    HIV/AIDS: Changes Needed to Improve the Distribution of Ryan
    White CARE Act and Housing Funds (28-FEB-06, GAO-06-332).

    Among federal efforts to address the HIV/AIDS epidemic are the
    CARE Act of 1990 and the Housing Opportunities for Persons with
    AIDS program (HOPWA) administered by the Departments of Health
    and Human Services (HHS) and Housing and Urban Development (HUD),
    respectively. Both use formulas based upon a grantee's number of
    AIDS cases, rather than HIV and AIDS cases, to distribute funds
    to metropolitan areas, states, and territories. HIV cases must be
    incorporated with AIDS cases in CARE Act formulas not later than
    fiscal year 2007. GAO was asked to examine (1) how CARE Act and
    HOPWA funds are allocated among types of services, (2) the extent
    of funding distribution differences among CARE Act and HOPWA
    grantees, and how funding formula provisions contribute to these
    differences, and (3) what distribution differences could result
    from incorporating HIV case counts in CARE Act and HOPWA funding
    formulas.
    -------------------------Indexing Terms-------------------------
    REPORTNUM:   GAO-06-332
        ACCNO:   A47957
      TITLE:     HIV/AIDS: Changes Needed to Improve the Distribution of
    Ryan White CARE Act and Housing Funds
         DATE:   02/28/2006
      SUBJECT:   Acquired immunodeficiency syndrome
    	     Allocation (Government accounting)
    	     Data collection
    	     Data integrity
    	     Eligibility determinations
    	     Federal funds
    	     Federal grants
    	     Formula grants
    	     Funds management
    	     Health care programs
    	     Health care services
    	     Infectious diseases
    	     HIV/AIDS
    	     HUD Housing Opportunities for Persons
    	     with AIDS Program

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    GAO-06-332

         * HIV/AIDS
         * Changes Needed to Improve the Distribution of Ryan White CARE Act and
           Housing Funds
              * Background
                   * HIV/AIDS in the United States
                        * The CARE Act
                             * CARE Act Amendments
                             * Metropolitan Statistical Areas
                             * HIV Case Counts
                        * HOPWA
                   * Results in Brief
                   * CARE Act and HOPWA Funds Allocated for Health Care, Housing
                     Assistance, and a Variety of Other Services
                        * More Than Half of Title I Fiscal Year 2003 Funding Was
                          Allocated for Health Care Services
                        * Over Two-thirds of Title II Fiscal Year 2003 Funding
                          Was Allocated for Medications
                        * Over Three-quarters of Title III Fiscal Year 2002
                          Funding Was Allocated for Health Care Services
                        * CARE Act Grants Funded Other Activities in Fiscal Year
                          2003
                        * Two-thirds of HOPWA Fiscal Year 2003 Funds Were Spent
                          on Housing Costs
                   * Multiple Provisions Contribute to Disproportionate
                     Distribution of CARE Act and HOPWA Formula Funding
                        * CARE Act and HOPWA Grants Are Not Distributed Solely in
                          Proportion to Number of Persons Living with AIDS
                        * Provisions in HOPWA and CARE Act Funding Formulas
                          Incorporate Measures of AIDS Cases That Do Not Reflect
                          an Accurate Count of Persons Living with AIDS
                             * HOPWA Grants
                             * CARE Act Grants
                        * CARE Act Funding Provisions for Metropolitan Areas
                          Result in Disproportionate Funding
                             * Counting ELCs within EMAs Twice Results in
                               Disproportionate Funding per ELC across States and
                               Puerto Rico
                             * The Two-tiered Division of Emerging Communities
                               Results in Funding Disparities Among Metropolitan
                               Areas
                        * Hold-harmless Provisions and Grandfather Clause Protect
                          Funding of Certain CARE Act Grantees
                             * One EMA Has Been the Primary Recipient of Title I
                               Hold-harmless Funding
                             * Grandfathering Maintains Eligibility for EMAs That
                               No Longer Meet Certain Eligibility Criteria
                             * Title II Hold-harmless Funding Could Diminish ADAP
                               Severe Need Grants in the Future
                        * HOPWA Provision Restricts Bonus Grant Eligibility for
                          Some Grantees
                        * The Use of Revised OMB Metropolitan Area Definitions
                          Would Change Most EMA Boundaries, but Increase in ELCs
                          within EMAs Would Be Minimal
                   * Funding Effect of Using HIV Case Counts Would Depend on
                     Multiple Factors
                        * Current HIV Case-reporting Systems Have Limitations for
                          Providing Case Counts for Funding Allocations
                        * The Use of HIV Case Counts in Funding Formulas Would
                          Have Changed the Distribution of Fiscal Year 2004 CARE
                          Act and HOPWA Funds
                             * Methodological Approaches Used
                             * Changes in CARE Act Funding Using HIV Cases and
                               Hold-harmless and Minimum-grant Provisions
                                  * Title I Base Funding
                                  * Title II Base Funding
                                  * ADAP Base Funding
                        * Changes in CARE Act Formula Funding Would Be Larger If
                          Hold-harmless and Minimum-grant Provisions Were Not in
                          Effect
                             * Title I Base Funding
                                  * Title II Base Funding
                                  * ADAP Base Funding
                        * HOPWA Base Funding Would Generally Shift If HIV Cases
                          Were Used in Formula Allocations
                             * Differences in Case-reporting Systems Would Affect
                               Allocations
                   * Conclusions
                   * Matters for Congressional Consideration
                   * Agency Comments and Our Evaluation
              * Appendix I: Objectives, Scope, and Methodology
                   * Objectives
                   * Scope and Methodology
                        * Allocation of CARE Act and HOPWA Funds among Service
                          Categories
                        * Funding-formula Provisions
                        * Use of HIV Cases in Formulas
              * Appendix II: CARE Act Title I Awards, Fiscal Year 2004
              * Appendix III: CARE Act Title II Awards, Fiscal Year 2004
              * Appendix IV: HOPWA Formula Grantees and Award Amounts, Fiscal
                Year 2004
              * Appendix V: HOPWA Base Funding Allocations Using Cumulative and
                Living AIDS Cases, Fiscal Year 2004
              * Appendix VI: Total CARE Act Title I and Title II Funding by State
                and Territory, Fiscal Year 2004
              * Appendix VII: HRSA's Title I EMAs, GAO-Identified Set of
                Comparable 2004 OMB-Defined Metropolitan Areas, and Changes
              * Appendix VIII: Estimated CARE Act Title I Funding Changes from
                Use of HIV Case Counts and ELCs with Hold-harmless
              * Appendix IX: Estimated CARE Act Title II Base Funding Changes
                from Use of HIV Case Counts and ELCs with Hold-harmless
              * Appendix X: Estimated CARE Act ADAP Base Funding Changes from Use
                of HIV Case Counts and ELCs with Hold-harmless
              * Appendix XI: Estimated CARE Act Title I Base Funding Changes from
                Use of HIV Case Counts and ELCs without Hold-harmless
              * Appendix XII: Estimated CARE Act Title II Base Funding Changes
                from Use of HIV Case Counts and ELCs without Hold-harmless
              * Appendix XIII: Estimated CARE Act ADAP Base Funding Changes from
                Use of HIV Case Counts and ELCs without Hold-harmless
              * Appendix XIV: Estimated HOPWA Base Funding Changes from Use of
                HIV and Living AIDS Case Counts, Fiscal Year 2004
              * Appendix XV: Comments from the Department of Health and Human
                Services
              * Appendix XVI: Comments from the Department of Housing and Urban
                Development
              * Appendix XVII: GAO Contact and Staff Acknowledgments
                   * GAO Contact
                   * Acknowledgments
              * Related GAO Products
                   * Order by Mail or Phone

    Report to Congressional Requesters

    United States Government Accountability Office

    GAO

    February 2006

    HIV/AIDS

    Changes Needed to Improve the Distribution of Ryan White CARE Act and
    Housing Funds

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    GAO-06-332

    Contents

    Letter 1

    Background 6
    Results in Brief 14
    CARE Act and HOPWA Funds Allocated for Health Care, Housing Assistance,
    and a Variety of Other Services 17
    Multiple Provisions Contribute to Disproportionate Distribution of CARE
    Act and HOPWA Formula Funding 21
    Funding Effect of Using HIV Case Counts Would Depend on Multiple Factors
    45
    Conclusions 63
    Matters for Congressional Consideration 64
    Agency Comments and Our Evaluation 65
    Appendix I Objectives, Scope, and Methodology 69
    Objectives 69
    Scope and Methodology 69
    Appendix II CARE Act Title I Awards, Fiscal Year 2004 80
    Appendix III CARE Act Title II Awards, Fiscal Year 2004 82
    Appendix IV HOPWA Formula Grantees and Award Amounts, Fiscal Year 2004 84
    Appendix V HOPWA Base Funding Allocations Using Cumulative and Living AIDS
    Cases, Fiscal Year 2004 88
    Appendix VI Total CARE Act Title I and Title II Funding by State and
    Territory, Fiscal Year 2004 92
    Appendix VII HRSA's Title I EMAs, GAO-Identified Set of Comparable 2004
    OMB-Defined Metropolitan Areas, and Changes 94
    Appendix VIII Estimated CARE Act Title I Funding Changes from Use of HIV
    Case Counts and ELCs with Hold-harmless 99
    Appendix IX Estimated CARE Act Title II Base Funding Changes from Use of
    HIV Case Counts and ELCs with Hold-harmless 101
    Appendix X Estimated CARE Act ADAP Base Funding Changes from Use of HIV
    Case Counts and ELCs with Hold-harmless 103
    Appendix XI Estimated CARE Act Title I Base Funding Changes from Use of
    HIV Case Counts and ELCs without Hold-harmless 105
    Appendix XII Estimated CARE Act Title II Base Funding Changes from Use of
    HIV Case Counts and ELCs without Hold-harmless 107
    Appendix XIII Estimated CARE Act ADAP Base Funding Changes from Use of HIV
    Case Counts and ELCs without Hold-harmless 109
    Appendix XIV Estimated HOPWA Base Funding Changes from Use of HIV and
    Living AIDS Case Counts, Fiscal Year 2004 111
    Appendix XV Comments from the Department of Health and Human Services 115
    Appendix XVI Comments from the Department of Housing and Urban Development
    120
    Appendix XVII GAO Contact and Staff Acknowledgments 127
    Related GAO Products 128

    Tables

    Table 1: CARE Act Programs, 2004 9
    Table 2: Description of CARE Act Title I and Title II Formula Grants 11
    Table 3: Relationship between ELCs in EMAs and Total CARE Act Title I and
    II Funding per ELC, Fiscal Year 2004 28
    Table 4: Title II Emerging Communities in Fiscal Year 2004 30
    Table 5: Title I Hold-harmless Funding, Fiscal Year 2004 33
    Table 6: Grandfathered EMAs, Fiscal Year 2004 36
    Table 7: States That Received Title II Hold-harmless Funding from Severe
    Need Set-aside, Fiscal Year 2004 39
    Table 8: Fiscal Year 2004 HOPWA Formula Funding 40
    Table 9: CDC Acceptance of HIV Case Counts and Year of Establishment of
    HIV-reporting Systems, December 2005 48
    Table 10: Reported HIV Cases and ELCs as of June 2003 61
    Table 11: U.S. Census Bureau Regions 78
    Table 12: EMAs with Service Area Changes 94
    Table 13: EMAs with No Service Area Changes 97

    Figures

    Figure 1: Federal HIV/AIDS Funding by Category, Fiscal Year 2004 8
    Figure 2: Allocation of CARE Act Title I Funds, Fiscal Year 2003 18
    Figure 3: Allocation of CARE Act Title II Funds, Fiscal Year 2003 19
    Figure 4: Allocation of CARE Act Title III Funds, Fiscal Year 2002 20
    Figure 5: Allocation of HOPWA Funds, Fiscal Year 2003 21

    Abbreviations

    ADAP AIDS Drug Assistance Program AIDS acquired immunodeficiency syndrome
    CARE Act Ryan White Comprehensive AIDS Resources Emergency Act CDC Centers
    for Disease Control and Prevention ELC estimated living AIDS case EMA
    eligible metropolitan area EMSA eligible metropolitan statistical area HHS
    Department of Health and Human Services HIV human immunodeficiency virus
    HOPWA Housing Opportunities for Persons with AIDS program HRSA Health
    Resources and Services Administration HUD Department of Housing and Urban
    Development IOM Institute of Medicine MSA metropolitan statistical area
    OMB Office of Management and Budget

    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. However, 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

    Washington, DC 20548

    February 28, 2006

    The Honorable Michael B. Enzi Chairman Committee on Health, Education,
    Labor, and Pensions United States Senate

    The Honorable Mark E. Souder Chairman Subcommittee on Criminal Justice,
    Drug Policy and Human Resources Committee on Government Reform House of
    Representatives

    The Honorable Tom A. Coburn United States Senate

    The Honorable Judd Gregg United States Senate

    It has been nearly 25 years since the first cases of acquired
    immunodeficiency syndrome (AIDS) in the United States were identified.
    Treatment advances in combination antiretroviral therapy during the 1990s
    have significantly reduced AIDS mortality and slowed the progression from
    a positive human immunodeficiency virus (HIV) diagnosis to AIDS. 1 Yet the
    number of new HIV infections, which is estimated at 40,000 annually, has
    not decreased. The Centers for Disease Control and Prevention (CDC)
    estimate that between 1,039,000 and 1,185,000 people in the United States
    were living with HIV/AIDS at the end of 2003. The number of people
    infected with HIV/AIDS is likely to have risen since then, and CDC
    estimates that, as of December 2004, it included 415,193 individuals with
    AIDS.

    Among the federal government's efforts to address the HIV/AIDS epidemic
    are the Ryan White Comprehensive AIDS Resources Emergency Act of 1990
    (CARE Act) 2 and the Housing Opportunities for Persons with AIDS program
    (HOPWA). The CARE Act, which is administered by the Department of Health
    and Human Services's (HHS) Health Resources and Services Administration
    (HRSA), established a number of grant programs through which funds are
    made available to states-including the District of Columbia-territories, 3
    and metropolitan areas to provide health care, medications, and support
    services to individuals and families affected by HIV/AIDS. The AIDS
    Housing Opportunity Act, which was enacted in 1990 and is administered by
    the Department of Housing and Urban Development (HUD), established HOPWA.
    4 HOPWA provides housing assistance for low-income persons with HIV/AIDS
    and their families. In fiscal year 2004, over $2 billion was distributed
    through the CARE Act and $295 million was distributed through HOPWA.

    1HIV is the virus that causes AIDS. Throughout this report, 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.

    2Pub. L. No. 101-381, 104 Stat. 576 (codified as amended at 42 U.S.C. S:S:
    300ff-300ff-111 (2000)). Unless otherwise indicated, references to the
    CARE Act are to current law.

    3In addition to the 50 states, the CARE Act authorizes grants to the
    District of Columbia, the Commonwealth of Puerto Rico, Guam, the Virgin
    Islands, American Samoa, the Commonwealth of the Northern Mariana Islands,
    the Republic of the Marshall Islands, the Federated States of Micronesia,
    and the Republic of Palau. Throughout this report, the term state refers
    to the 50 states and the District of Columbia, and territory refers to
    these listed territories.

    4Pub. L. No. 101-625, tit. VIII, subtit. D, 104 Stat. 4079, 4375 (codified
    as amended at 42 U.S.C. S:S: 12901-12912 (2000)). Unless otherwise
    indicated, references to HOPWA are to the program as administered under
    current law.

    5Pub. L. No. 106-345, S: 206(b), 114 Stat. 1319, 1334-35.

    6GAO, Ryan White CARE Act: Opportunities to Enhance Funding Equity,
    GAO/T-HEHS-00-150 (Washington, D.C.: July 11, 2000), 6.

    7Our analyses of CARE Act and HOPWA funding-formula provisions and the use
    of HIV cases in making CARE Act and HOPWA funding allocations include the
    states, Puerto Rico, and metropolitan areas eligible for funding.

    8In this report, cumulative AIDS cases are the total number of AIDS cases,
    both living and dead, reported in a jurisdiction in a given period.

    9The 1990 CARE Act added a new title XXVI to the Public Health Service
    Act. In general, because Part A of that new title, which authorizes grants
    to metropolitan areas, was established by Title I of the CARE Act, it is
    commonly referred to as Title I, and because part B, which authorizes
    grants to states and territories, was established by Title II of the CARE
    Act, it is commonly referred to as Title II. Titles III and IV of the Act
    established Parts C and D, respectively, authorizing grants for early
    intervention services as well as grants for services to women and
    children, among other things. Under Title I, a metropolitan area with a
    population of at least 500,000 and more than 2,000 reported AIDS cases in
    the last 5 calendar years is eligible to receive Title I funding, and is
    defined as an EMA.

    10Under HOPWA, cumulative AIDS cases are the total AIDS cases reported in
    a jurisdiction since the beginning of the epidemic in 1981.

    11Under HOPWA there is a single formula grant for each grantee. It
    consists of funding determined using a base factor and funding determined
    using a bonus factor (which may be zero). In this report, we use the terms
    base grants and bonus grants to differentiate between funding determined
    using these factors.

    12Bonus grants are awarded to EMSAs that have a higher-than-average per
    capita incidence of AIDS over the previous year. Allocations are based on
    the number of cases in excess of the average AIDS incidence rates of
    EMSAs.

    13In our November 1995 report, we showed that differences under the CARE
    Act in funding per living AIDS case were not related to cost differences.
    For a discussion of this issue as well as criteria for distributing funds,
    see GAO, Ryan White CARE Act of 1990: Opportunities to Enhance Funding
    Equity, GAO/HEHS-96-26 (Washington, D.C.: Nov. 13, 1995).

    14For our CARE Act analyses, we used ELCs as our measure of living AIDS
    cases. For HOPWA we used a measure of living AIDS cases calculated by
    subtracting the number of reported deaths among AIDS cases in a
    jurisdiction from the number of reported cases. In our analysis of HOPWA,
    we used living AIDS cases instead of cumulative AIDS cases, which is the
    measure currently required by law to be used to determine HOPWA base
    funding. Consequently, our analyses of HOPWA funding reflect the effect of
    using HIV and living AIDS cases instead of cumulative AIDS cases. We do
    not compare how allocations could be affected if HIV cases and cumulative
    cases were used to determine funding.

    15Prevalence reflects the number of people living with the disease.

    16In addition to the 50 states, these grants are authorized to the
    District of Columbia, the Commonwealth of Puerto Rico, Guam, and the
    Virgin Islands.

    17All EMAs received a supplemental grant in fiscal year 2004.

    18Pub. L. No. 104-146, 110 Stat. 136.

    19Pub. L. No. 106-345, 114 Stat. 1319.

    20HRSA calculates a jurisdiction's ELCs by using data from CDC on the
    reported AIDS case counts for the last 10 years and weighting those
    numbers to account for the likelihood of deaths. We used this measure as
    our estimate of living AIDS cases in our analyses of CARE Act
    funding-formula provisions and the use of HIV cases in CARE Act funding
    formulas.

    21See GAO, Ryan White CARE Act of 1990: Opportunities Are Available to
    Improve Funding Equity, GAO/T-HEHS-95-126 (Washington, D.C.: Apr. 5,
    1995).

