	Background

MAI, a component of the CARE Act, provides for funds to eligible grantees  with the goal of reducing HIV-related health disparities among minority  populations. HRSA Administration of CARE Act Funding

HRSA primarily awards CARE Act funds to grantees for core medical  services, support services, and education through five primary sections of  the legislation—Parts A, B, C, D, and F. In fiscal year 2007, 22 EMAs and 34  TGAs received grants under Part A; all 50 states, the District of Columbia,  Puerto Rico, and 7 U.S. territories received grants under Part B; 354  public and private organizations that provide services directly to  individuals with HIV received grants under Part C; and 90 public and  private organizations that provide services to families in which at least one  member is HIV positive received grants under Part D. For Parts A, B, C,  and D, programs funded by the CARE Act are the payers of last resort for  care. Ryan White Comprehensive AIDS Resources Emergency Act of 1990, as amended. Prior to the enactment of RWTMA, the MAI funds for Part A and B  grantees were awarded according to a formula that solely reflected the  number of living minority AIDS cases in the metropolitan area, state, or  territory receiving funds. Barriers to Care

Barriers to HIV/AIDS care can delay or prevent individuals’ timely  entrance into, or continuation of, core medical or support services, thus  reducing the likely success of care. The New Competitive Process for Parts A and B Altered MAI Funding Amounts, Increased Administrative Requirements for Grantees, and Generally Funded the Same Initiatives

The new competitive process for Parts A and B resulted in changes in the  amount of funding from what grantees would have received under the old  formula-based process. Grantees that received MAI funding stated that the  administrative requirements of the grant increased significantly in fiscal  year 2007, and some grantees chose not to apply for MAI funds. Grantees  continued funding existing initiatives to reduce health disparities for  minorities rather than funding new initiatives, and grantees generally  provided funding to the same service providers as they had in prior years. However, since RWTMA changed the process by  which MAI funds were awarded, some grantees’ MAI grant amounts  differed from what they would have been awarded under the previous  formula-based process. The New Competitive Process Generally Resulted in the Funding of the Same Initiatives

Some Part A and B grantees reported that they have continued to fund the  same initiatives to reduce minority health disparities that they did prior to  the implementation of the new MAI competitive process. Part A grantees reported funding a range of core medical and support  services under MAI. According to our survey, four of the top five services  most commonly funded in fiscal year 2007 were categorized as core  medical services—medical case management, outpatient and ambulatory  health services, substance abuse outpatient care, and mental health  services. Similar to Part A grantees, Part C and D grantees used MAI funding for a  range of core medical and support services, while Part B and F grantees  used MAI funding for specific services designated by the MAI provisions in  the CARE Act. Part F MAI  grantees told us that they use MAI funds for education efforts targeting  health care professionals who are from, or primarily serve, minority  communities. MAI Grantees Identified Multiple Barriers to Minorities’ Access to the Services Provided by HIV/AIDS Programs

MAI grantees identified multiple barriers that make it difficult for  minorities to obtain services through HIV/AIDS programs. The comments are  reprinted in appendix V. In its comments, HHS suggested that we identify  the law authorizing Ryan White programs as either Title XXVI of the Public  Health Service Act or the Ryan White HIV/AIDS program. Consistent with  our previous work, we continue to refer to the law authorizing Ryan White  programs as the CARE Act. To gather background information about the challenges to  HIV/AIDS program integration experienced by CARE Act grantees, we  interviewed officials from the Health Resources and Services  Administration (HRSA) of the Department of Health and Human Services  and staff of the National Minority AIDS Council, Kaiser Family  Foundation, the National Alliance of State and Territorial AIDS Directors,  and the Communities Advocating Emergency AIDS Relief Coalition. Appendix II: Objectives, Scope, and Methodology

The CARE Act requires us to report on the Minority AIDS Initiative (MAI)  and related issues. In this report, we are providing information on (1) the  effect on grantees and service providers of the new competitive process  for awarding Part A and B MAI funds, (2) the types of services grantees  funded under MAI, and (3) barriers to minorities obtaining services from  HIV/AIDS programs that were identified by grantees.
Why GAO Did This Study

The Ryan White Comprehensive AIDS Resources Emergency Act of 1990 (CARE Act) makes federal funds available to assist individuals affected by HIV/AIDS. The Department of Health and Human Services' (HHS) Health Resources and Services Administration (HRSA) awards CARE Act funding to grantees that include states, territories, and metropolitan areas. Because minorities have been disproportionately affected by HIV/AIDS, the CARE Act's Minority AIDS Initiative (MAI) provides funding through five parts (A, B, C, D, and F) of the act with the goal of reducing HIV-related health care disparities among minorities. The reauthorization of CARE Act programs changed the process by which HRSA awards MAI grants under Part A (funding for metropolitan areas) and Part B (for states and territories) from a formula based solely on demographics of the metropolitan area, state, or territory to a competitive process. The CARE Act requires GAO to report on MAI and related issues. This report provides information on (1) the effect on grantees and service providers of the new competitive process for awarding Part A and B MAI funds, (2) the types of services grantees funded under MAI, and (3) barriers to minorities obtaining services from HIV/AIDS programs that were identified by grantees. GAO surveyed CARE Act grantees and interviewed selected grantee and HRSA officials. GAO also reviewed Part A and B MAI applications.

What GAO Found

The new competitive process for Parts A and B altered MAI funding amounts from what they would have been under the old formula-based process, increased administrative requirements for grantees, and resulted in continued funding for existing initiatives to reduce health disparities for minorities. In determining the award amounts under the new process, HRSA considered the number of minorities with HIV/AIDS living in the grantee metropolitan area, state, or territory, along with the MAI applications grantees were required to file. The quality of the grant applications sometimes resulted in considerable differences in grantees' share of MAI funds from what they would have received under the old process. Part A and B grantees that received MAI funding told us that the administrative requirements increased significantly because of the new process. All Part A and B grantees that applied for MAI funding received it, but some Part B grantees decided that the administrative requirements, including a separate application for MAI funds, were not worth the amount of funds that they expected to receive and therefore chose not to apply. Grantees generally funded the same service providers and initiatives to reduce minority health disparities as they had in prior years. After the reauthorization of CARE Act programs, MAI grantees continued to fund a range of core medical services, which include essential medical care services, and support services, which are services needed for individuals with HIV/AIDS to achieve their medical outcomes. Consistent with HRSA guidance, the types of services funded under MAI generally did not differ from services provided with other CARE Act funds. The five services Part A grantees funded most frequently were medical case management, outpatient and ambulatory health services, outreach services, substance abuse outpatient care, and mental health services--outreach services being the only support service among these. Part B grantees used MAI funds for efforts associated with the CARE Act-funded HIV/AIDS drug program, Part C and D grantees funded a range of core medical and support services with MAI funds, and Part F grantees used MAI funds for education efforts targeting health care professionals who are from, or primarily serve, minority communities. Grantees identified many barriers that make it more difficult for minorities to obtain services from HIV/AIDS programs, including those funded by the CARE Act. Barriers to HIV/AIDS care can delay or prevent individuals' timely entrance into, or continuation of, core medical or support services, thus reducing the likely success of care. The barriers grantees identified included the presence of other diseases that impact immune systems, housing issues, and poverty. In commenting on this report, HHS suggested that we identify the law authorizing Ryan White programs as either Title XXVI of the Public Health Service Act (PHSA) or the Ryan White HIV/AIDS program. We continue to refer to the law authorizing Ryan White programs as the CARE Act, but have clarified that it refers to Title XXVI of PHSA.