CDC and SAMHSA  award MAI grants directly to 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. A fraction of the grantees  reported providing medical services to their clients. The services provided by MAI grantees were similar to those provided by  grantees awarded HRSA’s and CDC’s core HIV/AIDS funding. 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. 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. 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. For example, the city of Chicago received nine grants from HHS to  provide HIV/AIDS services. MAI grantees face challenges in managing  the multiple administrative requirements for each of these grants. 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. 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. 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. 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. 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. 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. 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. 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. 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.
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.