    22In 2005, OMB issued 2004 MSA definitions using fundamentally revised
    standards issued in 2000 and data from the 2000 census. In an attempt to
    make the classification of areas simpler and more transparent than the
    previous standards, OMB's 2000 standards introduced new terminology and
    employed new criteria for identifying central counties and their outlying
    counties, and did not seek to conform with past standards nor to preserve
    past metropolitan status.

    2342 U.S.C. S:S: 300 ff-13(a)(3)(D)(i) and 300ff-28(a)(2)(D)(i) (2000).

    24Institute of Medicine of the National Academies, Measuring What Matters:
    Allocation, Planning, and Quality Assessment for the Ryan White CARE Act
    (Washington, D.C.: The National Academies Press, 2004).

    25Fiscal year 2002 allocations were the most recent funding data available
    for Title III.

    26The CARE Act requires that grantees' administrative costs not exceed 5
    percent of the Title I funds awarded. Each EMA must establish a planning
    council, which sets spending priorities according to local unmet needs.

    27The CARE Act requires that grantees not use more than 10 percent of
    Title II funds for administration. The combined funding for
    administration, planning, and program evaluation may not exceed 15 percent
    of a Title II grantee's award.

    28The CARE Act requires that grantees not use more than 10 percent of
    Title III funds for administration costs, including planning and
    evaluation.

    29Unless otherwise indicated, we use the term grantees to indicate the
    jurisdictions on which our analyses are based, that is, the states, Puerto
    Rico, and metropolitan areas.

    30ELCs are the 10-year weighted estimate of living AIDS cases as specified
    in the CARE Act. HRSA calculates a jurisdiction's ELCs by using data from
    CDC on the reported AIDS case counts for the last 10 years. Data for each
    of the 10 years are adjusted to take into account the number of deaths in
    each year. However, rather that simply subtracting the number of deceased
    cases in each jurisdiction, the number of reported cases is adjusted by
    the national average death rate among AIDS cases.

    31In this report, cumulative AIDS cases are the total number of AIDS
    cases, both living and dead, reported in a jurisdiction in a given period.
    Under HOPWA, cumulative AIDS cases encompass all reported cases since the
    beginning of the epidemic in 1981. By statute, 75 percent of HOPWA formula
    funding is allocated on the basis of cumulative AIDS cases.

    32In the absence of a measure of living AIDS cases used for HOPWA funding,
    we used a measure of living AIDS cases calculated by subtracting the
    number of reported deaths among AIDS cases in a jurisdiction from the
    number of reported cases. This measure of living AIDS cases is used for
    illustrative purposes only.

    33Until fiscal year 2006, bonus funding was based on the per capita
    incidence of AIDS over a 1-year period. As a result, the amount of bonus
    funding a grantee received could vary significantly from year to year.
    With respect to fiscal year 2006 funding, HUD's appropriation act included
    a provision to help mitigate this variability by changing to the use of
    data reported over a 3-year period. Pub. L. No. 109-115, S: 303(d), 119
    Stat. 2396, 2460 (2005).

    34Eligibility for Minority AIDS Initiative grants and grant amounts are
    determined using the last 2 years of reported AIDS cases.

    35GAO/HEHS-96-26, 6.

    36We used living AIDS case counts as of March 31, 2003, because this date
    was the cutoff for reporting AIDS cases to be used for determining fiscal
    year 2004 HOPWA formula funding.

    37When determining CARE Act funding for fiscal year 2004, HRSA used a
    survival weight of .28 for AIDS cases that had been reported 10 years
    earlier. This figure represents the proportion of persons who had been
    reported with AIDS 10 years earlier and were known to be alive.

    38The estimate of reported living AIDS cases was calculated by subtracting
    the number of reported deaths among AIDS cases from the number of reported
    AIDS cases since the beginning of the epidemic.

    39For an assessment of three methods for estimating the number of persons
    living with AIDS, including the method used for the CARE Act, see Centers
    for Disease Control and Prevention, "AIDS Cases and Persons Living with
    AIDS," HIV/AIDS Surveillance Supplemental Report, vol. 8, no. 3 (2002).

    40There are three EMAs in Puerto Rico: Caguas, Ponce, and San Juan.

    41For EMAs that cross state boundaries, we estimated the amount of funding
    received by each state. Using data obtained from HRSA, we calculated the
    number of ELCs from each state in these EMAs. We then calculated the
    percentage of ELCs in each state and allocated the EMA funding to each
    state according to this percentage. For example, approximately 96 percent
    of the ELCs in the Boston EMA are in Massachusetts and 4 percent are in
    New Hampshire. Consequently, we allocated 96 percent of the Boston EMA's
    funding to Massachusetts and 4 percent to New Hampshire.

    42Approximately 80 percent of Puerto Rico's ELCs are in EMAs.

    43Under Title I, a metropolitan area with a population of at least 500,000
    and more than 2,000 reported AIDS cases in the last 5 calendar years is
    eligible to receive funding.

    44We excluded from our analyses the nine states that received minimum
    Title II base grant awards.

    45HRSA provides Minority AIDS Initiative grants according to the number of
    nonwhite reported AIDS cases in the most recent 2-year period.

    46The hold-harmless provision is triggered when, because of its current
    number of ELCs, an EMA would not receive at least a specified level of
    base funding. Hold-harmless funding under Title I is calculated using a
    base year. The base year is the year preceding the fiscal year in which
    the hold-harmless provision is triggered for a particular EMA. Because the
    hold-harmless provision can first be triggered in different years in
    different EMAs, the base year can differ among EMAs. Under the CARE Act
    Amendments of 2000, an EMA is guaranteed not less than 98 percent of its
    base grant in the first year the hold-harmless is triggered, 95 percent in
    the second year, 92 percent in the third year, 89 percent in the fourth
    year, and 85 percent in the fifth or subsequent years.

    47The funds used to meet the Title I hold-harmless requirement are
    deducted from the funds otherwise available for supplemental grants before
    these grants are awarded. Supplemental grants are awarded by HRSA to EMAs
    using a competitive process based on the demonstration of severe need and
    other criteria.

    48San Francisco was the only EMA that received hold-harmless funding from
    fiscal year 1999 through fiscal year 2002. In fiscal year 2003, 19
    additional EMAs qualified for hold-harmless funding. Twenty-one EMAs
    received hold-harmless funding in fiscal year 2004. Eleven EMAs qualified
    in both fiscal years 2003 and 2004.

    49This analysis shows how the hold-harmless funding would have been
    distributed if it had been allocated in the same proportions as the
    supplemental grant funding. For example, Newark received about 2.5 percent
    of the funds available for supplemental grants and, consequently, we
    allocated 2.5 percent of the $8,033,563 hold-harmless funding to Newark.
    It is not possible to determine the exact effect of the hold-harmless
    provision on the amount of supplemental funding for each EMA because it is
    not known how the funds would have been distributed in the absence of the
    hold-harmless awards.

    50The CARE Act Amendments of 1996 guaranteed amounts ranging from 95 to
    100 percent of the 1995 base grant. The CARE Act Amendments of 2000
    guaranteed amounts ranging from 85 to 98 percent of the grant received in
    a base year. The base year varies by EMA.

    51The guaranteed amount is calculated by multiplying the two percentages
    (89 and 95) together. In fiscal year 2004 San Francisco was guaranteed to
    receive at least 89 percent of its fiscal year 2000 Title I base grant.
    Its fiscal year 2000 Title I base grant was guaranteed to be no less than
    95 percent of its fiscal year 1995 Title I base grant.

    52To be eligible for Title I funding, a metropolitan area must have
    reported a cumulative total of more than 2,000 AIDS cases during the most
    recent 5 calendar years and have a population of at least 500,000. These
    criteria differ from those used to calculate base grant funding
    allocations, which are determined using the number of ELCs.

    53The AIDS case eligibility thresholds contained in the 1990 statute were
    either that an area had a cumulative total of more than 2,000 AIDS cases
    (that is, more than 2,000 cases living or deceased) or greater than 25
    AIDS cases per 100,000 population reported to CDC. This standard was
    changed in 1996 to the current threshold of more than 2,000 reported AIDS
    cases during the most recent 5 calendar years and a population of 500,000
    or more.

    54Both EMA eligibility and Emerging Community funding are based on the
    number of AIDS cases reported in the most recent 5 calendar years.

    55To be eligible for a Severe Need grant, a jurisdiction must have met one
    of four eligibility criteria as of January 1, 2000. It must have limited
    (1) the eligibility of ADAP clients to those with incomes at or below 200
    percent of the federal poverty level, (2) the number of ADAP clients by
    using medical eligibility restrictions, (3) the number of antiretroviral
    drugs covered in its drug formulary, or (4) the number of opportunistic
    infection medications to fewer than 10 in its drug formulary.
    (Opportunistic infections are illnesses such as parasitic, viral, and
    fungal infections, and some types of cancer, some of which usually do not
    cause disease in people with normal immune systems.) In addition, a
    jurisdiction must also have agreed to provide a 25 percent match and not
    impose eligibility requirements more restrictive than those in place on
    January 1, 2000. According to HRSA, grantees have provided funds or
    in-kind services to meet the matching requirement.

    5642 U.S.C. S: 300ff-28(a)(2)(I)(ii)(VI) (2000). Title II also contains a
    hold-harmless provision that requires HRSA to consider separately Title II
    base grants and ADAP base grants. For the Title II base grants, this
    hold-harmless provision is funded by proportionately reducing the size of
    the Title II base grants made to other jurisdictions that did not qualify
    for this hold-harmless funding or receive a minimum grant . The ADAP
    portion would be funded by reducing the size of the ADAP base grants made
    to those grantees that did not qualify for ADAP base grant hold-harmless
    funding. 42 U.S.C. S: 300ff-28(a)(2)(H) (2000).

    57States and Puerto Rico, as well as EMSAs, receive HOPWA base grants that
    are determined by the grantee's proportion of the total number of
    cumulative AIDS cases. CDC reported that there were 5.4 AIDS cases per
    100,000 people in nonmetropolitan areas in 2000 and 6.2 cases per 100,000
    people in these areas in 2004.

    58Twenty-five percent of HOPWA formula funding is distributed through
    bonus grants. Until fiscal year 2006, bonus funding was based on the per
    capita incidence of AIDS over a one-year period. As a result, the amount
    of bonus funding a grantee received could vary significantly from year to
    year. With respect to fiscal year 2006 funding, HUD's appropriation act
    included a provision to help mitigate this variability by changing to the
    use of data reported over a 3-year period.

    59These funding levels were calculated by dividing a grantee's fiscal year
    2004 formula allocation by the number of living cases in the jurisdiction.
    If the funding had been allocated proportionally on the basis of living
    AIDS cases, each grantee would have received $716 per case.

    60OMB's new MSA standards and definitions represent a major break with the
    classification scheme used in the past. In some instances OMB retained a
    term that was used in the past, such as MSA, but OMB has altered the
    meaning. As a result, 2004 MSA boundaries of some EMAs are very different
    from those in 1993.

    61We use the term "metropolitan area" here in a generic sense to refer to
    both the MSA (metropolitan statistical area) and the metropolitan division
    (OMB's newly defined term for a subdivision of the very largest MSAs).

    62If Title I EMA boundaries were reconfigured to conform with new OMB
    definitions, those areas outside of EMAs that are currently served by
    governments under Title II would also be changed. Though the effect on
    areas outside EMAs can be inferred from the changes to EMAs, we do not
    explicitly report those results here.

    63While we focus on Title I of the CARE Act, the Title II Emerging
    Communities program also uses metropolitan area definitions and it would
    also be affected if the new OMB definitions were applied. We also exclude
    HOPWA from this subsection because these new OMB definitions have already
    been used to determine fiscal year 2004 HOPWA grant funding. For HOPWA,
    HUD implemented a different method than we use for the analysis here. HUD
    provided no grandfathering of eligibility for previously designated EMSAs
    and instead, among all newly defined metropolitan areas, HUD selected
    those whose data qualified them to be eligible for HOPWA funding. In
    contrast, in our method we assume a policy whereby the 51 current EMAs
    would retain their eligibility for CARE Act Title I grants without needing
    to qualify on the basis of their number of ELCs or population size, and we
    selected only those new metropolitan areas (or combinations of those
    areas) that most closely correspond to the geographic area of each of the
    51 existing Title I EMAs.

    64App. I provides further explanation of the methodology we used for
    selecting those combinations of metropolitan areas that would minimize
    changes to current EMAs. As shown in the tables in app. VII, our
    conversion method would equate some EMAs with more than one newly defined
    metropolitan area in order to minimize any change in boundaries that would
    occur. For example, we equate the New Haven EMA with two newly defined
    units (the New Haven MSA and the Bridgeport MSA) because the two units
    together have boundaries identical to the New Haven EMA.

    65The Bergen-Passaic, Jersey City, and New York City EMAs would be
    consolidated into the new New York City EMA (with no change to the
    geographic area encompassed and no change to the numbers of ELCs served).
    The Caguas and San Juan EMAs would be consolidated into the new San Juan
    EMA (with a net increase of 6 counties and 4 percent in ELCs.) Increases
    or decreases in the number of outlying counties included in metropolitan
    area boundaries would mostly have small effect on the numbers of ELCs
    because such outlying counties have many fewer ELCs than the more populous
    central counties. In those instances where EMAs would be consolidated, the
    changes to boundaries would be substantial, though there would be little
    or no net change in numbers of ELCs within those boundaries.

    66Institute of Medicine, Measuring What Matters, 87-134. While IOM
    examined only the CARE Act, its findings regarding the use of HIV data for
    determining funding allocations are also relevant for HOPWA.

    67In our analyses, we considered the Title I hold-harmless provision and
    the Title II hold-harmless provisions that are funded by proportional
    reductions in Title II base grants and ADAP base grants. We did not
    include the Title II hold-harmless provision funded by amounts otherwise
    available for Severe Need grants.

    68See app. I for a listing of the four U.S. Census Bureau regions and the
    jurisdictions that constitute each region. Because Puerto Rico is not
    included in any of these four regions, we excluded it from our regional
    analyses.

    69HIV case-reporting systems are generally either name- or code-based. In
    name-based systems, cases are collected by name while in a code-based
    system cases are collected using a coded identifier. Currently, 38 states
    and Puerto Rico have name-based systems while 8 states have code-based
    systems. In the remaining 5 states, names are collected and converted to
    codes by public health authorities.

    70 GAO/T-HEHS-00-150 .

    71Name-based HIV reporting has been established in all parts of
    Pennsylvania except Philadelphia since 2002. Philadelphia was given
    permission by the state to establish code-based HIV reporting, and the
    system began in 2004. However, in August 2005, the Philadelphia Board of
    Health voted to implement a name-based HIV-reporting system. This system
    went into effect in October 2005. Philadelphia is in the process of having
    its HIV surveillance data certified by CDC; once certified, its data will
    be accepted by CDC.

    72HRSA uses AIDS case counts provided by CDC for determining CARE Act
    formula funding. All states and territories report AIDS cases by name.

    73CDC has established a set of performance standards for accepting case
    counts from HIV-reporting systems. These standards include that case
    reporting be complete (greater than or equal to 85 percent of cases are
    reported) and timely (greater than or equal to 66 percent of cases
    reported within 6 months of diagnosis) and that evaluation studies
    demonstrate that the approach must result in accurate case counts (less
    than or equal to 5 percent of reported cases are duplicates). CDC has
    determined that the only systems which have been evaluated that meet these
    standards use confidential, name-based reporting. Some jurisdictions use
    codes instead of names to secure the privacy of the individuals being
    counted. In July 2005, CDC began recommending that all states and
    territories adopt confidential name-based surveillance systems to report
    HIV infections.

    74Two of the 13 states, Illinois and Maine, established name-based HIV
    reporting in January 2006.

    75CDC also has other concerns about code-based reporting. For example,
    code-based reporting places a greater burden on health care providers
    because submitted codes are frequently incomplete and require extensive
    follow-up with providers to resolve potential duplicate reports on the
    same person.

    76Unlike the CARE Act, there is currently no law requiring the use of HIV
    cases in determining HOPWA funding. In our analysis of HOPWA, we used
    living AIDS cases instead of cumulative AIDS cases, which is the measure
    currently required by law to be used to determine HOPWA base funding. As
    we reported in 1995, we believe that cumulative AIDS cases is an
    inappropriate measure for allocating funds ( GAO/HEHS-96-26 , 6).
    Consequently, our analyses of HOPWA funding reflect the effect of using
    HIV and living AIDS cases instead of cumulative AIDS cases. This measure
    of living AIDS cases is used for illustrative purposes only.

    77We used ELCs in our analyses of CARE Act programs, which is the measure
    of AIDS cases used by HRSA in determining funding for the grants we
    examined: Title I, Title II, and ADAP base grants. HUD does not have a
    measure of living AIDS cases that it uses to determine HOPWA funding.
    Because ELCs are specific to the CARE Act and because of shortcomings in
    this measure discussed earlier, we calculated an alternative measure of
    living AIDS cases in our examination of HOPWA funding. For the HOPWA
    analyses, the living AIDS case counts were calculated by subtracting the
    number of reported deaths among AIDS cases from the number of reported
    AIDS cases.

    78Because HIV-reporting systems in some jurisdictions are changing to
    name-based systems, CDC now accepts HIV case counts from some
    jurisdictions from which it did not accept HIV case counts earlier. For
    our analyses, we classified Connecticut, Kentucky, and New Hampshire as
    having HIV case counts that are not accepted by CDC. Our analyses were
    conducted using fiscal year 2004 allocations, which were based on case
    reports as of June 30, 2003, for the CARE Act and as of March 31, 2003,
    for HOPWA. At those times, Connecticut had name-based HIV reporting for
    only pediatric cases, but established name-based reporting for all cases
    in 2005. Kentucky had code-based reporting at that time and established
    name-based reporting in 2004. New Hampshire established mandatory
    name-based reporting in 2005, but previously accepted reports using the
    patient name, a code, or no identifier. A fourth state, Georgia, had not
    established any HIV case reporting as of June 30, 2003, but did so in
    2004. Consequently, the HIV case count for Georgia is zero in our
    analyses. Pennsylvania is classified as having its HIV case counts
    accepted by CDC. However, these counts do not include any cases from
    Philadelphia, which established its code-based system in 2004.
    Philadelphia established a name-base HIV-reporting system in October 2005
    and is in the process of having its HIV surveillance data certified by
    CDC; once certified, its data will be accepted by CDC. Illinois and Maine
    established name-based HIV-reporting systems in January 2006 and are also
    in the process of having their HIV data certified by CDC; once certified,
    their data will be accepted by CDC.

    79CDC receives, reviews, and processes name-based HIV case reports on
    individual cases. Potential duplicate reports across jurisdictions are
    reviewed through a CDC-coordinated process to remove duplicate reports
    from the national database. Code-based reports cannot be included in this
    de-duplication process because name-based and code-based systems do not
    have comparable patient identifiers. Because the name- and code-based case
    counts are not comparable, in its comments on a draft of this report HHS
    stated that it would not be appropriate to use the code-based case counts
    in monitoring HIV/AIDS nationally. Our purpose in using both the name- and
    code-based case counts was to provide a general indication of how funding
    would be affected by using HIV and AIDS cases to distribute CARE Act and
    HOPWA funds in light of the statutory requirement that HIV cases be used
    in CARE Act funding formulas not later than fiscal year 2007. Our use of
    the code-based case counts should not be taken as endorsement for their
    use in monitoring HIV/AIDS or distributing funds. An assessment of the
    feasibility of using code-based case counts was beyond the scope of our
    report.

