Part B provides for grants to states and territories and  associated jurisdictions to improve quality, availability, and organization  of HIV services. CDC and HRSA Have Coordinated on HIV Activities to Assist Health Care Professionals, and Both Agencies Have Taken Steps to Encourage Routine HIV Testing

CDC and HRSA have coordinated on activities to assist health care  professionals who provide HIV-related services. CDC also provided HRSA with funding to expand HIV consultation  services offered to health care professionals at the National HIV/AIDS  Clinicians’ Consultation Center. For example, officials from 3 of these health departments  attributed the lack of coordination to differing guidelines CDC and HRSA  use for their grantees. HRSA Has Encouraged Routine HIV Testing by Providing for Training for Health Care Providers as Part of CDC-Funded Initiatives

Since the release of CDC’s 2006 routine HIV testing recommendations,  HRSA has encouraged routine HIV testing by providing for training for  health care providers, as part of CDC-funded initiatives. CDC  required health departments to spend all funding on HIV testing and  related activities, including the purchase of HIV rapid tests and connecting  HIV-positive individuals to care. Over Half of the Selected State and Local Health Departments Reported Implementing Routine HIV Testing in Their Jurisdictions, but Generally Did So in a Limited Number of Sites

Officials from 9 of the 14 state and local health departments we  interviewed said that their departments had implemented routine HIV  testing, but 7 said that they did so in a limited number of sites. Officials from Selected State and Local Health Departments and Other Sources Have Identified Barriers That Exist to Implementing Routine HIV Testing

Officials from 11 of the 14 state and local health departments we  interviewed and other sources knowledgeable about HIV have identified  barriers that exist to implementing routine HIV testing. CDC Officials Estimated That About 30 Percent of the Agency’s Annual HIV Prevention Funding Is Spent on HIV Testing

CDC officials estimated that approximately 30 percent of the agency’s  annual HIV prevention funding is spent on HIV testing. For example,  according to CDC officials, in fiscal year 2008 this would make the total  amount spent on HIV testing about $200 million out of the $652.8 million  CDC allocated for domestic HIV prevention to its Division of HIV/AIDS  Prevention. CDC officials said that, outside of special testing initiatives, they could not  provide the exact amount CDC spent on HIV testing. A National Estimate of the Number of Undiagnosed HIV- Positive Individuals Is Available, but an Estimate Is Not Available for the Total Number of Diagnosed Individuals Not Receiving Care Nationally and Neither Estimate Is Available at the State Level

CDC has calculated a national estimate of more than 200,000 undiagnosed  HIV-positive individuals—that is, individuals who were unaware they are  HIV positive and were therefore not receiving care for HIV. CDC estimated  that 232,700 individuals, or 21 percent of the 1.1 million people living with  HIV at the end of 2006, were unaware that they were HIV positive. CDC reported that the estimated proportion of individuals with HIV who  did not receive care within a year of diagnosis—which CDC measures by  the number of HIV-positive individuals who did not have a reported CD4  or viral load test within this time—was 32.4 percent, or 12,285 of the  37,880 individuals who were diagnosed with HIV in 2003. In these examples, the individuals’ change in status as  receiving care or not receiving care is not included in CDC’s estimate of  the proportion of diagnosed individuals not receiving care. HRSA also collects states’ estimates of the number of diagnosed HIV- positive individuals not receiving care for HIV, but data are not  consistently collected or reported by states, and therefore estimates are  not available for comparison across all states. Agency Comments

HHS provided technical comments on a draft of the report, which we  incorporated as appropriate. We are sending copies of this report to the Secretary of Health and Human  Services. Additionally, we provide information on steps taken by the Centers for  Disease Control and Prevention (CDC) and states to address this issue. To provide information related to the steps that CDC and HRSA have  taken to address the provision of HIV prevention and care for incarcerated  persons, we interviewed CDC and HRSA officials.
Why GAO Did This Study

Of the estimated 1.1 million Americans living with HIV, not all are aware of their HIV-positive status. Timely testing of HIV-positive individuals is important to improve health outcomes and to slow the disease's transmission. It is also important that individuals have access to HIV care after being diagnosed, but not all diagnosed individuals are receiving such care. The Centers for Disease Control and Prevention (CDC) provides grants to state and local health departments for HIV prevention and collects data on HIV. In 2006, CDC recommended routine HIV testing for all individuals ages 13-64. The Health Resources and Services Administration (HRSA) provides grants to states and localities for HIV care and services. GAO was asked to examine issues related to identifying individuals with HIV and connecting them to care. This report examines: 1) CDC and HRSA's coordination on HIV activities and steps they have taken to encourage routine HIV testing; 2) implementation of routine HIV testing by select state and local health departments; 3) available information on CDC funding for HIV testing; and 4) available data on the number of HIV-positive individuals not receiving care for HIV. GAO reviewed reports and agency documents and analyzed CDC, HRSA, and national survey data. GAO interviewed federal officials, officials from nine state and five local health departments chosen by geographic location and number of HIV cases, and others knowledgeable about HIV.

What GAO Found

The Secretary of Health and Human Services (HHS) is required to ensure that HHS agencies, including CDC and HRSA, coordinate HIV programs to enhance the continuity of prevention and care services. CDC and HRSA have coordinated to assist health care professionals who provide HIV-related services. For example, in 2007 and 2008, CDC provided funding to HRSA to expand consultation services at the National HIV/AIDS Clinicians' Consultation Center. Both CDC and HRSA have taken steps to encourage routine HIV testing--that is, testing all individuals in a health care setting without regard to risk. For example, CDC has funded initiatives on routine HIV testing and HRSA has provided for training as part of these initiatives. Officials from over half of the 14 selected state and local health departments in GAO's review reported implementing routine HIV testing in their jurisdictions. However, according to officials we interviewed, those that implemented it generally did so at a limited number of sites. Officials from most of the selected health departments and other sources knowledgeable about HIV have identified barriers that exist to implementing routine HIV testing, including lack of funding and legal barriers. CDC officials estimated that approximately 30 percent of the agency's annual HIV prevention funding is spent on HIV testing. For example, according to CDC officials, in fiscal 2008, this would make the total amount spent on HIV testing about $200 million out of the $652.8 million CDC allocated for domestic HIV prevention to its Division of HIV/AIDS Prevention. However, CDC officials said that they could not provide the exact amount the Division spends on HIV testing, because they do not routinely aggregate how much all grantees spend on a given activity, including HIV testing. CDC estimated that 232,700 individuals with HIV were undiagnosed--that is, unaware that they were HIV positive--in 2006, and were therefore not receiving care for HIV. CDC has not estimated the total number of diagnosed HIV-positive individuals not receiving care, but has estimated that 32.4 percent, or approximately 12,000, of HIV-positive individuals diagnosed in 2003 did not receive care for HIV within a year of diagnosis. State-level estimates of the number of undiagnosed and diagnosed HIV-positive individuals not receiving care for HIV are not available from CDC. HRSA collects states' estimates of the number of diagnosed individuals not receiving care, but data are not consistently collected or reported by states, and therefore estimates are not available for comparison across all states. HHS provided technical comments on a draft of this report, which GAO incorporated as appropriate.