C.: Mar. 27, 
2009). 

[33] In our review of MAI services from our sample, we found that 57 
out of 100 grantees reported services that we define to be best 
practices in their fiscal year 2011MAI annual grantee reports. We 
define the term best practices to include any successes, lessons 
learned and/or challenges overcome that we found grantees to report 
regarding their MAI activities. MAI grantees generally are not 
required to report best practices in their annual grantee reports; 
therefore, our reporting of these best practices is not generalizable 
to the 100 grantees in our sample. 

[34] Officials from two HHS agencies told us their MAI funds have been 
used to implement capacity building services to expand their ability 
to provide services to clients. 

[35] In addition to grants, some agencies may have awarded MAI 
(including SMAIF) funding to recipients through other mechanisms such 
as cooperative agreements, contracts, or interagency agreements. We 
have treated these recipients as "grantees" for purposes of this 
report regardless of the funding mechanism by which they received 
their MAI or SMAIF funds. 

[36] See Ryan White HIV/AIDS Treatment Modernization Act of 2006, Pub. 
L. No. 109-415, § 603, 120 Stat. 2767, 2818 (codified at 42 U.S.C. § 
300ff-121). 

[37] Eligible metropolitan areas are areas that have a population of 
50,000 persons or more and had a cumulative total of more than 2,000 
new AIDS cases during the most recent 5-year period. Transitional 
grant areas are areas that have a population of 50,000 persons or more 
and had a cumulative total of 1,000 to 1,999 new AIDS cases during the 
most recent 5-year period. 

[38] We identified a total of 1067 organizations awarded MAI grants by 
the ten HHS agencies and offices in fiscal year 2011. In addition to 
grants, some agencies may have awarded MAI funding to recipients 
through other mechanisms such as cooperative agreements, contracts, or 
interagency agreements. We have treated these recipients as "grantees" 
for purposes of this report regardless of the funding mechanism by 
which they received their funds. Fiscal year 2011 was the most recent 
year that grantee data was available for most HHS agencies and offices. 

[39] We obtained fiscal year 2010 MAI annual grantee reports for some 
grantees who had not yet submitted their fiscal year 2011 reports. We 
reviewed all grantee reports in our sample for accuracy and to ensure 
they contained information on MAI services. 

[40] NVivo is a qualitative data analysis software system that allows 
organization and analysis of information from a variety of sources 
including complex nonnumeric or unstructured data. 

[41] MAI grantees submit annual grantee reports to the agency that 
awarded their MAI grants that typically include information on the 
types of services they provide with their MAI grants. Grantees that 
receive more than one MAI grant often have to submit a separate report 
to each agency from which they receive funds. 

[End of section] 

GAO’s Mission: 

The Government Accountability Office, the audit, evaluation, and 
investigative arm of Congress, exists to support Congress in meeting 
its constitutional responsibilities and to help improve the 
performance and accountability of the federal government for the 
American people. GAO examines the use of public funds; evaluates 
federal programs and policies; and provides analyses, recommendations, 
and other assistance to help Congress make informed oversight, policy, 
and funding decisions. GAO’s commitment to good government is 
reflected in its core values of accountability, integrity, and 
reliability. 

Obtaining Copies of GAO Reports and Testimony: 

The fastest and easiest way to obtain copies of GAO documents at no 
cost is through GAO’s website [hyperlink, http://www.gao.gov]. Each 
weekday afternoon, GAO posts on its website newly released reports, 
testimony, and correspondence. To have GAO e-mail you a list of newly 
posted products, go to [hyperlink, http://www.gao.gov] and select 
“E-mail Updates.” 

Order by Phone: 

The price of each GAO publication reflects GAO’s actual cost of 
production and distribution and depends on the number of pages in the 
publication and whether the publication is printed in color or black 
and white. Pricing and ordering information is posted on GAO’s 
website, [hyperlink, http://www.gao.gov/ordering.htm]. 

Place orders by calling (202) 512-6000, toll free (866) 801-7077, or 
TDD (202) 512-2537. 

Orders may be paid for using American Express, Discover Card, 
MasterCard, Visa, check, or money order. Call for additional 
information. 

Connect with GAO: 

Connect with GAO on facebook, flickr, twitter, and YouTube.
Subscribe to our RSS Feeds or E mail Updates. Listen to our Podcasts.
Visit GAO on the web at [hyperlink, http://www.gao.gov]. 

To Report Fraud, Waste, and Abuse in Federal Programs: 

Contact: 
Website: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]; 
E-mail: fraudnet@gao.gov; 
Automated answering system: (800) 424-5454 or (202) 512-7470. 

Congressional Relations: 

Katherine Siggerud, Managing Director, siggerudk@gao.gov: 
(202) 512-4400: 
U.S. Government Accountability Office: 
441 G Street NW, Room 7125: 
Washington, DC 20548. 

Public Affairs: 

Chuck Young, Managing Director, youngc1@gao.gov: 
(202) 512-4800: 
U.S. Government Accountability Office: 
441 G Street NW, Room 7149: 
Washington, DC 20548. 

[End of document]