    80HIV case counts for three states-Georgia, Kentucky, and the District of
    Columbia-were unavailable. Consequently, their HIV case counts are zero
    under both approaches. HIV case counts were also unavailable for
    Philadelphia, and as a consequence HIV counts were incomplete for
    Pennsylvania.

    81For example, for CARE Act Title I base funding, we calculated the EMA's
    percentage of the total number of HIV/AIDS cases in all EMAs.

    82Under the CARE Act, there is a minimum-grant provision for Title II base
    grants, but not for Title I and ADAP base funding. However, there are
    hold-harmless provisions for Title I, Title II, and ADAP base funding.
    There is no comparable hold-harmless provision in HOPWA and minimum-grant
    requirements have been effectively waived in recent years. Consequently,
    the analyses in which the hold-harmless and minimum-grant provisions are
    maintained are limited to the CARE Act. For purposes of this analysis, we
    considered the Title I hold-harmless provision and the Title II
    hold-harmless provision that is funded by proportional reductions in Title
    II base grants and ADAP base grants. We did not include the Title II
    hold-harmless provision funded by amounts otherwise available for Severe
    Need grants. The effect on HOPWA allocations are discussed later.

    83There is no minimum funding provision for Title I base grants.

    84See app. I for a listing of the four U.S. Census Bureau regions and the
    jurisdictions that constitute each region.

    85We assume that the case threshold for determining the size of minimum
    grants would remain at 90 even if HIV cases were included in the case
    counts. Currently, states with fewer than 90 ELCs are guaranteed a minimum
    Title II base grant of $200,000 while states with 90 or more cases are
    guaranteed at least $500,000. Our analyses assume that the threshold would
    be a total of 90 HIV cases and ELCs.

    86There is no minimum funding provision for ADAP base grants.

    87The ADAP base grant funding reported to us included any hold-harmless
    funding taken from funds otherwise set aside for the ADAP Severe Need
    grants. This hold-harmless funding results from a different Title II
    hold-harmless provision than that which requires HRSA to consider
    separately Title II base grants and ADAP base grants. In our analyses, we
    excluded hold-harmless funding taken from the ADAP Severe Need grants when
    we estimated the dollar and percent changes in the ADAP base grants.

    88For a description of features in funding formulas, see National Research
    Council, Statistical Issues in Allocating Funds by Formula: Panel on
    Formula Allocations (Washington, D.C.: The National Academies Press,
    2003).

    89In these analyses we considered the Title I hold-harmless provision and
    the Title II hold-harmless provisions that are funded by proportional
    reductions in Title II base grants and ADAP base grants. We did not
    include the Title II hold-harmless provision funded by amounts otherwise
    available for Severe Need grants.

    90There is no minimum funding provision for Title I base funding.

    91The amount of base grant funding would have been about $8 million less
    without the hold-harmless provision. This money would have been
    distributed to EMAs in supplemental grants.

    92EMAs in the West would gain funding under both approaches if the
    hold-harmless was maintained but would receive less funding under both
    approaches if it was not maintained.

    93Grantees in the West would gain funding under both approaches if the
    hold-harmless and minimum-grant provisions were maintained but would
    receive less funding under both approaches if they were not maintained.

    94There is no minimum funding provision for ADAP base funding.

    95For the HOPWA analyses, the living AIDS case counts were calculated by
    subtracting the number of reported deaths among AIDS cases from the number
    of reported AIDS cases.

    96This analysis indicates how HOPWA base funding would have changed if
    living AIDS cases and HIV cases had been used to distribute funding rather
    than cumulative case counts. The effect of using living AIDS cases but not
    HIV cases on HOPWA base funding is shown in app. V.

    97These six grantees are the state of Alabama; Birmingham, Alabama;
    Charlotte, North Carolina; Memphis, Tennessee; the state of North
    Carolina; and Wake County, North Carolina.

    98In those cases in which an EMSA included both southern and nonsouthern
    jurisdictions, we classified the EMSA as not being in the South.

    99In this instance, AIDS cases refers to ELCs for the CARE Act and
    cumulative AIDS cases for HOPWA.

    100Other factors may also affect the ratio of HIV to AIDS cases in a
    reporting system. For example, some jurisdictions with newer HIV-reporting
    systems were among the first to be affected by the HIV epidemic. This
    factor could mean that in those jurisdictions there are relatively more
    AIDS cases and the ratio of HIV to AIDS cases would be lower than in
    jurisdictions more recently experiencing an HIV epidemic.

    101Institute of Medicine, Measuring What Matters, 92.

    1Grantees are those entities that receive CARE and HOPWA funding. Grantees
    vary by program and can include states, territories, metropolitan areas,
    and primary-care providers.

    2HRSA calculates a jurisdiction's ELCs by using data from CDC on the
    reported AIDS case counts for the last 10 years and weighting those
    numbers to account for the likelihood of death.

    3Title II also contains a hold-harmless provision that requires HRSA to
    consider separately Title II base grants and ADAP base grants. For the
    Title II base grants, this hold-harmless provision is funded by
    proportionately reducing the size of the Title II base grants made to
    other jurisdictions that did not qualify for this hold-harmless funding or
    receive a minimum grant. The ADAP portion would be funded by reducing the
    size of the ADAP base grants made to those grantees that did not qualify
    for ADAP base grant hold-harmless funding.

    4Unlike the CARE Act in which ELCs in EMAs are counted once for
    determining Title I funding and a second time for determining Title II
    funding, under HOPWA AIDS cases in EMSAs are counted only for determining
    funding for EMSAs. These cases are not counted a second time for
    determining HOPWA base funding allocations for states and territories.
    Funding for states and territories is based on the number of cumulative
    AIDS cases outside of EMSAs. For example, HOPWA base funding for Colorado
    is based on the number of cumulative AIDS cases in the state minus the
    number of cumulative cases in the Denver EMSA.

    5The AIDS case count used in the analyses varied by program (e.g., ELCs
    and cumulative AIDS cases).

    6In our November 1995 report, we showed under the CARE Act that
    differences in funding per living AIDS case were not related to cost
    differences. For a discussion of this issue as well as criteria for
    distributing funding per case, see GAO, Ryan White CARE Act of 1990:
    Opportunities to Enhance Funding Equity, GAO/HEHS-96-26 (Washington, D.C.:
    Nov. 13, 1995).

    7GAO, Metropolitan Statistical Areas: New Standards and Their Impact on
    Selected Federal Programs, GAO-04-758 (Washington, D.C.: June 14, 2004).

    8There is no straightforward way to equate EMAs based on OMB's 1993
    metropolitan areas with OMB's 2004 metropolitan areas. In developing its
    2000 metropolitan area standards and its 2004 metropolitan area boundary
    definitions, OMB did not seek to make them conform to past standards and
    definitions. Moreover, even where OMB employed the same terminology (e.g.,
    the term "metropolitan statistical area" was retained), the terms were
    given new meanings.

    9These include combinations of adjoining MSAs or adjoining MSAs and
    metropolitan divisions. We exclude the use of the smaller micropolitan
    statistical areas (a new OMB designation for less-populated areas) and
    also exclude combined statistical areas (a new OMB designation for
    groupings of adjacent metropolitan and micropolitan areas).

    10Unlike the CARE Act, there are no requirements regarding the use of HIV
    cases in determining HOPWA funding.

    11In our analysis of HOPWA, we used living AIDS cases instead of
    cumulative AIDS cases, which is the measure currently required by law to
    be used to determine HOPWA base grant funding. Therefore, our analyses
    reflect the effect of using HIV cases and living AIDS cases instead of
    cumulative AIDS case counts on fiscal year 2004 HOPWA base grant funding.

    12These 35 include 34 states and Puerto Rico.

    13Some HIV case-reporting systems are name-based while others are
    code-based. Currently, CDC will only accept name-based case counts as no
    code-based system has yet met CDC's quality criteria. CDC has established
    a set of performance standards for accepting case counts from
    HIV-reporting systems. These standards include that case reporting be
    complete (greater than or equal to 85 percent of cases are reported) and
    timely (greater than or equal to 66 percent of cases reported within 6
    months of diagnosis) and that evaluation studies demonstrate that the
    approach must result in accurate case counts (less than or equal to 5
    percent of reported cases are duplicates). CDC has determined that the
    only systems that have been evaluated that meet these standards use
    confidential, name-based reporting. Some jurisdictions use codes instead
    of names to secure the privacy of the individuals being counted. In July
    2005, CDC began recommending that all states and territories adopt
    confidential, name-based surveillance systems to report HIV infections.

    14Because HIV-reporting systems in some jurisdictions are changing to
    name-based systems, CDC now accepts HIV case counts from some
    jurisdictions from which it did not accept HIV case counts earlier. For
    our analyses, we classified Connecticut, Kentucky, and New Hampshire as
    having HIV case counts that are not accepted by CDC. Our analyses were
    conducted using fiscal year 2004 allocations, which were based on case
    reports as of June 30, 2003, for the CARE Act and as of March 31, 2003,
    for HOPWA. At those times, Connecticut had name-based HIV reporting for
    only pediatric cases, but established name-based reporting for all cases
    in 2005. Kentucky had code-based reporting at that time and established
    name-based reporting in 2004. New Hampshire established mandatory
    name-based reporting in 2005, but previously accepted reports using the
    patient name, a code, or no identifier. A fourth state, Georgia, had not
    established any HIV case reporting as of June 30, 2003, but did so in
    2004. Consequently, the HIV case count for Georgia is zero in our
    analyses. Pennsylvania is classified as having its HIV case counts
    accepted by CDC. However, these counts do not include any cases from
    Philadelphia, which established its code-based system in 2004.
    Philadelphia establsihed a name-based system in October 2005. Philadelphia
    is in the process of having its HIV surveillance data certified by CDC;
    once certified, its data will be accepted by CDC. Illinois and Maine
    established name-based HIV-reporting systems in January 2006 and are also
    in the process of having their HIV data certified by CDC; once certified,
    their data will be accepted by CDC.

    15HIV case counts for three of these jurisdictions, Georgia, Kentucky, and
    the District of Columbia, were unavailable. Consequently, their HIV case
    counts are zero under both approaches. HIV case counts were also
    unavailable for Philadelphia, and as a consequence HIV counts were
    incomplete for Pennsylvania.

    16CDC receives, reviews, and processes name-based HIV case reports on
    individual cases. Potential duplicate reports across jurisdictions are
    reviewed through a CDC-coordinated process to remove duplicate reports
    from the national database. Code-based reports cannot be included in this
    de-duplication process because name-based and code-based systems do not
    have comparable patient identifiers. Because the name- and code-based case
    counts are not comparable, in its comments on a draft of this report HHS
    stated that it would not be appropriate to use the code-based case counts
    in monitoring HIV/AIDS nationally. Our purpose in using both the name- and
    code-based case counts was to provide a general indication of how funding
    would be affected by using HIV and AIDS cases to distribute CARE Act and
    HOPWA funds. Our use of the code-based case counts should not be taken as
    endorsement for their use in monitoring HIV/AIDS or distributing funds. An
    assessment of the feasibility of using code-based case counts was beyond
    the scope of our report.

    17For example, for CARE Act Title I base funding, we calculated the EMA's
    percentage of the total number of HIV cases and ELCs across all EMAs.

    18Under the CARE Act, there is a minimum-grant provision for Title II base
    grants, but not for Title I and ADAP base grants. However, there are
    hold-harmless provisions for Title I, Title II, and ADAP base grants.
    There are no comparable hold-harmless provisions in HOPWA and
    minimum-grant requirements have been effectively waived in recent years.
    Consequently, the analyses in which the hold-harmless and minimum-grant
    provisions are maintained are limited to the CARE Act.

    19Puerto Rico is not included in any of these regions and is, therefore,
    excluded from these analyses.

    20Michael Saag (paper presented at the XIV International AIDS Conference:
    Plenary Session, HIV/AIDS Treatment and Care in the New Century,
    Barcelona, July 2002); "UAB Announces Results of First HIV Patient Care
    Cost Analysis," UAB Media Relations (Birmingham, Ala.: University of
    Alabama at Birmingham, July 2002),
    http://main.uab.edu/show.asp?durki=51750 (downloaded March 30, 2005).

    Under the CARE Act and HOPWA, funding is distributed through a combination
    of competitive grants and, in accordance with CDC data on the number of
    individuals diagnosed with AIDS, formula grants. Approximately 68 percent
    of CARE Act funding and 90 percent of HOPWA funding were distributed
    through formula grants in fiscal year 2004. The use of AIDS cases in the
    distribution of formula grants was prescribed because most jurisdictions
    tracked and reported AIDS cases instead of HIV cases when the grant
    programs were established. Because of concerns that a jurisdiction's
    disease burden is not adequately reflected by only counting cases that
    have progressed to AIDS, the Ryan White CARE Act Amendments of 2000
    required the use of HIV/AIDS case counts in the distribution of formula
    grants not later than fiscal year 2007. 5 We have reported that because
    CARE Act grants serve persons who have been diagnosed with HIV that has
    not progressed to AIDS as well as those for whom it has, it would be
    reasonable to distribute funds on the basis of the total number of persons
    living with HIV/AIDS. 6 Incorporating HIV data along with AIDS data would
    result in targeting funds more accurately according to need. However,
    because there is a lack of HIV data that are sufficiently adequate and
    reliable to serve as a basis for CARE Act formula grant allocations, as of
    December 2005, HIV cases have not been used in the distribution of formula
    grants under the CARE Act.

    Various provisions governing CARE Act and HOPWA grants affect the
    distribution of funds. As Congress prepares to reauthorize CARE Act
    programs, you asked us to examine how funds are distributed under the CARE
    Act and HOPWA. We are reporting on (1) how CARE Act and HOPWA funds are
    allocated by grantees among the types of services each program supports;
    (2) the extent of funding differences among CARE Act and HOPWA grantees,
    and how specific CARE Act and HOPWA funding-formula provisions contribute
    to these differences; and (3) what distribution differences could result
    from using HIV cases in CARE Act and HOPWA funding formulas.

    To report on these issues, we reviewed the CARE Act of 1990, as well as
    the 1996 and 2000 CARE Act amendments, the AIDS Housing Opportunity Act of
    1990, HRSA and HUD documents on CARE Act and HOPWA funding, HUD memoranda,
    Institute of Medicine (IOM) reports on the CARE Act, and other related
    reports. We analyzed data, spanning from 2002 through 2004, obtained from
    HRSA, HUD, and CDC. 7 We also collected data on HIV case counts from state
    and local HIV/AIDS officials. We interviewed CDC, HRSA, HUD, and state
    officials, as well as officials from the National Alliance of State and
    Territorial AIDS Directors.

    To determine how grantees allocate CARE Act and HOPWA funds by type of
    service, we obtained information from HRSA and HUD on grantees' use of
    funds. We analyzed these data and, where available, calculated the
    percentage of total spending represented by each category of service. To
    assess the reliability of HRSA and HUD data on allocations of CARE Act and
    HOPWA grant funds, we interviewed agency officials about the data and
    reviewed relevant documentation. We determined that the data were
    sufficiently reliable for the purposes of our report.

    In order to examine the effect of specific funding-formula provisions on
    the distribution of fiscal year 2004 funds by HRSA and HUD under the CARE
    Act and HOPWA to grantees, we first assessed the use of 2- and 5-year
    cumulative AIDS case counts 8 and the use of estimated living AIDS cases
    (ELC) in CARE Act programs by comparing these measures with living AIDS
    case counts received from CDC. HRSA calculates a jurisdiction's ELCs by
    using data from CDC on the reported AIDS case counts for the last 10 years
    and weighting those numbers to account for the likelihood of deaths. We
    then examined the effect of the following CARE Act formula provisions: the
    counting of ELCs in eligible metropolitan areas (EMA) for both Title I and
    Title II funding, 9 the dividing of Emerging Communities into two tiers
    for determining funding, the Title I hold-harmless provision, the Title I
    grandfather clause, and the Title II hold-harmless provision that is
    funded from amounts that would otherwise be available for states with
    severe need in their drug programs. To examine the effect of each
    provision on the distribution of CARE Act and HOPWA funds, we measured
    differences either on a per case basis, by the amount of funding received,
    or both. To determine the effects of adopting the Office of Management and
    Budget's (OMB) 2004 definitions of metropolitan statistical areas (MSA) on
    EMAs, we compared the boundaries of existing EMAs with those that would be
    created, and we determined the change in the number of ELCs that would be
    counted under Title I. In addition, we examined the effect of using living
    AIDS cases instead of cumulative AIDS cases 10 in making HOPWA base grant
    distributions by comparing the actual funding distributions with simulated
    distributions using living AIDS cases. 11 We also assessed the effect of
    HOPWA bonus grants on funding for eligible metropolitan statistical areas
    (EMSA) by examining the size of these grants and which EMSAs received
    them. 12

    In our analyses we used funding per AIDS case to illustrate the effect of
    certain funding-formula provisions on the distribution of CARE Act and
    HOPWA funds. There are other considerations that could be included in
    funding formulas that could justify deviations from equal funding per
    case. For example, differing health care and housing costs across regions
    and differences in grantees' capacities to fund services from local
    resources could be used as bases for distributing program funds and could
    justify such deviations. 13 Currently, these considerations are not taken
    into account when distributing formula grants under either the CARE Act or
    HOPWA, and are not considered here. To assess the reliability of the HRSA
    and HUD data on the distribution of funds under the CARE Act and HOPWA, we
    asked agency officials about how the data were developed and reported. We
    also reviewed relevant documentation. We determined the data were
    sufficiently reliable for the purposes of our report.

    To show how CARE Act and HOPWA funding could be affected by including HIV
    cases in funding formulas, we examined how CARE Act and HOPWA fiscal year
    2004 formula grants would have been affected by using HIV cases in
    addition to living AIDS cases to determine formula funding. 14 We
    undertook our analyses in light of the statutory requirement that HIV
    cases be used in CARE Act funding formulas not later than fiscal year
    2007. Our analyses, however, rely on data whose reliability has been
    questioned. The Secretary of Health and Human Services has determined that
    because of the problems associated with these data, they should not
    currently be used in determining CARE Act funding. We used these data in
    our analyses to give a general indication of the effect of using HIV cases
    in future formula allocations as required by the CARE Act. The extent to
    which the use of HIV cases could affect formula allocations cannot be
    determined by these analyses because jurisdictions use different methods
    to identify HIV cases, and it is unclear to what degree the resulting case
    counts are comparable. However, we think our approaches in these analyses
    are informative given the required incorporation of HIV cases into CARE
    Act funding formulas. To assess the reliability of the case-count data, we
    asked HRSA, HUD, CDC, state, and local officials a series of questions
    about how the data were collected and the methods used to ensure their
    accuracy. On the basis of the information provided regarding the
    verification of these data, we determined these data to be sufficiently
    reliable for the purposes of our analyses. Appendix I provides a more
    detailed explanation of the scope and methodology for this report. We
    performed our work from July 2004 through February 2006, in accordance
    with generally accepted government auditing standards.

    Background

    In 1990, Congress passed the CARE Act and HOPWA legislation to address the
    needs of jurisdictions, health care providers, and people with HIV/AIDS
    and their family members. Within the CARE Act and HOPWA legislation, there
    are provisions for determining the distribution of program funding.
    Furthermore, amendments in 1996 and 2000 changed some CARE Act provisions,
    and public debate continues on how best to measure the effect of HIV/AIDS
    within the United States, and how to distribute funding accordingly.

    HIV/AIDS in the United States

    Over the course of the last quarter century, the HIV/AIDS epidemic has
    spread to every region of the country. CDC has estimated that in the 50
    states approximately 40,000 persons become infected with HIV annually.
    While AIDS cases remained concentrated in metropolitan areas through 2004,
    AIDS prevalence rates in nonmetropolitan areas rose. 15

    The United States population living with HIV/AIDS is diverse. Racial and
    ethnic minorities have been disproportionately affected by HIV/AIDS since
    the beginning of the epidemic, but in 2004 African Americans accounted for
    more new AIDS cases, more of those estimated to be living with AIDS, and
    more of those who died with AIDS than any other racial or ethnic group.
    Latinos also account for a greater proportion of AIDS cases and deaths
    than their representation in the overall population.

    Despite the number of deaths from AIDS and the steady increase of AIDS
    prevalence, there have been successes in the fight against HIV/AIDS.
    Developments in treatment have enhanced care options and can extend the
    lives of those living with HIV/AIDS. The introduction of highly active
    antiretroviral therapy in 1996 was followed by a decline in the number of
    deaths and new AIDS cases in the United States for the first time since
    the beginning of the epidemic.

    The federal government's efforts to address the domestic HIV/AIDS epidemic
    include providing federal funding for the following categories of
    activities-treatment and income support for individuals with HIV/AIDS,
    prevention efforts, and research. In fiscal year 2004, federal funding for
    domestic HIV/AIDS programs was nearly $16.3 billion. Of this total, about
    $2.1 billion was distributed through CARE Act programs, and $295 million
    was distributed through the HOPWA program. Medicaid was the largest source
    of federal assistance for HIV/AIDS health care, with $5.4 billion in
    federal funding. Other large sources of federal funding for HIV/AIDS are
    Medicare-$2.6 billion-and the National Institutes of Health-about $2.5
    billion. Funding from other federal sources ranged from $1 million from
    the Department of Labor to more than $1 billion from the Social Security
    Disability Insurance Program. Figure 1 provides a breakdown of federal
    HIV/AIDS funding by category.

    Figure 1: Federal HIV/AIDS Funding by Category, Fiscal Year 2004

    The CARE Act

    The majority of CARE Act funds are distributed through four different
    programs, each contained in a separate title, to the states, EMAs, and
    other entities. Titles I and II of the act provide for formula grants
    (base grants) to EMAs and states according to each jurisdiction's number
    of ELCs relative to all EMAs and states. These titles also provide for
    other grants to subsets of eligible jurisdictions either by formula or by
    a competitive process. For example, in addition to AIDS Drug Assistance
    Program (ADAP) base grants, Title II also authorizes grants for states and
    certain territories with demonstrated need for additional funding to
    support their ADAPs. 16 These grants, known as Severe Need Grants, are
    funded through a set-aside of funds otherwise available for ADAP grants.
    Title II also authorizes funding for "Emerging Communities," which are
    communities affected by AIDS that have not had a sufficient number of AIDS
    cases reported in the last 5 calendar years to be eligible for Title I
    grants as EMAs. In order to address the effect of the disease on racial
    and ethnic minorities, HRSA has used funds otherwise available under Title
    I and Title II for Minority AIDS Initiative grants to EMAs, states, and
    territories. EMAs may also receive Title I supplemental grants, which are
    awarded using a competitive application process based on the demonstration
    of severe need and other criteria. 17 Table 1 describes the purposes and
    the grantees of each title.

    Table 1: CARE Act Programs, 2004

    CARE Act program    Grantees                 Purpose
    Title I. Grants to  51 EMAsa                 Support primary health care,
    Eligible                                     medications, and a range of
    Metropolitan Areas                           services, such as case
    (EMAs)                                       management, substance abuse
                                                    treatment, housing, mental
                                                    health treatment, and
                                                    nutritional counseling.
    Title II. Grants to States and territories   Support primary and
    States and                                   home-based health care,
    Territories                                  insurance coverage,
                                                    medications, support
                                                    services, and early
                                                    intervention services, such
                                                    as HIV counseling, testing,
                                                    and referral. Funding for
                                                    AIDS Drug Assistance Programs
                                                    provides medications,
                                                    treatment adherence and
                                                    support, and health insurance
                                                    with prescription drug
                                                    benefits.
    Title III. Early    Primary care providers,  Support comprehensive
    Intervention        including health         services including HIV
    Services, Capacity  centers, city and county counseling, testing,
    Development, and    health departments, and  outpatient medical care, and
    Planning Grants     outpatient medical       case management; funds also
                           centers                  go toward developing HIV
                                                    service delivery systems and
                                                    building capacity to provide
                                                    services.
    Title IV. Services  Health care facilities,  Support family-centered and
    for Women, Infants, public health agencies,  coordinated health care and
    Children, Youth,    and community-based      support services that benefit
    and Their Affected  organizations that serve children, youth, and women
    Family Members      Title IV target          living with HIV, and their
                           populations              families. Also support
                                                    initiatives to help identify
                                                    HIV-positive pregnant women
                                                    and ensure access to prenatal
                                                    care that could prevent
                                                    perinatal transmission.
    Special Projects of University and community Support the development of
    National            clinics, evaluation      innovative models of HIV/AIDS
    Significance        centers,b local and      care that can be replicated,
                           state health             such as interventions for
                           departments,             HIV-positive substance
                           community-based          abusers.
                           organizations, and
                           nonprofit agencies
    AIDS Education and  4 national centers and   Conduct education and
    Training Center     11 regional centers with training programs for health
    Program             130 associated sites     care providers treating
                                                    people with HIV/AIDS.
    Dental Programs     Dental education         Improve access to oral health
                           institutions, hospitals, care and enhance dental
                           and other institutions   training on caring for people
                           with dental education    with HIV/AIDS through the
                           programs                 Dental Reimbursement Program
                                                    and Community-Based Dental
                                                    Partnership grants.

    Source: HRSA.

    aUnder Title I, a metropolitan area with a population of at least 500,000
    and more than 2,000 reported AIDS cases in the last 5 calendar years is
    eligible to receive a formula base grant. As a result of the CARE Act
    Amendments of 1996, EMAs that were eligible for Title I grants in that
    year are grandfathered: they will be eligible for grants under Title I
    even if their number of AIDS cases drops below the threshold for
    eligibility. App. II contains a list of the EMAs.

    bEvaluation centers support Special Projects grantees and coordinate the
    evaluation of initiatives under the Special Projects of National
    Significance program.

    CARE Act Amendments

    The Ryan White CARE Act Amendments of 1996 18 and the Ryan White CARE Act
    Amendments of 2000 19 modified the original funding formulas. For example,
    prior to the 1996 amendments, the CARE Act required that for purposes of
    determining grant amounts a metropolitan area's caseload be measured by a
    cumulative count of AIDS cases recorded in the jurisdiction since
    reporting began in 1981. The 1996 amendments required the use of ELCs
    instead of cumulative AIDS cases. 20 Because this switch would have
    resulted in large shifts of funding away from jurisdictions with a longer
    history of the disease than other jurisdictions, due in part to a higher
    proportion of deceased cases, the 1996 CARE Act amendments added a
    hold-harmless provision under Title I, as well as under Title II, that
    limit the extent a grantee's funding can decline from one year to the
    next.

    Metropolitan areas heavily affected by HIV/AIDS have always been
    recognized within the structure of the CARE Act. We previously found that,
    with combined funding under Title I and Title II, states with EMAs receive
    more funding per AIDS case than states without EMAs. 21 To adjust for this
    situation, the 1996 amendments instituted a two-part formula for Title II
    base grants that takes into account the number of ELCs that reside within
    a state but outside of any EMA. Under this distribution formula, 80
    percent of the Title II base grant is based upon a state's proportion of
    all ELCs, and 20 percent of the base grant is based on a states'
    proportion of ELCs outside of EMAs relative to all such ELCs. A second
    provision included in 1996 protected the eligibility of EMAs. The 1996
    amendments provided that a jurisdiction designated as an EMA for that
    fiscal year would be "grandfathered" so it would continue to receive Title
    I funding even if its reported number of AIDS cases dropped below the
    threshold for eligibility. Table 2 describes CARE Act formula grants for
    Titles I and II.

    Table 2: Description of CARE Act Title I and Title II Formula Grants

    Formula      Eligible      Distribution        Minimum      Hold-harmless
    grant        grantees                          grant        provisiona
    Title I Base Metropolitan  Distributed among   No           Grant annually
    Grant        areas with    EMAs according to                declines to
                    500,000 or    each EMA's                       98%, 95%, 92%,
                    more in       proportion of ELCs               and 89% of the
                    population    relative to all                  base year
                    and with more EMAs.                            grant,
                    than 2,000                                     respectively.c
                    reported AIDS                                  In the fifth
                    cases in the                                   and all
                    most recent 5                                  subsequent
                    calendar                                       years, EMA
                    yearsb                                         receives 85%
                                                                   of base year
                                                                   grant. The
                                                                   funds
                                                                   necessary to
                                                                   meet the
                                                                   hold-harmless
                                                                   requirement
                                                                   are deducted
                                                                   from funds
                                                                   available for
                                                                   supplemental
                                                                   grants under
                                                                   Title I.d
    Title II     States and    Eighty percent of   For states   Grant declines
    Base Grant   territoriese  base grant funding  with fewer   by 1% per year
                                  divided among       than 90      from the
                                  states/territories  ELCs,        fiscal year
                                  according to each   $200,000;    2000 grant. In
                                  grantee's           states with  fifth year,
                                  proportion of all   90 or more   grant is 95%
                                  ELCs. Twenty        ELCs,        of 2000 grant.
                                  percent of base     $500,000;
                                  grant funding       for
                                  divided among       territories,
                                  states/territories  $50,000
                                  according to each
                                  grantee's ELCs
                                  located outside the
                                  EMAs within the
                                  state's/territory's
                                  borders relative to
                                  such ELCs in all
                                  states/territories.
    Title II     States and    Distributed         No           Grant declines
    ADAP Base    certain       according to each                by 1% per year
    Grant        territoriesf  grantee's                        from the
                                  proportion of all                fiscal year
                                  ELCs.                            2000 grant. In
                                                                   fifth year
                                                                   grant is 95%
                                                                   of 2000 grant.
    Title II     States and    Distributed         No           No
    ADAP Severe  certain       according to each
    Need Grantg  territoriesf  grantee's
                    with a severe proportion of all
                    need for a    ELCs: grantees must
                    grant to      agree to match 25
                    increase      percent of their
                    access to     severe need grant
                    medications   and not to impose
                                  eligibility
                                  requirements
                                  stricter than those
                                  in place on January
                                  1, 2000.
    Title II     States and    Funds are divided   Minimum of   No
    Emerging     territories   into two tiers: 50% $5 million
    Communities  with          distributed among   for each
    Grant        metropolitan  communities with    tier
                    areas that    1,000-1,999 AIDS
                    are not       cases, and 50%
                    eligible for  distributed among
                    Title I, and  communities with
                    that have     500-999 AIDS cases.
                    500-1,999     Funding is
                    reported AIDS distributed
                    cases in the  according to each
                    most recent 5 community's
                    calendar      proportion of AIDS
                    years         cases (reported in
                                  the most recent 5
                                  calendar years) in
                                  Emerging
                                  Communities within
                                  the tier.

    Source: HRSA.

    Notes: HRSA has also awarded Minority AIDS Initiative grants to EMAs,
    states, and territories. HRSA characterizes Minority AIDS Initiative
    grants to EMAs as Title I grants and Minority AIDS Initiative grants to
    states and territories as Title II grants. These funds are allocated by
    formula. Title I funds have been used for grants to EMAs with greater than
    zero reported nonwhite AIDS cases in the most recent 2 calendar years. The
    funds are distributed among all EMAs according to each EMA's proportion of
    nonwhite AIDS cases reported over the most recent 2 calendar years. Title
    II funds have been used for grants to states and territories with greater
    than zero reported nonwhite AIDS cases in the most recent 2 calendar
    years. The funds are distributed among all grantees according to each
    grantee's proportion of nonwhite AIDS cases reported over the most recent
    2 calendar years. There are no minimum-grant or hold-harmless provisions
    for these grants.

    aIf the distribution formula would otherwise result in a funding decrease
    from a prior year, a hold-harmless provision may be triggered to mitigate
    the decrease in funding.

    bA grandfather clause added in 1996 provides that areas eligible at that
    time continue to be eligible even if they no longer meet the eligibility
    critieria.

    cThe base year is the fiscal year prior to that in which the EMA first
    becomes eligible for hold-harmless funding.

    dTitle I also includes supplemental grants, which are awarded to EMAs
    using a competitive application process based on the demonstration of
    severe need and other criteria.

    eIn addition to the 50 states, Title II base grants are authorized for the
    District of Columbia, the Commonwealth of Puerto Rico, Guam, the Virgin
    Islands, American Samoa, the Commonwealth of the Northern Mariana Islands,
    the Federated States of Micronesia, the Republic of Palau, and the
    Republic of the Marshall Islands.

    fIn addition to the 50 states, these grants are authorized for the
    District of Columbia, the Commonwealth of Puerto Rico, Guam, and the
    Virgin Islands.

    gFunding for Severe Need grants may be reduced to maintain funding for
    some states under a Title II hold-harmless provision. Severe Need grants
    are funded by setting aside 3 percent of the funds earmarked specifically
    for ADAPs.

    Metropolitan Statistical Areas

    In determining a metropolitan area's eligibility for Title I funding and
    for purposes of defining areas served under Title I, the CARE Act uses the
    OMB 1993 definitions of MSAs. OMB's 1993 definitions were based on
    applying OMB's 1990 standards for defining an MSA to data from the 1990
    census. OMB's standards create a metropolitan classification scheme that
    includes rules for determining which counties (the basic building block of
    MSAs) would be designated as the central counties of metropolitan areas
    and which outlying counties would be associated with particular central
    counties. The 1996 CARE Act amendments froze the metropolitan areas to
    those specified in the 1993 OMB definitions. 22

    HIV Case Counts

    The 2000 amendments provided for HIV case counts to be incorporated in the
    Title I and Title II funding formulas as early as fiscal year 2005 if such
    data were available and deemed "sufficiently accurate and reliable" by the
    Secretary of Health and Human Services. 23 They also required that HIV
    data be used no later than the beginning of fiscal year 2007. In June 2004
    the Secretary of Health and Human Services determined that HIV data were
    not yet ready to be used for the purposes of distributing formula funding
    under Title I and Title II of the CARE Act. The Secretary cited a 2004 IOM
    report, which identified several limitations in the ability of states to
    provide adequate and reliable HIV case counts for use in distributing CARE
    Act grants. 24

    HOPWA

    HOPWA is the only federal program dedicated to providing housing
    assistance to persons living with HIV/AIDS and their families. Funding
    under HOPWA supports a variety of services, including rental assistance
    and the acquisition, rehabilitation, and construction of housing units.
    HOPWA funds also provide for supportive services, such as health care,
    substance abuse treatment, and case management. In fiscal year 2004, $295
    million was distributed through HOPWA.

    Ninety percent of HOPWA funds are distributed through formula grants to
    states, Puerto Rico, and metropolitan areas. The remaining 10 percent of
    HOPWA funds are provided through competitive grants to states, Puerto
    Rico, local governments, and nonprofit organizations. Formula grants under
    HOPWA incorporate cumulative AIDS case counts, rather than an estimate of
    persons living with AIDS, such as ELCs as used in the CARE Act.
    Seventy-five percent of HOPWA formula funding is awarded through base
    grants to EMSAs, which are jurisdictions with more than 500,000 people and
    more than 1,500 cumulative AIDS cases, and to states and Puerto Rico that
    have more than 1,500 cumulative AIDS cases outside EMSAs. The remaining 25
    percent of HOPWA formula funding is awarded through bonus grants for EMSAs
    that meet the eligibility threshold but also demonstrate a
    higher-than-average per capita incidence of AIDS. These grants are based
    on the number of cases in excess of the average AIDS incidence rates of
    EMSAs. HUD first used OMB's new MSA definitions in determining EMSAs for
    fiscal year 2004 funding.

    Results in Brief

    CARE Act and HOPWA grants are used for health care, housing assistance,
    and a variety of services for people with HIV/AIDS. In fiscal year 2003,
    more than half of the approximately $600 million in Title I CARE Act funds
    were allocated by grantees for health care services such as outpatient
    care and home health services, and over two-thirds of the approximately $1
    billion in Title II funds were allocated by states and territories for
    medications. Over three-quarters of the approximately $194 million in
    Title III fiscal year 2002 funds were allocated for health care services.
    In fiscal year 2003, about $68 million in Title IV grants was provided for
    health care and support services for children, youth, and women with
    HIV/AIDS and their families. Also in fiscal year 2003, about $74 million
    in funding was provided in total for dental programs, projects that
    support innovative models of HIV/AIDS care, and AIDS Education and
    Training Centers for health care providers. HOPWA funds were used for a
    variety of housing-related expenses, such as rental assistance, and
    support services. In fiscal year 2003, two-thirds of the approximately
    $249 million in HOPWA funds were used for direct housing costs, such as
    rental assistance, for people with HIV/AIDS and their families.

    Multiple provisions in the CARE Act and HOPWA grant funding formulas
    result in funding not being distributed according to the current
    distribution of the disease. Grantees do not receive the same level of
    CARE Act or HOPWA funding per person living with AIDS because various
    formula provisions affect the proportional allocation of funding.

               o  We found that both the CARE Act and HOPWA use measures of AIDS
               cases that do not accurately reflect the number of persons living
               with AIDS. Some CARE Act grants and HOPWA base grant funding are
               based on case counts that could include deceased cases because the
               eligibility and allocations are determined using cumulative case
               counts. In addition, the CARE Act's use of ELCs, which are
               determined using the most recent 10 years of reported AIDS cases,
               to distribute the majority of formula funding does not take into
               account that many AIDS patients now live longer than 10 years
               after their disease is reported.
               o  We found that certain CARE Act Title I and II provisions
               related to metropolitan areas result in variability in the amounts
               of funding per ELC among grantees. For instance, the counting of
               ELCs within EMAs once for determining Title I base grants and once
               again for determining Title II base grants results in states with
               a higher proportion of ELCs in EMAs and Puerto Rico, which has a
               similar percentage, receiving more total Title I and Title II
               funding per ELC than states with no EMA or with comparatively few
               ELCs located in EMAs. Also, the division of Emerging Communities
               into two tiers based on their numbers of reported AIDS cases in
               the past 5 years leads to funding disparities among grantees. This
               divergence occurs because funding is divided equally between the
               two tiers regardless of the number of communities or the number of
               reported AIDS cases in each tier. In fiscal year 2004, the 4
               communities in the first tier received $1,052 per reported case
               while the 25 communities in the second tier received $313 per
               reported case.
               o  We found that because of CARE Act hold-harmless provisions
               under Titles I and II and the grandfather clause for EMAs under
               Title I, the funding of certain grantees is protected. For
               example, the CARE Act Title I hold-harmless provision results in
               the San Francisco EMA's funding being based in part on deceased
               cases in the EMA in 1995. In addition, a Title II hold-harmless
               provision, which has had little effect thus far, has the potential
               to reduce the amount of funding to grantees with severe need for
               drug treatment funds because the hold-harmless provision is funded
               from amounts set aside for ADAP Severe Need grants. The Title I
               grandfather clause protected the funding of more than half of
               EMAs.

               The Ryan White CARE Act Amendments of 2000 required the use of
               HIV/AIDS case counts in the distribution of formula grants not
               later than fiscal year 2007. If case counts from HIV-reporting
               systems had been used along with a measure of the number of
               persons living with AIDS in distributing fiscal year 2004 CARE Act
               and HOPWA grants, funding would have shifted among jurisdictions.
               Although CARE Act and HOPWA grantees have established HIV
               case-reporting systems, differences between these systems-in their
               maturity and reporting methods, for instance-would have affected
               the distribution of CARE Act and HOPWA funds based on HIV/AIDS
               case counts. Recently established HIV-reporting systems might not
               have captured an accurate count of a grantee's HIV cases in part
               because cases diagnosed prior to the establishment of the
               reporting system might not have been reported and entered into the
               system. Also, because CDC does not accept case reports that are
               reported using a code rather than a person's name to protect their
               anonymity, those states with code-based systems would not have had
               their HIV cases counted when funding distributions were made.
               Accordingly, we developed two approaches to assess the effect of
               using the HIV case counts, as they currently exist, on CARE Act
               and HOPWA formula grants. While the extent to which funding may
               have shifted cannot be determined given the different methods
               jurisdictions use to identify HIV cases, we think these approaches
               are informative given the required corporation of HIV cases into
               CARE Act funding formulas. Using these approaches, we found that
               up to 13 percent of CARE Act formula funding would have shifted
               among grantees if HIV cases were included in the funding formulas
               and the hold-harmless provisions analyzed and minimum-grant
               provision were maintained. Larger changes for individual grantees
               would have occurred with some grantees more than doubling their
               funding. Grantees in the South and Midwest would generally have
               received more funding from using HIV cases in funding formulas.
               However, there would have been grantees that would have received
               increased funding and grantees that would have received decreased
               funding in every region of the country. If, in addition to using
               HIV data, the hold-harmless provisions we analyzed and
               minimum-grant provisions were eliminated, the redistribution of
               program funds would have been more dramatic. Up to 24 percent of
               funding would have shifted. HOPWA base funding would also have
               shifted if HIV and living AIDS cases were used to distribute
               funding. In fiscal year 2004, up to 15 percent of HOPWA base
               funding would have shifted among grantees, with six grantees more
               than doubling their funding. Differences in HIV case-reporting
               systems would affect the distribution of funding, and we found
               that funding would have tended to shift to jurisdictions with
               older HIV-reporting systems. Jurisdictions with older
               HIV-reporting systems tend to have more reported HIV cases
               compared with their number of AIDS cases than do jurisdictions
               with newer reporting systems.

               If Congress wishes CARE Act and HOPWA funding to more closely
               reflect the distribution of persons living with AIDS, it should
               take actions that lead to more-comparable funding per case by
               revising the funding formulas. In accordance with achieving
               more-comparable funding per AIDS case, we raise a number of
               matters for consideration when Congress reviews the CARE Act and
               HOPWA.

               We provided a draft of this report to HHS and HUD. HHS and HUD
               generally agreed with our identification of issues in the funding
               formulas. While HHS also generally agreed with our matters for
               congressional consideration, it expressed concern that our
               discussion of the Title I grandfather provision in the CARE Act
               could be interpreted as suggesting that the metropolitan areas
               that continue to receive grants because of this provision need not
               be funded. However, these areas could still receive funding
               through their respective states or territories, which receive
               funds under Title II. HUD concurred with our matter for
               congressional consideration that HOPWA formula grant eligibility
               and base grant funding be based on a measure of living AIDS cases.

    CARE Act and HOPWA Funds Allocated for Health Care, Housing Assistance,
    and a Variety of Other Services

    The CARE Act and HOPWA grants fund a variety of treatment and support
    services for people with HIV/AIDS. For fiscal year 2003, Title I grantees
    allocated more than half of the approximately $600 million in Title I
    grants for health care services such as outpatient care and home health
    care, and over 70 percent of the approximately $1 billion in Title II
    funds were allocated for medications. Almost 80 percent of the
    approximately $194 million in Title III fiscal year 2002 funds were
    allocated for health care services such as physician office visits and HIV
    counseling and testing. 25 In fiscal year 2003, there was also about $68
    million in funding for Title IV grantees and about $74 million for other
    programs, such as Special Projects of National Significance. Two-thirds of
    the approximately $249 million in HOPWA fiscal year 2003 funds were used
    to assist with housing costs for people with HIV/AIDS and their families.

    More Than Half of Title I Fiscal Year 2003 Funding Was Allocated for
    Health Care Services

    For fiscal year 2003, HRSA provided about $600 million in grants to EMAs
    under Title I of the CARE Act to support services for people with
    HIV/AIDS. Grantees allocated the largest portion of these funds, about 52
    percent, for health care services such as outpatient care, home health
    care, rehabilitation care, and medications. About 12 percent of these
    Title I health care services funds were allocated for substance abuse
    treatment and counseling services. For the same year, Title I grantees
    allocated about 36 percent of those funds for case management and support
    services. Support services include child care, client advocacy, and
    emergency financial assistance, among others. The remaining 12 percent of
    Title I funding was allocated for administration, planning councils, and
    program support. 26 (See fig. 2.)

    Figure 2: Allocation of CARE Act Title I Funds, Fiscal Year 2003

    Note: About $600 million was allocated under Title I.

    Over Two-thirds of Title II Fiscal Year 2003 Funding Was Allocated for
    Medications

    HRSA provided approximately $1 billion to states and territories under
    Title II in fiscal year 2003. Title II grantees allocated the majority of
    these funds, about 71 percent, for medications, which includes ADAP
    medications, non-ADAP medications, and pharmacy assistance for CARE Act
    clients. Ten percent of Title II funds were allocated for health care
    services, similar to those provided under Title I. Grantees allocated
    about 3 percent of Title II health care services funds for substance abuse
    treatment services. Case management and support services similar to those
    provided under Title I accounted for approximately 10 percent of the Title
    II funds. The remainder of Title II funds, about 9 percent, was allocated
    for program administration, planning, and evaluation. 27 (See fig. 3.)

    Figure 3: Allocation of CARE Act Title II Funds, Fiscal Year 2003

    Notes: Approximately $1 billion was allocated under Title II.

    aMedications includes ADAP medications, non-ADAP medications, and pharmacy
    assistance.

    Over Three-quarters of Title III Fiscal Year 2002 Funding Was Allocated
    for Health Care Services

    Under Title III of the CARE Act, HRSA provided about $194 million in
    grants to certain public and nonprofit primary care providers in support
    of early intervention services for people with HIV/AIDS for fiscal year
    2002. Title III grantees allocated about 79 percent of these funds for
    health care services such as physician office visits, HIV counseling and
    testing, and employing primary care personnel. Health care services also
    included outpatient mental health care and substance abuse treatment.
    Title III grantees allocated another 13 percent for other activities,
    including case management and HIV patient education. The remaining 8
    percent was allocated for administration. 28 (See fig. 4.)

    Figure 4: Allocation of CARE Act Title III Funds, Fiscal Year 2002

    Note: About $194 million was allocated under Title III.

    CARE Act Grants Funded Other Activities in Fiscal Year 2003

    Grants made under Title IV of the CARE Act address the specific needs of
    women, infants, children, and youth living with HIV/AIDS. The funds cover
    primary and specialty medical care, psychosocial services, case
    management, and other activities. For fiscal year 2003, HRSA provided
    about $68 million for Title IV programs. Other CARE Act programs include
    the Special Projects of National Significance Program, funded at about $25
    million for fiscal year 2003; the AIDS Education and Training Centers
    Program, funded at about $36 million for fiscal year 2003; and the
    HIV/AIDS Dental Reimbursement Program and Community-Based Dental
    Partnership program funded at nearly $10 million and $3 million
    respectively for fiscal year 2003.

    Two-thirds of HOPWA Fiscal Year 2003 Funds Were Spent on Housing Costs

    For fiscal year 2003, HOPWA grantees spent about $249 million to support
    housing services for people with HIV/AIDS. The largest portion of these
    funds, about 66 percent, was spent on direct housing costs, such as rental
    assistance, and housing facility operating costs. Support services
    accounted for 25 percent of the funds. HOPWA-funded support services
    include case management, health care, alcohol and drug abuse treatment,
    and child care, among others. Housing information services and permanent
    housing placement costs accounted for 4 percent of HOPWA funds, while
    grant administration was 5 percent of the total. (See fig. 5.)

    Figure 5: Allocation of HOPWA Funds, Fiscal Year 2003

    Notes: About $249 million was spent under HOPWA.

    Multiple Provisions Contribute to Disproportionate Distribution of CARE
    Act and HOPWA Formula Funding

    Provisions in the CARE Act and HOPWA funding formulas result in a
    distribution of funds among grantees that does not reflect the relative
    distribution of AIDS cases in these jurisdictions. 29 CARE Act grantees do
    not receive the same amount of funding per ELC, and HOPWA grantees do not
    receive the same amount of funding per living AIDS case. We found that
    provisions affected the proportional allocation of funding as follows: (1)
    the AIDS case-count provisions in the CARE Act and HOPWA each result in a
    distribution of funding that is not reflective of the distribution of
    persons living with AIDS, (2) CARE Act provisions related to metropolitan
    areas result in variability in the amounts of funding per ELC among
    grantees, (3) the CARE Act hold-harmless provisions and grandfather clause
    protect the funding of certain grantees, and (4) the ineligibility of
    grantees other than EMSAs for HOPWA bonus funding restricts the
    distribution of these funds and limits HUD's ability to fund areas outside
    of EMSAs with high rates of new AIDS cases. We also considered the
    provision in the 1996 CARE Act amendments that froze the EMA boundaries to
    1993 OMB definitions. We found that the boundaries for more than half of
    current EMAs would change if OMB's 2004 MSA definitions were adopted for
    purposes of CARE Act funding.

    CARE Act and HOPWA Grants Are Not Distributed Solely in Proportion to
    Number of Persons Living with AIDS

    Funds distributed under Title I of the CARE Act are not distributed
    proportionally per ELC across EMAs. 30 In fiscal year 2004, the total
    funding for all Title I grants to EMAs was about $595 million. If this
    funding had been distributed solely by a grantee's proportion of ELCs,
    each EMA would have received $2,443 per ELC. However, Title I provisions
    affect the grant awards so that funding is not distributed strictly on a
    proportional basis, but instead is allocated in part according to the
    number of ELCs and in part on other bases, such as the amounts awarded in
    a prior year, as reflected in the hold-harmless funding. Total funding for
    EMAs also reflects Minority AIDS Initiative grants and supplemental
    grants. In fiscal year 2004, total Title I funding for the 51 EMAs ranged
    from $2,130 per ELC case in Riverside-San Bernardino to $4,137 in San
    Francisco, with an average of $2,380. Excluding San Francisco, West Palm
    Beach had the highest Title I funding per ELC at $2,515. Appendix II lists
    the EMAs and amounts awarded under Title I for fiscal year 2004.

    CARE Act Title II funding is also not distributed proportionally per ELC.
    In fiscal year 2004, the total funding for all Title II grants was about
    $1.051 billion. If this funding had been distributed solely according to
    the proportion of ELCs, each grantee would have received $3,053 per ELC.
    However, minimum-award requirements and hold-harmless provisions affect
    the distribution of Title II funds. In addition, grants for Emerging
    Communities as well as the Minority AIDS Initiative are not determined
    proportionally by the number of ELCs. Total Title II funding for fiscal
    year 2004 ranged from $2,793 for the District of Columbia to $7,275 for
    South Dakota, with an average of $3,559. Appendix III shows the grantees
    and amounts awarded under Title II for fiscal year 2004.

    HOPWA formula funding is also disproportionate across grantees. In fiscal
    year 2004, about $263 million was allocated by formula to 117 grantees.
    Seventy-five percent of this funding was distributed according to the
    number of cumulative AIDS cases 31 in a jurisdiction and 25 percent was
    distributed based on the rate of new AIDS cases in EMSAs. If this funding
    had been distributed proportionally by the number of cumulative AIDS cases
    across jurisdictions each grantee would have received $306 per cumulative
    case. However, 26 grantees received bonus grants that are based on the
    rate of new AIDS cases in an EMSA, not the number of cumulative AIDS
    cases. Therefore, the actual amounts grantees received ranged from $230
    per cumulative AIDS case for 91 grantees to $626 per case in Baton Rouge,
    with an average of $260. We also determined how much funding each grantee
    received per living AIDS case. 32 We found that grantees received an
    average of $573 per living AIDS case, with funding ranging from $387 per
    case in Nashville to $1,290 per case in Baton Rouge. These funding
    differences are due to the use of cumulative AIDS cases to distribute base
    grant funding and because bonus grants are distributed according to the
    rate of new cases in EMSAs. 33 Appendix IV identifies the fiscal year 2004
    HOPWA formula grantees and award amounts.

    Provisions in HOPWA and CARE Act Funding Formulas Incorporate Measures of
    AIDS Cases That Do Not Reflect an Accurate Count of Persons Living with
    AIDS

    HOPWA and the CARE Act both use measurements of AIDS cases that do not
    reflect an accurate count of people currently living with AIDS. To
    determine eligibility for HOPWA formula grants and to distribute base
    funding, allocations are determined using a measure of AIDS cases that is
    based on the number of living and deceased AIDS cases reported in the
    jurisdiction since the beginning of the AIDS epidemic in 1981. Also,
    eligibility and distribution of certain CARE Act grants are based on the
    number of reported AIDS cases over either the last 2- or 5-year period, 34
    which likely does not reflect all live cases and could include deceased
    AIDS cases. In addition, Title I, Title II, and ADAP base grants are
    calculated using ELCs, which can underestimate the number of living cases
    because many persons with AIDS now live longer than 10 years after their
    cases are reported.

    HOPWA Grants

    Eligibility for HOPWA formula grants is determined by the number of
    cumulative AIDS cases in a metropolitan area, state, and Puerto Rico, and
    base funding allocations (which represent 75 percent of total HOPWA
    formula funding) to grantees are determined by the grantee's proportion of
    the total number of cumulative AIDS cases. As we reported in 1995, the use
    of cumulative case counts is an inappropriate caseload measure because it
    includes all AIDS cases, living and dead, reported to CDC for the
    jurisdiction since the beginning of the epidemic in 1981. 35

    Because the HOPWA funding formula includes deceased persons, the
    distribution of funds does not reflect the current distribution of people
    living with AIDS. Using estimates of living AIDS cases obtained from CDC,
    we calculated how base funding for grantees would have changed in fiscal
    year 2004 if these estimates had been used instead of the cumulative case
    counts. Each of the 117 grantees would have received approximately $537
    per living AIDS case. We found that 25 grantees received more funding in
    fiscal year 2004 using cumulative case counts than they would have
    received if the number of living AIDS cases had been used. The additional
    funding received by the grantees ranged from approximately $2,000 in San
    Jose to $4,020,000 in New York City. Conversely, if the number of living
    cases had been used, 92 grantees would have received increased funding.
    The funding increases would have ranged from $1,000 in Springfield,
    Massachusetts, to $1,120,000 in the District of Columbia. Areas that
    receive more funding from the use of cumulative case counts include
    jurisdictions in California, Michigan, New Jersey, and New York. (App. V
    contains information on funding using cumulative AIDS counts and living
    AIDS cases.)

    Use of cumulative case counts rather than living cases can lead to areas
    with similar numbers of living AIDS cases receiving markedly different
    amounts of funding. For example, as of March 31, 2003, Oakland and New
    Orleans both reported 3,374 living AIDS cases. 36 However, in fiscal year
    2004 Oakland received $221,000 more ($66 more per living AIDS case) in
    HOPWA base funding than did New Orleans. Atlanta and Houston also have
    similar numbers of living AIDS cases (8,557 and 8,579 respectively).
    However, in fiscal year 2004 Houston received $806,000 more ($93 more per
    case) in HOPWA base funding than did Atlanta.

    CARE Act Grants

    The use of cumulative case counts is not limited to the HOPWA program.
    Deceased cases can also be included when determining eligibility for CARE
    Act funding. Eligibility for Title I funding and Title II Emerging
    Communities grants is based on cumulative totals of AIDS cases reported in
    the most recent 5-year period, not on the number of ELCs. Funding amounts
    for Emerging Communities grants are also determined using the most recent
    5 years of reported cases. In addition, HRSA determines eligibility and
    funding amounts of Minority AIDS Initiative grants according to the number
    of reported AIDS cases in the most recent 2-year period.

    The use of the cumulative number of reported cases over a certain period
    to determine eligibility and allocate funding results in funding not being
    distributed according to the current distribution of the disease. For
    example, because Emerging Communities funding is determined by using
    5-year cumulative case counts, allocations could be based in part on
    deceased cases, that is, people for whom AIDS was reported in the past 5
    years but who have since died. In addition, these case counts do not take
    into account living cases in which AIDS was diagnosed more than 5 years
    earlier. Consequently, 5-year cumulative case counts can substantially
    misrepresent the number of AIDS patients in these communities. For
    example, while the 5-year cumulative case count in Buffalo for determining
    fiscal year 2004 Emerging Communities eligibility and funding was 581
    cases, the number of ELCs was 956. Similarly, the 5-year cumulative case
    count in Charleston, South Carolina, was 538, but the number of ELCs was
    758.

    The use of ELCs as provided for in the CARE Act can also lead to
    inaccurate estimates of living AIDS cases. Currently, Title I, Title II,
    and ADAP base funding, which constitute the majority of formula funding,
    are distributed according to ELCs. ELCs are an estimate of living AIDS
    cases calculated by applying annual national survival weights to the most
    recent 10 years of reported AIDS cases and adding the totals from each
    year. This method for estimating cases was first included in the CARE Act
    Amendments of 1996. At that time, this approach captured the vast majority
    of living AIDS cases. However, some persons with AIDS now live more than
    10 years after their case is first reported, and they are not accounted
    for by this formula. 37 Thus, like the 2- and 5-year reported case counts,
    ELCs can misrepresent the number of living AIDS cases in an area in part
    by not taking into account those persons living with AIDS whose cases were
    reported more than 10 years earlier. For example, fiscal year 2004 Title I
    base funding for the Atlanta EMA was based on 7,589 ELCs, but CDC
    estimated that there were 8,560 reported living AIDS cases in the EMA. 38
    Similarly, funding for the Seattle EMA was based on 2,468 ELCs while CDC
    estimated that there were 3,273 reported living cases. 39

    CARE Act Funding Provisions for Metropolitan Areas Result in
    Disproportionate Funding

    The counting of ELCs within EMAs once to determine the amount of the base
    grant under Title I and once again to determine the amount of the Title II
    base grant results in states with EMAs and Puerto Rico receiving more
    total Title I and Title II funding per ELC than states without EMAs. 40 In
    addition, the formula for awarding Title II Emerging Communities grants
    results in different levels of funding per AIDS case across grantees.

    Counting ELCs within EMAs Twice Results in Disproportionate Funding per
    ELC across States and Puerto Rico

    When total Title I and Title II funding is considered, states with EMAs
    and Puerto Rico receive more funding per ELC than states without EMAs
    because cases within EMAs are counted twice, once in connection with Title
    I base grants and once for Title II base grants. Eighty percent of Title
    II base grants is determined by the total number of ELCs in the state or
    territory. The remaining 20 percent is based on the number of ELCs in each
    jurisdiction outside of any EMA. This 80/20 split was established by the
    1996 CARE Act amendments to address the concern that grantees with EMAs
    received more total Title I and Title II funding per case than grantees
    without EMAs. However, even with the 80/20 split, states with EMAs and
    Puerto Rico receive more total Title I and Title II funding per ELC than
    states without EMAs. States without EMAs receive no funding under Title I,
    and thus, when total Title I and Title II funds are considered, states
    with EMAs and Puerto Rico receive more funding per ELC. 41 Appendix VI
    shows the combined Title I and Title II fiscal year 2004 funding received
    by each state and Puerto Rico.

    Table 3 illustrates the effect of counting EMA cases twice by comparing
    the relationship between the percentage of a state's and Puerto Rico's
    ELCs that are within EMAs and the amount of total Title I and Title II
    funding they receive per ELC. Table 3 shows that as the percentage of a
    state's or Puerto Rico's ELCs within EMAs increases, the total Title I and
    II funding per ELC also increases. For example, states with no ELCs in
    EMAs received on average $3,592 per ELC. States with 75 percent or more of
    their cases in EMAs and Puerto Rico 42 received on average $4,955 per ELC,
    or 38 percent more funding than states with no EMA. If the total Title I
    and Title II funding had been distributed proportionally per ELC among all
    states and Puerto Rico, each grantee would have received $4,782 per ELC.

    Table 3: Relationship between ELCs in EMAs and Total CARE Act Title I and
    II Funding per ELC, Fiscal Year 2004

    Percentage of states' and Puerto Rico's ELCs in   Average funding per ELCa
    EMAs
    None                                                                $3,592
    Less than 50 percent                                                 3,954
    50 to 75 percent                                                     4,717
    More than 75 percent                                                 4,955

    Source: GAO analysis of HRSA data.

    aWe excluded from our analyses the nine states that received the minimum
    Title II base grant awards. Under Title II, states with fewer than 90
    cases receive no less than $200,000 in Title II base grant and states with
    90 or more cases receive at least $500,000.

    The effect of counting EMA cases twice is that grantees with similar
    numbers of ELCs can receive different levels of combined Title I and Title
    II funding. For example, for fiscal year 2004 funding, Connecticut had
    5,363 ELCs while South Carolina had 5,563 ELCs. However, Connecticut had
    two EMAs that accounted for 91.3 percent of its ELCs while South Carolina
    had none. Connecticut received $26,797,308 ($4,997 per ELC) in combined
    Title I and Title II funding while South Carolina, with 200 more cases,
    received $20,705,328 ($3,722 per ELC). Connecticut received 29 percent
    more funding than South Carolina, a difference of $6,091,980, or $1,275
    per ELC. (See app. VI.)

    The Two-tiered Division of Emerging Communities Results in Funding
    Disparities Among Metropolitan Areas

    The two-tiered division of Emerging Communities results in disparities in
    funding among metropolitan areas. Title II provides for a minimum of $10
    million to states with metropolitan areas that have 500 to 1,999 AIDS
    cases reported in the last 5 calendar years but do not qualify for funding
    under Title I as EMAs. 43 The funding is equally split so that half the
    funding is divided among the first tier of communities with 500 to 999
    reported cases in the most recent 5 calendar years while the other half is
    for a second tier of communities with 1,000 to 1,999 reported cases in
    that period. The funding is then allocated within each tier by the
    proportion of reported cases in the most recent 5 calendar years in each
    community. The two tiers and the 50/50 split were meant to ensure that a
    significant portion of the Emerging Communities funding was allocated to
    the communities with the largest number of new cases.

    In fiscal year 2004, the two-tiered structure of Emerging Communities
    funding led to large differences in funding per reported AIDS case in the
    last 5 calendar years among the Emerging Communities because the total
    number of AIDS cases in each tier was not equal. Twenty-nine communities
    qualified for Emerging Communities funds in fiscal year 2004. Four of
    these communities had 1,000 to 1,999 reported AIDS cases in the last 5
    calendar years and 25 communities had 500 to 999 cases. This distribution
    meant that the 4 communities with a total of 4,754 reported cases in the
    last 5 calendar years split $5 million while the remaining 25 communities
    with a total of 15,994 reported cases in the last 5 calendar years also
    split $5 million. These case counts resulted in the 4 communities
    receiving $1,052 per reported case while the other 25 received $313 per
    reported case. These 4 communities received 236 percent more funding per
    reported case than the other 25. If the total $10 million funding for
    Emerging Communities grants had been distributed equally per reported case
    among the communities, each would have received $482 per reported case.
    Table 4 lists the 29 Emerging Communities along with their reported AIDS
    case counts over the most recent 5 years and their funding.

    Table 4: Title II Emerging Communities in Fiscal Year 2004

    Emerging Community                    AIDS cases      Emerging Communities
                                        reported in the     funding per AIDS case
                                          most recent 5      reported in the most
                                         calendar years   recent 5 calendar years
    Memphis, Tenn.                             1,588                    $1,052
    Nashville, Tenn.                           1,123                     1,052
    Baton Rouge, La.                           1,038                     1,052
    Indianapolis, Ind.                         1,005                     1,052
    Columbia, S.C.                               972                       313
    Charlotte, N.C.                              875                       313
    Wilmington, Del.                             801                       313
    Richmond, Va.                                783                       313
    Raleigh-Durham-Chapel Hill, N.C.             775                       313
    Jackson, Miss.                               722                       313
    Louisville, Ky.                              705                       313
    Rochester, N.Y.                              681                       313
    Fort Pierce-Port St. Lucie, Fla.             636                       313
    Greensboro-Winston-Salem, N.C.               617                       313
    Birmingham, Ala.                             615                       313
    Oklahoma City, Okla.                         608                       313
    Pittsburgh, Pa.                              602                       313
    Springfield, Mass.                           588                       313
    Monmouth-Ocean, N.J.                         582                       313
    Buffalo-Niagara Falls, N.Y.                  581                       313
    Greenville, S.C.                             560                       313
    Columbus, Ohio                               558                       313
    Milwaukee, Wis.                              558                       313
    Salt Lake City, Utah                         555                       313
    Sarasota, Fla.                               539                       313
    Charleston, S.C.                             538                       313
    Cincinnati, Ohio                             517                       313
    Daytona Beach, Fla.                          514                       313
    Providence, R.I.                             512                       313
    Total                                     20,748

    Source: GAO analysis of HRSA data.

    Note: Emerging Communities are metropolitan areas not eligible for Title I
    grants and that have 500-1,999 reported AIDS cases in the most recent 5
    calendar years. The 5 most recent calendar years are 1998-2002.

    Similar to the counting of ELCs in EMAs for both Title I and Title II base
    grant funding, AIDS cases reported in the past 5 calendar years in
    Emerging Communities are counted more than once for determining Title II
    funding. For example, these cases are counted once for determining Title
    II base funding and again for Emerging Communities grants. Title II
    grantees with Emerging Communities receive an average of $3,443 per ELC
    while grantees without an Emerging Community receive about $3,089. 44 The
    Emerging Communities funding accounted for about $125 per ELC of this
    difference. Other Title II funds that are also not distributed
    proportionally by the number of ELCs, such as the Minority AIDS Initiative
    grants, account for the rest of the difference. 45

    Hold-harmless Provisions and Grandfather Clause Protect Funding of Certain
    CARE Act Grantees

    Titles I and II of the CARE Act both contain provisions that protect
    certain grantees' funding levels. Title I has a hold-harmless provision
    that guarantees that the Title I base grant to an EMA will be at least as
    large as a statutorily specified percentage of a previous year's funding.
    The Title I hold-harmless provision has primarily protected the funding of
    one EMA. Title I also contains a grandfather clause that has resulted in a
    large number of EMAs maintaining their eligibility for grants despite no
    longer meeting the eligibility criteria. Title II has a hold-harmless
    provision that ensures that the total of Title II and ADAP base grants
    awarded to a grantee will be at least as large as the total of these
    grants a grantee received the previous year. This provision has the
    potential of reducing the amount of funding to grantees that had
    demonstrated severe need for drug treatment funds because it is funded out
    of amounts that would otherwise be used for that purpose.

    One EMA Has Been the Primary Recipient of Title I Hold-harmless Funding

    The San Francisco EMA has been the primary recipient of Title I
    hold-harmless funding. An EMA's base funding is determined according to
    its proportion of ELCs. The hold-harmless provision guarantees each EMA a
    statutorily specified percentage of the base grant it received in a
    previous year regardless of how much its proportion of the number of ELCs
    in all EMAs may have decreased in the current year. 46 If an EMA qualifies
    for hold-harmless funding, that amount is added to the base funding and
    distributed together as the base grant. In fiscal year 2004, the San
    Francisco EMA received $7,358,239 in hold-harmless funding, or 91.6
    percent of the hold-harmless funding that was distributed. 47 The second
    largest recipient was Kansas City, which received $134,485, or 1.7 percent
    of the hold-harmless funding under Title I. Table 5 lists the EMAs that
    received hold-harmless funding in fiscal year 2004. 48

    Table 5: Title I Hold-harmless Funding, Fiscal Year 2004

    EMA                           Hold-harmless    Percent of Hold-harmless   Base Hold-harmless
                                        funding hold-harmless   funding per  grant  as a percent
                                                      funding           ELC    per of base grant
                                                                              ELCa
    San Francisco, Calif.            $7,358,239         91.6%        $1,020 $2,241         45.5%
    Kansas City, Mo.                    134,485           1.7           104  1,325           7.8
    Santa Rosa, Calif.                   22,614           0.3            47  1,268           3.7
    Sacramento, Calif.                   36,456           0.5            29  1,251           2.3
    Minneapolis-St. Paul, Minn.          33,770           0.4            27  1,248           2.1
    Bergen-Passaic, N.J.                 55,288           0.7            26  1,248           2.1
    Jersey City, N.J.                    58,310           0.7            24  1,245           1.9
    Oakland, Calif.                      50,744           0.6            18  1,239           1.4
    New Haven, Conn.                     42,573           0.5            14  1,236           1.2
    Tampa-St. Petersburg, Fla.           44,908           0.6            12  1,233           0.9
    San Jose, Calif.                     12,097           0.2            11  1,232           0.9
    Boston, Mass.                        60,284           0.8            10  1,231           0.8
    Nassau-Suffolk, N.Y.                 21,212           0.3             8  1,230           0.7
    Middlesex-Somerset-Hunterdon,         8,315           0.1             7  1,228           0.5
    N.J.
    Jacksonville, Fla.                   12,825           0.2             6  1,228           0.5
    San Juan, P.R.                       41,011           0.5             6  1,228           0.5
    Seattle, Wash.                        9,844           0.1             4  1,225           0.3
    Denver, Colo.                         6,745           0.1             3  1,225           0.3
    Cleveland, Ohio                       4,616           0.1             3  1,224           0.2
    West Palm Beach, Fla.                 8,523           0.1             2  1,224           0.2
    Newark, N.J.                         10,975           0.1             2  1,223           0.1
    All Other EMAs                            0             0             0  1,221           0.0
    Total                           $8,033,563b       100.0%b

    Source: GAO analysis of HRSA data.

    Notes: An EMA's base funding is determined according to its proportion of
    ELCs. If an EMA qualifies for hold-harmless funding, that amount is added
    to the base funding and distributed together as the base grant.

    aThis amount was calculated by dividing the base grant, including any
    hold-harmless funding, received by each EMA by the number of ELCs in the
    EMA.

    bIndividual entries do not sum to total because of rounding.

    The effect of the hold-harmless provision varies among the EMAs that
    receive hold-harmless funding, but it can be substantial. In order to
    place hold-harmless funding in perspective, it is helpful to consider how
    much of an EMA's Title I base grant was made up of hold-harmless funding.
    EMAs that did not receive hold-harmless funding received approximately
    $1,221 in base grant funding per ELC in fiscal year 2004. Fiscal year 2004
    base grant funding per ELC in EMAs that received hold-harmless funding
    ranged from $1,223 (Newark) to $2,241 (San Francisco). Thus, the San
    Francisco EMA received $1,020 more in base grant funding per ELC than did
    EMAs that did not receive hold-harmless funding. This hold-harmless
    funding represents approximately 46 percent of San Francisco's base grant.
    Because of its hold-harmless funding, San Francisco, which had 7,216 ELCs
    in fiscal year 2004, received a base grant equivalent to what an EMA with
    approximately 13,245 ELCs (84 percent more) would have received. Kansas
    City, the second largest hold-harmless grantee, received about what an EMA
    with 9 percent more ELCs would have received.

    Forty-eight of the 51 EMAs would have received more funding if there had
    been no hold-harmless provision and if the $8 million that was actually
    used for hold-harmless funding had been distributed in the same
    proportions as the supplemental grants. 49 Although 21 EMAs received
    hold-harmless funding in fiscal year 2004, only 3 (San Francisco, Kansas
    City, and Santa Rosa) received more funding because of the hold-harmless
    provision than they would have received through supplemental grants in the
    absence of the hold-harmless provision. Without the hold-harmless funding,
    San Francisco would have received $960 less per ELC, Kansas City $70 less,
    and Santa Rosa $15 less.

    In fiscal year 2004 the San Francisco EMA was guaranteed to receive 89
    percent of its fiscal year 2000 Title I base grant under the hold-harmless
    provision. However, the amount of San Francisco's 2000 Title I base grant
    had been determined by formulas specified in the CARE Act Amendments of
    1996, which guaranteed EMAs 95 percent of their 1995 base grant in fiscal
    year 2000. 50 San Francisco was the only EMA to qualify for hold-harmless
    funding in 2000 because it was the only EMA that would have received less
    than 95 percent of its fiscal year 1995 base grant. Taken together, the
    hold-harmless provisions mean that in fiscal year 2004 San Francisco was
    guaranteed approximately 85 percent of its fiscal year 1995 base grant of
    $19,126,679. 51 Prior to the CARE Act Amendments of 1996, funding was
    distributed among EMAs on the basis of the cumulative count of diagnosed
    AIDS cases (that is, all cases reported in an EMA both living and deceased
    since the beginning of the epidemic in 1981). Because San Francisco's
    Title I funding reflects the application of hold-harmless provisions under
    the 1996 amendments, as well as under current law, San Francisco's Title I
    base grant is determined in part by the number of deceased cases in the
    San Francisco EMA as of 1995.

    Grandfathering Maintains Eligibility for EMAs That No Longer Meet Certain
    Eligibility Criteria

    More than half of the EMAs received Title I funding in fiscal year 2004
    even though they were below Title I eligibility thresholds. 52 The
    eligibility of these EMAs was protected based on a CARE Act grandfather
    clause. Under a grandfather clause established by the CARE Act Amendments
    of 1996, metropolitan areas eligible for funding for fiscal year 1996
    remain eligible for Title I funding even if the number of reported cases
    in the most recent 5 calendar years drops below the statutory threshold.
    We found that in fiscal year 2004, 29 of the 51 EMAs did not meet the
    eligibility threshold of more than 2,000 reported AIDS cases during the
    most recent 5 calendar years but nonetheless retained their status as EMAs
    (see table 6). The number of reported AIDS cases in the most recent 5
    calendar years in the 29 EMAs ranged from 223 to 1,941. Title I funding
    awarded to these 29 EMAs was about $116 million, or approximately 20
    percent of the total Title I funding.

    Table 6: Grandfathered EMAs, Fiscal Year 2004

    EMA                                     Number of AIDS cases Total Title I
                                               reported in the most       funding
                                            recent 5 calendar years
    Riverside-San Bernardino, Calif.                       1,941    $6,823,183
    New Haven, Conn.                                       1,717     7,069,348
    Oakland, Calif.                                        1,633     6,611,607
    Nassau-Suffolk, N.Y.                                   1,560     5,951,789
    Norfolk, Va.                                           1,502     4,820,201
    Seattle, Wash.                                         1,459     5,842,615
    Jacksonville, Fla.                                     1,423     4,863,093
    Orange County, Calif.                                  1,422     5,233,329
    St. Louis, Mo.                                         1,247     4,371,154
    Jersey City, N.J.                                      1,226     5,884,194
    Las Vegas, Nev.                                        1,182     4,473,401
    Denver, Colo.                                          1,167     4,529,097
    Austin, Tex.                                           1,149     3,800,250
    Bergen-Passaic, N.J.                                   1,067     4,814,704
    Hartford, Conn.                                        1,059     4,552,237
    San Antonio, Tex.                                      1,034     3,833,443
    Cleveland, Ohio                                          970     3,486,936
    Portland, Oreg.                                          937     3,567,475
    Fort Worth, Tex.                                         854     3,373,450
    Kansas City, Mo.                                         822     3,240,813
    Minneapolis, Minn.                                       794     3,093,915
    Sacramento, Calif.                                       717     2,968,051
    Ponce, P.R.                                              710     2,718,331
    Middlesex-Somerset-Hunterdon, N.J.                       682     2,723,697
    San Jose, Calif.                                         656     2,656,550
    Caguas, P.R.                                             411     1,816,647
    Dutchess County, N.Y.                                    255     1,231,242
    Vineland-Millville-Bridgeton, N.J.                       238       847,898
    Santa Rosa, Calif.                                       223     1,107,428
    Total                                                         $116,306,348

    Source: GAO analysis of CDC and HRSA data.

    Note: The 5 most recent calendar years are 1998-2002.

    The number of EMAs ineligible for Title I funds in the absence of the
    grandfather clause reflects the combination of the decline in the number
    of new AIDS cases following the advent of more effective therapies and the
    more restrictive eligibility standards adopted in the CARE Act Amendments
    of 1996. 53 No metropolitan areas have become eligible for Title I funding
    since 1999, when Las Vegas and Norfolk received their initial funding,
    because no additional metropolitan areas have reported enough new cases to
    meet the AIDS case-count-eligibility threshold. This decline in the number
    of new cases reflects the general pattern of AIDS case counts in the
    country. While the number of people living with AIDS has been increasing
    as persons with AIDS live longer, the number of new AIDS cases reported
    each year throughout the country decreased from about 1993 until about
    1999 and has since leveled off. In addition, six of the EMAs not meeting
    the current eligibility threshold became eligible on the basis of their
    case rates, under the 1990 thresholds, rather than their number of cases.
    These include Caguas, Dutchess County, Santa Rosa, and
    Vineland-Millville-Bridgeton, the four EMAs with the fewest reported
    cases. In addition, the Jersey City and Ponce EMAs also became eligible on
    the basis of their case rates.

    As discussed earlier, some metropolitan areas are designated as Emerging
    Communities under Title II because their numbers of reported AIDS cases in
    the most recent 5 calendar years are not large enough to make them
    eligible for Title I funding as EMAs. However, some Emerging Communities
    had more reported AIDS cases in the last 5 years than some EMAs that were
    eligible for Title I funding because of the grandfather clause. 54 For
    example, for fiscal year 2004 Memphis, a designated Emerging Community,
    had 1,588 reported AIDS cases during the most recent 5 calendar years,
    which is more than the number of cases reported in 26 EMAs. The overall
    effect is that Emerging Communities received less funding than EMAs with
    comparable numbers of reported AIDS cases in the most recent 5 calendar
    years. For example, Baton Rouge, with 1,038 reported cases, received
    $1,091,976 in Emerging Communities funding while the San Antonio EMA, with
    1,034 reported cases, received $3,833,443 in Title I funding.

    Title II Hold-harmless Funding Could Diminish ADAP Severe Need Grants in
    the Future

    A Title II hold-harmless provision established by the CARE Act Amendments
    of 2000 could diminish ADAP Severe Need grant amounts in the future
    because the hold-harmless payments and the grants are funded from the same
    3 percent set-aside of Title II funds available for drug treatment
    programs. If larger amounts are needed to meet this hold-harmless
    provision in the future, grantees that have demonstrated a severe need for
    drug treatment funds could get less than the amounts they would otherwise
    receive. 55

    Fiscal year 2004 was the first time that any grantees triggered the Title
    II hold-harmless provision funded with amounts that would otherwise be
    used for Severe Need grants. Severe Need grants are funded with a 3
    percent set-aside of the funds appropriated specifically for ADAPs. The
    Title II hold-harmless provision, also funded by the 3 percent set-aside
    for Severe Need grants, guarantees that the total of Title II and ADAP
    base grants made to a grantee will be at least as large as the total the
    previous year. 56 Eight states became eligible for this hold-harmless
    funding in fiscal year 2004. In 2004, the 3 percent set-aside for Severe
    Need grants was $22.5 million. Of these funds, $1.6 million, or 7 percent,
    was used to provide this Title II hold-harmless protection. (See table 7.)
    The remaining $20.8 million, or 93 percent of the set-aside amount, was
    distributed in Severe Need grants.

    Table 7: States That Received Title II Hold-harmless Funding from Severe
    Need Set-aside, Fiscal Year 2004

    State        Hold-harmless amount
    Arkansas                  $23,705
    Kansas                     22,168
    New Mexico                 55,171
    North Dakota                1,820
    Oklahoma                   96,423
    Tennessee               1,300,502
    Utah                      119,695
    Vermont                       128
    Total                  $1,619,612

    Source: HRSA.

    The potential exists for this Title II hold-harmless provision to diminish
    the size of Severe Need grants further in the future if larger amounts are
    needed to fund this hold-harmless protection. The total amount of Severe
    Need grant funds available in fiscal year 2004 to distribute among the
    eligible grantees was less than it would have been without the
    hold-harmless payments. However, in fiscal year 2004 not all 25 of the
    Title II grantees eligible for Severe Need grants made the required match.
    Consequently, the Severe Need grants were not as small as they would
    otherwise have been because of the application of the hold-harmless
    provision. In future years, if all of the eligible Title II grantees make
    the match, and if there are also grantees that qualify to receive
    hold-harmless funds under this provision, grantees with severe need for
    ADAP funding would get less than the amounts they would otherwise receive.

    HOPWA Provision Restricts Bonus Grant Eligibility for Some Grantees

    The structure of the HOPWA program restricts states and Puerto Rico from
    receiving HOPWA bonus grant funding for areas outside EMSAs. 57 Bonus
    grants, which totaled about $66 million in fiscal year 2004, are awarded
    only to the EMSAs in which the AIDS epidemic is spreading most rapidly. 58
    In fiscal year 2004, EMSAs with more than 19.5 new AIDS cases per 100,000
    people over the past year qualified for bonus grants. In fiscal year 2004,
    26 EMSAs qualified for bonus grants (see table 8).

    Table 8: Fiscal Year 2004 HOPWA Formula Funding

    EMSA                 Base      Bonus   Bonus      Total HOPWA  Total HOPWA
                         funding    funding funding  formula funding      formula
                                               as a  when calculated funding when
                                            percent   per cumulative   calculated
                                            of base       AIDS casea   per living
                                            funding                     AIDS case
    Atlanta, Ga.   $4,262,000   $637,000     15%             $264         $573
    Baltimore, Md.  3,940,000  3,996,000     101              463        1,039
    Baton Rouge,      666,000  1,147,000     172              626        1,290
    La.
    Bridgeport,       752,000     27,000       4              238          476
    Conn.
    Charleston,       411,000      7,000       2              234          480
    S.C.
    Chicago, Ill.   5,622,000  2,716,000      48              341          805
    Columbia, S.C.    626,000    644,000     103              466          824
    Detroit, Mich.  1,624,000    355,000      22              280          749
    District of     5,626,000  6,176,000     110              482          939
    Columbia
    Fort            3,337,000  2,903,000      87              430          954
    Lauderdale,
    Fla.
    Jackson, Miss.    449,000    275,000      61              371          728
    Jacksonville,   1,195,000    369,000      31              301          623
    Fla.
    Memphis, Tenn.    920,000  1,214,000     132              533        1,000
    Miami, Fla.     6,149,000  4,566,000      74              400          934
    New Haven,        937,000    295,000      31              302          605
    Conn.
    New Orleans,    1,785,000  1,207,000      68              385          887
    La.
    New York, N.Y. 33,487,000 26,868,000      80              414        1,099
    Newark, N.J.    4,297,000    885,000      21              277          828
    Philadelphia,   4,340,000  3,292,000      76              404          799
    Pa.
    Orlando, Fla.   1,660,000  1,529,000      92              441          913
    Wake County,      345,000      7,000       2              234          408
    N.C.
    San Francisco,  6,698,000  1,864,000      28              294        1,130
    Calif.
    San Juan, P.R.  4,585,000  2,555,000      56              358        1,000
    Tampa, Fla.     2,221,000    168,000       8              247          569
    West Palm       2,019,000  1,817,000      90              436          933
    Beach, Fla.
    Wilmington,       566,000    232,000      41              325          624
    Del.
    All other               b          0       0              230            c
    grantees

    Source: GAO analysis of CDC and HUD data.

    aCumulative AIDS cases are the total number of AIDS cases, both living and
    dead, reported in the jurisdiction since the beginning of the epidemic in
    1981.

    bVaries by number of cumulative AIDS cases.

    cVaries by number of living AIDS cases.

    Bonus funding can be an important component of an EMSA's HOPWA formula
    funding. Bonus grants exceeded base funding amounts in five EMSAs
    (Baltimore, Maryland; Baton Rouge, Louisiana; Columbia, South Carolina;
    Memphis, Tennessee; and the District of Columbia), and were more than 50
    percent of base funding in another nine. EMSAs that did not receive bonus
    funding received approximately $230 per cumulative AIDS case in fiscal
    year 2004 formula funding. Because grantees other than EMSAs were not
    eligible for the bonus funding, they also received $230 per cumulative
    case. However, the 26 EMSAs that received bonus funding were allocated an
    average of $367 per cumulative case in total formula funding, ranging from
    $234 to $626 per case. If all of the formula funding had been allocated on
    the basis of cumulative AIDS cases, instead of allocating base grants by
    cumulative cases and bonus grants by incidence rates, each grantee would
    have received $306 per case. The last column in table 8 shows that EMSAs
    that received bonus funding also received more funds per living AIDS case.
    59 These EMSAs received an average of approximately $816 per living case,
    ranging from $408 per case in Wake County, North Carolina, to $1,290 per
    case in Baton Rouge, Louisiana. Those grantees that did not receive bonus
    funding received about $503 per living case, ranging from $387 to $627 per
    case. (See app. IV).

    The Use of Revised OMB Metropolitan Area Definitions Would Change Most EMA
    Boundaries, but Increase in ELCs within EMAs Would Be Minimal

    Title I EMA boundaries were made permanent by the 1996 amendments to the
    CARE Act, and they have not been altered to conform to OMB's 2004
    definitions of metropolitan areas. 60 Since existing Title I and Title II
    organizational and administrative arrangements within states and EMAs are
    connected to current EMA boundaries, changing EMA boundaries to conform to
    OMB 2004 metropolitan areas could disrupt those arrangements. On the other
    hand, adopting the 2004 OMB definitions for EMAs would reflect the same
    metropolitan areas for which statistical agencies make data available to
    the public and reflect the 2000 decennial census demographic data. OMB
    recommends that policymakers review and consider the appropriateness of
    the new definitions of metropolitan area boundaries for program purposes.

    If OMB's 2004 definitions of metropolitan area 61 boundaries were used to
    establish the area to be considered when defining an EMA under Title I, 62
    the service area boundaries would change for the majority of the current
    EMAs. 63 To demonstrate the changes involved in reconfiguring EMA
    boundaries to conform to the new metropolitan areas, we chose a method
    that could be used for this conversion. As described in appendix I, the
    method we chose would combine new metropolitan areas so as to minimize
    changes to current EMA boundaries. 64

    If our method of converting EMA boundaries to metropolitan areas using the
    2004 definitions were incorporated in the CARE Act funding formulas, the
    service area boundaries of more than half of current EMAs would change. In
    addition, 5 EMAs would be consolidated to 2, reducing the total number of
    EMAs from 51 to 48. 65 We found that 31 of the 51 current EMAs would add,
    lose, or both add and lose counties in their service areas. For example,
    the Atlanta EMA would add 8 counties, the Las Vegas EMA would lose 2
    counties, and the Newark EMA (New Jersey) would both add 2 counties and
    lose 1 other county. Overall, 17 counties would no longer be part of an
    EMA and 53 counties that were not previously included in an EMA would be
    added to the service area of a newly reconfigured EMA. Service area
    boundaries of 20 current EMAs would not change if the new OMB metropolitan
    area definitions were adopted. (See app. VII.)

    Changing the service area boundaries of current Title I EMAs to reflect
    the new OMB metropolitan area definitions would result in most EMAs having
    a change in the number of ELCs within their boundaries, and the total net
    effect would be an increase of ELCs counted under Title I of less than 1
    percent. Any ELCs that would no longer be counted under Title I would
    continue to be considered for purposes of Title II base grants as ELCs
    outside an EMA. Our analysis of the change in ELCs resulting from a change
    in EMA boundaries to the new OMB definitions shows that 19 of the 51
    current EMAs would have less than a 2 percent change in their number of
    ELCs, and 23 EMAs would have no change in the number of ELCs in their
    service area. In total, these 42 EMAs represent about 88 percent of the
    total number of Title I ELCs. Of the remaining 9 EMAs, 3 EMAs would
    experience a gain or loss of more than 9 percentage points in their ELCs.
    The Dutchess County EMA (New York) would have about a 93 percentage-point
    increase in ELCs (a gain of 486 in the number of ELCs) as a result of
    adding Orange County to its service area. In New Jersey, Middlesex would
    have a 79 percentage-point increase in ELCs (a gain of 979 in the number
    of ELCs) by adding Monmouth and Ocean Counties. The Boston EMA would have
    about a 9 percentage-point decrease (a loss of 554 in the number of ELCs)
    because Bristol County (Massachusetts) would be reassigned from the Boston
    EMA to the Providence (Rhode Island) metropolitan area, which is not an
    EMA. Because the overall change in the number of Title I ELCs that would
    result from EMA service area boundary changes under the new OMB
    definitions would be an increase of less than 1 percent (a net gain of
    1,742 in the number of ELCs), a minimal overall effect on funding per ELC
    would be expected.

    Funding Effect of Using HIV Case Counts Would Depend on Multiple Factors

    CARE Act and HOPWA funding would have shifted among grantees if HIV case
    counts had been used with a measure of persons living with AIDS to
    allocate fiscal year 2004 formula grants. While all states and Puerto Rico
    have established HIV case-reporting systems, IOM identified
    characteristics of these systems that limit their appropriateness for the
    distribution of CARE Act and HOPWA funds. 66 We found that up to 13
    percent of CARE Act funding would have shifted if HIV case counts had been
    used with ELCs in the distribution of fiscal year 2004 funds and if the
    hold-harmless and minimum-grant provisions we considered were maintained.
    67 Larger changes for individual grantees would have occurred with some
    grantees more than doubling their funding. Grantees in the South and
    Midwest would generally have received more funding from using HIV cases in
    funding formulas. 68 However, there would have been grantees that would
    have received increased funding and grantees that would have received
    decreased funding in every region of the country. Larger funding shifts
    would have occurred without these CARE Act hold-harmless and minimum-grant
    provisions. HOPWA funding would also have shifted if HIV cases along with
    living AIDS cases had been used to determine funding rather than
    cumulative AIDS case counts. Differences in HIV case-reporting systems
    would affect funding allocations, and we found that funding would have
    tended to shift to jurisdictions with older HIV-reporting systems.
    Jurisdictions with older HIV-reporting systems tend to have more reported
    HIV cases compared with their number of AIDS cases than do jurisdictions
    with newer reporting systems.

    Current HIV Case-reporting Systems Have Limitations for Providing Case
    Counts for Funding Allocations

    In order to monitor HIV infection, the states and Puerto Rico have
    established HIV case-reporting systems under which individuals who have
    been diagnosed with HIV are reported to health departments by physicians
    and other practitioners. 69 In 2000 we reported that HIV cases accounted
    for a much smaller percent of total HIV/AIDS cases in states with newer
    HIV-reporting systems. 70 In its 2004 report, IOM updated our earlier
    analysis and identified several limitations in the ability of these
    jurisdictions to provide accurate HIV case counts to CDC for use in CARE
    Act funding allocations. Among these limitations, IOM found that the
    maturity of HIV case-reporting systems continued to vary widely across
    grantees. The earliest HIV-reporting systems were established in Colorado,
    Minnesota, and Wisconsin in 1985, followed by most southern and other
    midwestern states prior to 1995. The newest systems were established after
    2003 in six states and Philadelphia, Pennsylvania. 71 Case-reporting
    systems need several years to become fully operational. Practitioners need
    to be made aware of the requirement to report new HIV cases and the
    methods for doing so. Existing cases also need to be reported by
    practitioners and entered into the system. Grantees with newer systems may
    not have collected and entered data on existing cases, and, consequently,
    may underreport the number of HIV cases. Underreporting of HIV cases in
    states with newer HIV-reporting systems would result in grantees receiving
    less funding than they would be entitled to receive according to the
    actual number of HIV/AIDS cases.

    IOM also found that differences in how jurisdictions report HIV case
    counts to CDC preclude HRSA's use of those case counts in the distribution
    of CARE Act funds. 72 While some HIV case-reporting systems are
    code-based, CDC will only accept name-based case counts as no code-based
    system has met its quality criteria as of January 2006. 73 Therefore, HIV
    cases reported using codes rather than names would not be counted in
    distributing CARE Act funds, if HIV case counts were used in funding
    formulas. As of December 2005, thirteen states have some form of a
    code-based system rather than a name-based system. 74 CDC does not accept
    the code-based data principally because methods have not been developed to
    make certain that a code-reported HIV case is only being counted once
    across all reporting jurisdictions. 75 Table 9 shows the 39 jurisdictions
    where HIV case counts are accepted by CDC and the 13 jurisdictions where
    they are not accepted, and the year in which each jurisdiction established
    its HIV-reporting system.

    Table 9: CDC Acceptance of HIV Case Counts and Year of Establishment of
    HIV-reporting Systems, December 2005

    Accepted              Not accepted
    Colorado (1985)       Maryland (1994)
    Minnesota (1985)      Massachusetts (1999)
    Wisconsin (1985)      Illinois (1999)d
    Idaho (1986)          Maine (1999)e
    South Carolina (1986) Washington (1999)
    Arizona (1987)        Montana (2000)
    Missouri (1987)       Rhode Island (2000)
    Alabama (1988)        Vermont (2000)
    Indiana (1988)        Delaware (2001)
    Mississippi (1988)    District of Columbia (2001)
    North Dakota (1988)   Hawaii (2001)
    Oklahoma (1988)       Oregon (2001)
    South Dakota (1988)   California (2002)
    Arkansas (1989)
    Utah (1989)
    Virginia (1989)
    West Virginia (1989)
    Wyoming (1989)
    North Carolina (1990)
    Ohio (1990)
    Michigan (1992)
    Nevada (1992)
    New Jersey (1992)
    Tennessee (1992)
    Louisiana (1993)
    Nebraska (1995)
    Florida (1997)
    Iowa (1998)
    New Mexico (1998)
    Alaska (1999)
    Kansas (1999)
    Texas (1999)
    New York (2000)
    Pennsylvania (2002)a
    Georgia (2003)
    Puerto Rico (2003)
    Kentucky (2004)
    Connecticut (2005)b
    New Hampshire (2005)c

    Sources: CDC, IOM, Connecticut, Kentucky, and Philadelphia. Connecticut,
    Kentucky, and Philadelphia provided us with updated information about
    their HIV case-reporting systems.

    Notes: Currently, CDC will only accept name-based case counts.

    aName-based HIV reporting has been established in all parts of
    Pennsylvania except Philadelphia since 2002. Philadelphia was given
    permission by the state to establish code-based HIV reporting, and the
    system began in 2004. However, in August 2005, the Philadelphia Board of
    Health voted to implement a name-based HIV-reporting system. This system
    went into effect in October 2005. Philadelphia is in the process of having
    its HIV surveillance data certified by CDC; once certified, its data will
    be accepted by CDC.

    bConnecticut established mandatory name-based HIV reporting in 2005.
    Previously, name-based reporting was only required for pediatric cases.

    cNew Hampshire established mandatory name-based HIV reporting in 2005.
    Previously, HIV cases could be reported using the patient name, a code, or
    no identifier at all.

    dIllinois established name-based HIV reporting in January 2006. It is in
    the process of having its HIV surveillance data certified by CDC and, once
    certified, its data will be accepted by CDC.

    eMaine established name-based HIV reporting in January 2006. It is in the
    process of having its HIV surveillance data certified by CDC and, once
    certified, its data will be accepted by CDC.

    The Use of HIV Case Counts in Funding Formulas Would Have Changed the
    Distribution of Fiscal Year 2004 CARE Act and HOPWA Funds

    While we are aware of differences in the HIV data across jurisdictions, we
    conducted this analysis in light of the CARE Act requirement that HIV case
    counts be used for the distribution of Title I and Title II formula grants
    not later than fiscal year 2007. We used two approaches to examine the
    potential effect of including HIV cases in addition to persons living with
    AIDS in fiscal year 2004 CARE Act and HOPWA funding formulas. We found
    that some CARE Act fiscal year 2004 funding would have shifted among
    grantees if HIV case counts and ELCs had been used to allocate the funds.
    While our analyses indicate that up to 13 percent of CARE Act funding
    would have shifted, larger changes for individual grantees would have
    occurred. Southern and midwestern grantees would generally have received
    more funding, but there would have been grantees that would have received
    increased funding and grantees that would have received decreased funding
    in every region of the country. Funding changes in our model would have
    been larger without the hold-harmless and minimum-grant provisions that we
    included. There would also have been at most a 15 percent shift in HOPWA
    funding if HIV cases were used to allocate funding, although there would
    have been larger changes for some grantees. 76 CARE Act and HOPWA funding
    changes could have resulted from the number of people living with HIV/AIDS
    in each jurisdiction or differences in HIV case-reporting systems.

    Methodological Approaches Used

    We used two approaches to examine the effect of using HIV cases in
    addition to AIDS cases 77 in funding formulas for CARE Act Title I and
    Title II base grants, ADAP base grants, and HOPWA base funding in the
    states and Puerto Rico. Under the first approach, we used HIV and AIDS
    case counts for the 35 grantees from which CDC accepted HIV data. 78
    Because CDC did not receive HIV case counts from the other 17 grantees, we
    used only the AIDS case counts received by CDC for these grantees.
    Consequently, for some grantees we used HIV and AIDS case counts, but for
    others we used only AIDS case counts. This approach reflects the data that
    would have been used if funding allocations were based on the HIV and AIDS
    case counts received by CDC in time for determining fiscal year 2004
    formula grants. Under the second approach, we used the same HIV and AIDS
    case counts as our first approach, but supplemented these data with the
    code-based HIV case counts collected by the grantees from which CDC did
    not receive HIV data. 79 We obtained these HIV case counts directly from
    these jurisdictions. 80

    For both approaches, we calculated the grantee's percentage of the total
    number of HIV/AIDS cases in each jurisdiction 81 and estimated the fiscal
    year 2004 formula grants that each would have received. Under each
    approach, CARE Act formula grants were calculated both with certain
    hold-harmless and minimum-grant provisions and again without those
    provisions. 82 Eliminating hold-harmless and minimum-grant provisions was
    done to reveal the full effect of distributing fiscal year 2004 funding
    solely according to HIV/AIDS data available at that time. We also
    estimated the effect of using HIV cases and living AIDS cases for HOPWA
    base funding. Although there are limitations associated with the
    underlying data, the results of our analyses indicate the general effect
    of using HIV and AIDS cases to distribute CARE Act and HOPWA formula
    funding. (See app. I for a discussion of the limitations in the data.)

    Changes in CARE Act Funding Using HIV Cases and Hold-harmless and
    Minimum-grant Provisions

    Our analyses indicate that for fiscal year 2004 as much as 13 percent of
    Title I, Title II, and ADAP base grants would have shifted, with southern
    and midwestern grantees being the primary beneficiaries, if hold-harmless
    and minimum-grant provisions were maintained. However, there would have
    been grantees that would have received increased funding and grantees that
    would have received decreased funding in every region of the country.
    Changes in funding could have resulted from the actual number of HIV/AIDS
    cases living in each jurisdiction or from differences across jurisdictions
    in HIV case-reporting systems. The funding changes under each of our
    approaches would have been larger if we had not applied the hold-harmless
    and minimum-grant provisions.

    Title I Base Funding

    Title I base grant funding would have shifted among grantees under both
    our approaches, but because the funds necessary to meet the hold-harmless
    provision are taken from funds that would otherwise be used for
    supplemental grants, the overall effect on Title I EMAs is unclear. 83 The
    Title I base grant includes (1) funding amounts determined by the number
    of ELCs and (2) the hold-harmless amounts, if applicable. In fiscal year
    2004, a total of about $8.0 million was needed to fund the hold-harmless
    payments for EMAs. The amount of Title I hold-harmless funding for all
    EMAs would have increased from $8.0 million to $43.3 million under our
    first approach in which we used only HIV data received by CDC and ELCs. It
    would have increased to $29.4 million under our second approach in which
    we used the HIV case counts collected by CDC, the code-based HIV counts we
    collected from the grantees, and ELCs. In order to meet the hold-harmless
    levels, funds would have to be deducted from the amounts otherwise
    available for Title I supplemental grants. Supplemental grants are divided
    among all EMAs using a competitive application process based on the
    demonstration of severe need and other criteria. Because these awards are
    made competitively, it is unclear how the reduction in funding for
    supplemental grants would have affected individual EMAs and, therefore,
    what the overall effect on funding for each EMA would have been under our
    two approaches.

    Under the first approach-using ELCs and HIV cases when accepted by CDC and
    only ELCs elsewhere-13 EMAs would have received a total of $2.8 million
    less in fiscal year 2004 Title I base grants, about 1 percent of the total
    Title I base grants. Twenty-nine grantees would have received $38.1
    million in additional Title I base grant funding, about 13 percent of
    total Title I base grants, if HIV cases and ELCs had been used to allocate
    funding instead of just ELCs. The other 9 EMAs would have had no change in
    their funding. The effect on certain EMAs would have been large, with the
    Denver EMA more than doubling its Title I base funding and 16 others
    receiving at least a 25 percent increase in funding. Of the 29 that would
    have received more funding, 13 are in the South. In addition, 5 of the 6
    EMAs in the Midwest and 8 of 12 EMAs in the Northeast would have received
    increased funding. However, only 3 of 14 EMAs in the West would have
    received increased funding. 84

    Under the second approach-using the HIV case counts collected by CDC, the
    code-based HIV counts we collected from the grantees, and ELCs- 15 EMAs
    would have received a total of $1.9 million less in fiscal year 2004 Title
    I base grants, about 1 percent of the total Title I base grants.
    Twenty-eight grantees would have received $23.3 million more in fiscal
    year 2004 Title I base grants, about 8 percent of total Title I base
    grants. Eight EMAs would have had no change in their funding. Some EMAs
    would have received large increases in funding, with the Denver EMA more
    than doubling its Title I base grant funding and 9 others receiving at
    least a 25 percent increase in funding. Of the 28 EMAs that would have
    received additional funding, 10 are in the South. All 6 midwestern EMAs
    would have received additional funding. Seven of 12 EMAs in the Northeast
    and 5 of 14 EMAs in the West would have received increased funding.
    Appendix VIII shows the results of the analyses for each EMA under each
    approach.

    Title II Base Funding

    There would be some shifting of funds if HIV cases and ELCs had been used
    to allocate CARE Act Title II base grants while maintaining the
    hold-harmless and minimum-grant provisions. 85 Most southern and
    midwestern grantees would receive increased funding under either approach
    we used for analysis. Under the first approach-using ELCs and HIV cases
    when accepted by CDC and only ELCs elsewhere-about 5 percent or $14.3
    million of Title II base grants would have shifted among grantees. Unlike
    funding for the Title I hold-harmless provision, the amounts necessary to
    fund the Title II base grant hold-harmless and minimum-grant provisions
    are subtracted from the base grants of those states that did not qualify
    for funding under these provisions. Consequently, the total amount of
    funding increases received by some Title II grantees would have to be
    equal to the total decreases received by other grantees. Twenty-one
    grantees would have received additional funding in their Title II base
    grants, and 22 would have received less. Nine grantees would have had no
    change in their funding. Of the 21 that would have received more funding,
    9 are in the South and 7 in the Midwest. Of the 22 that would have
    received less funding, 6 are in the Northeast and 5 are in the West.
    Changes in funding for individual grantees would have ranged from a 150
    percent increase in North Dakota and Wyoming to a 22 percent decrease in
    Delaware and the District of Columbia.

    The second approach-using the HIV case counts accepted by CDC, the
    code-based HIV counts we collected from the grantees, and ELCs-would yield
    a smaller shift in funding. Under this approach, approximately 4 percent
    or $12.6 million of fiscal year 2004 Title II base grants would have
    shifted. Of the 22 grantees that would have received additional funding,
    10 are in the South and 7 in the Midwest. Among those that would have
    received less funding, 4 are in the Northeast and 4 are in the West.
    Twenty grantees would have received less funding and 10 would have
    received the same amount. Funding changes for individual grantees would
    have ranged from a 150 percent increase in North Dakota and Wyoming to a
    22 percent decrease in Delaware and the District of Columbia. Appendix IX
    shows the results of these analyses for each grantee under each approach.

    While a majority of southern grantees would have received increased
    funding under both approaches, the amount of the increase would have been
    relatively small. Southern grantees would have received a total of about
    $430,000 more funding under our first approach and about $640,000 under
    the second approach. This relatively small shift can be attributed to the
    fact that southern states generally would not benefit from the
    minimum-grant and hold-harmless provisions. For example, many southern
    states would have their grants reduced in order to fund the hold-harmless
    provision. Midwestern grantees would have received larger dollar and
    percent increases in funding than the southern grantees under both
    approaches.

    ADAP Base Funding

    Our analyses indicate that there would have been some shifting of funding
    for ADAP base grants if HIV and AIDS case counts had been used to
    determine allocations while maintaining the hold-harmless provision, 86
    with southern and midwestern grantees generally being among the areas that
    would have received increased funding. 87 Under the first approach-using
    ELCs and HIV cases when accepted by CDC and only ELCs elsewhere-about 12
    percent or $85.2 million of fiscal year 2004 ADAP base grants would have
    shifted among grantees. The amounts necessary to fund the ADAP base grant
    hold-harmless provision are subtracted from the ADAP base grants of those
    states that did not qualify for hold-harmless funding. Consequently, the
    total amount of funding increases received by some Title II grantees must
    be equal to the total decreases received by other grantees. Thirty-one of
    the 52 grantees would have received additional funding in their ADAP base
    grants if HIV cases and ELCs had been used to allocate funding instead of
    just ELCs. Of the 31 that would have received more funding, 12 are in the
    South and 11 in the Midwest. The funding changes for some grantees would
    have been large. For example, Colorado's allocation would have doubled and
    South Dakota's would have increased by 84 percent while funding would be
    reduced by 38 percent in Delaware, the District of Columbia, Illinois,
    Kentucky, and Maryland.

    The second approach-using the HIV case counts accepted by CDC, the
    code-based HIV counts we collected from the grantees, and ELCs-yields a
    smaller shift in funding. Under this approach, approximately 9 percent or
    $65.2 million of fiscal year 2004 ADAP base grants would have shifted. Of
    the 35 grantees that would have received additional funding, 12 are in the
    South and 10 are in the Midwest. Funding changes for some grantees would
    have been large. For example, the allocation for Montana would have
    increased 93 percent and the allocation for Colorado 84 percent, while
    funding would have declined by 40 percent in the District of Columbia and
    by 38 percent in Kentucky. Appendix X shows the results of these analyses
    for each grantee under both approaches.

    Changes in CARE Act Formula Funding Would Be Larger If Hold-harmless and
    Minimum-grant Provisions Were Not in Effect

    Hold-harmless provisions limit how much funding can decline from one grant
    period to the next. However, while these provisions limit changes in
    funding they also reduce a program's ability to respond to changing need.
    Minimum-grant provisions guarantee that no grantee will receive less than
    a specified funding amount. These provisions also limit how funding can be
    distributed. 88

    Changes in CARE Act funding levels for Title I base grants, Title II base
    grants, and ADAP base grants caused by shifting to HIV cases and AIDS
    cases would be larger-up to 24 percent-if the current hold-harmless or
    minimum-grant amounts were not in effect than if they were in effect. 89
    Consider the hypothetical situation in which an EMA or Title II grantee
    received a $2 million base grant award according to its number of ELCs.
    Assume that in the following year, the formula is changed so that HIV
    cases and ELCs are used to determine funding allocations, and the grantee
    is then only entitled to $1 million. However, there is a hold-harmless
    provision that guarantees the grantee 98 percent of what it received the
    previous year. The grantee would receive 98 percent of its $2 million
    allocation, or $1.96 million, largely offsetting the reduction in funding
    due to the shift to HIV cases and ELCs. The change in funding with the
    hold-harmless provision would be a decrease of $40,000, but the loss would
    grow to $1,000,000 without the hold-harmless provision. If a grantee
    qualified for $100,000 in formula funding using HIV case counts and ELCs,
    but the minimum award was $500,000, the grantee would receive $500,000
    because of the minimum-grant provision, thereby offsetting the changes due
    to using HIV cases and ELCs.

    Title I Base Funding

    Under both our methodological approaches, Title I funding would have been
    affected by eliminating the Title I base grant hold-harmless provision. 90
    If the hold-harmless provision had been eliminated, the number of EMAs
    that would have received less Title I base grant funding would have
    increased from 13 to 23 under our first approach-using ELCs and HIV cases
    when accepted by CDC and only ELCs elsewhere-and from 15 to 24 under our
    second approach-using the HIV case counts collected by CDC, the code-based
    HIV counts we collected from the grantees, and ELCs. 91 The effect of the
    hold-harmless provision on an individual grantee can be illustrated with
    the New Haven EMA. New Haven, which would have had no change in base grant
    funding if the hold-harmless provision was maintained would have had Title
    I base grant funding reductions of 31 and 35 percent under the first and
    second approaches, respectively, without the hold-harmless provision.
    Overall, southern and midwestern EMAs would gain funding under both
    approaches whether or not the hold-harmless provision was maintained while
    northeastern EMAs would lose funding only under our second approach and
    only if the hold-harmless provision was not maintained. 92 However, in all
    four regions of the country, there would have been EMAs that would have
    received increased funding and EMAs that would have received decreased
    funding. Appendix XI shows the results of our analyses for Title I base
    grants if the hold-harmless provision was not maintained.

    Title II Base Funding

    The hold-harmless and minimum-grant provisions have a large effect on
    funding shifts in Title II base grants. Under our first approach-using
    ELCs and HIV cases when accepted by CDC and only ELCs elsewhere- 14
    percent of Title II base grants would have shifted among grantees if the
    hold-harmless and minimum-grant provisions had been eliminated, while 5
    percent would have shifted if they had been maintained. Under our second
    approach-using the HIV case counts collected by CDC, the code-based HIV
    counts we collected from the grantees, and ELCs-10 percent would have
    shifted if the provisions were eliminated and 4 percent if they had been
    maintained. The importance of these provisions can be illustrated by
    examining individual grantees. For example, Vermont, which received a
    minimum grant of $500,000 in fiscal year 2004, would have had a decrease
    of 74 percent under approach one and 52 percent under approach two if the
    hold-harmless and minimum-grant provisions had not been maintained.
    However, it would have had no change in funding if these provisions had
    been maintained. California would have received decreases of $11.8 million
    under our first approach and $5.0 million under our second approach if the
    provisions had been eliminated, but the state would have had no change in
    funding if the provisions had been maintained. Conversely, North Carolina
    would have received $5.0 million in additional funding under our first
    approach and $4.0 million under our second approach if the hold-harmless
    and minimum-grant provisions had not been maintained. It would have
    received $2.4 million and $2.1 million additional under each approach
    respectively if the provision had been maintained. Southern and midwestern
    grantees would gain funding under both approaches whether or not the
    hold-harmless and minimum-grant provisions had been maintained, while
    northeastern grantees would lose funding. 93 However, in all four regions
    of the country, there would have been grantees that would have received
    increased funding and grantees that would have received decreased funding.
    Appendix XII shows the results of our analyses for Title II base grants if
    the hold-harmless and minimum-grant provisions were not maintained.

    ADAP Base Funding

    The overall effect of the hold-harmless provision is smaller on funding
    shifts for the ADAP base grants. 94 Under our first approach-using ELCs
    and HIV cases when accepted by CDC and only ELCs elsewhere- 14 percent
    instead of 12 percent of ADAP base funding would have shifted among
    grantees if the hold-harmless provision was eliminated. Ten percent
    instead of 9 percent of the funding would have shifted under our second
    approach-using the HIV case counts collected by CDC, the code-based HIV
    counts we collected from the grantees, and ELCs. The reason for the
    smaller effect on the ADAP base grants than on the Title I and Title II
    base grants is the increase in ADAP base funding since fiscal year 2000.
    In fiscal year 2000, $528 million was distributed to grantees while $728
    million was distributed in fiscal year 2004. Because of these increases,
    the hold-harmless provision had less effect in our analyses. However,
    under all our scenarios grantees in the Northeast and West would have
    received less total funding while grantees in the Midwest and South would
    have received more. In all four regions of the country, there would have
    been grantees that would have received increased funding and grantees that
    would have received decreased funding. For example, in the Northeast, New
    Jersey would have gained funding and New York would have lost funding
    under both our approaches. In the South, Alabama would gain funding and
    Georgia would lose funding under both our approaches. Appendix XIII shows
    the results of our analyses for ADAP base grants if the hold-harmless
    provision had not been in effect.

    HOPWA Base Funding Would Generally Shift If HIV Cases Were Used in Formula
    Allocations

    There would have been some shifting of funds if HIV and living AIDS case
    counts 95 had been used to allocate HOPWA base grants instead of
    cumulative AIDS cases under either of our methodological approaches-with
    or without the code-based HIV case counts-with southern and midwestern
    grantees generally being among the jurisdictions that would have received
    increased funding. 96 Under the first approach-using living AIDS cases and
    HIV cases when accepted by CDC and only living AIDS cases elsewhere-about
    15 percent or $30.0 million of fiscal year 2004 HOPWA base grants would
    have shifted among grantees. Seventy of 117 grantees would have received
    additional funding in their HOPWA base grants if living HIV and AIDS cases
    had been used to allocate funding. Six grantees would have more than
    doubled their funding. 97 Thirty-five of 47 southern grantees 98 and 18 of
    the 20 midwestern grantees would have received more funding. Southern
    grantees would have received an additional $15.8 million (22 percent) in
    funding while those in the Midwest would have received an additional $3.3
    million (17 percent). Seventeen of the 24 northeastern grantees and 14 of
    the 24 western grantees would have received less funding. The northeastern
    and western grantees would have received $6.3 million (10 percent) and
    $9.7 million (24 percent) less in funding respectively.

    The second approach-using the HIV case counts accepted by CDC, the
    code-based HIV counts we collected from the grantees, and living AIDS
    cases-yields an overall smaller shift in funding although changes would
    have been larger in the Midwest and Northeast. Under this approach,
    approximately 13 percent or $25.6 million of fiscal year 2004 HOPWA base
    grants would have shifted, with Maryland and Charlotte, North Carolina,
    more than doubling their funding. Of the 82 grantees that would have
    received additional funding, 39 are in the South, 19 in the Midwest, 14 in
    the West, and 10 in the Northeast. Overall, the South would have received
    $13.7 million (19 percent) in additional funding and the Midwest would
    have received an additional $4.0 million (21 percent). The Northeast would
    have received $8.5 million (14 percent) less in funding and the West $5.8
    million (15 percent) less. Appendix XIV shows the results of these
    analyses for each jurisdiction under both approaches.

    Differences in Case-reporting Systems Would Affect Allocations

    One explanation for the changes in funding allocations when HIV cases and
    either ELCs or living AIDS cases are used-whether or not the code-based
    HIV case counts are included-instead of only AIDS cases 99 is the maturity
    of HIV case-reporting systems. We found that those grantees that would
    receive increased funding from the use of HIV cases tend to be those with
    the oldest HIV case-reporting systems. Those grantees with the oldest
    reporting systems include 11 southern and 8 midwestern states whose
    HIV-reporting systems were implemented prior to 1995. As shown in table
    10, jurisdictions with long histories of counting HIV cases tend to have
    many more reported HIV cases compared with their number of ELCs than do
    jurisdictions with less-mature reporting systems. This difference is
    likely because jurisdictions with newer systems do not have reports on
    many cases of HIV that were diagnosed before their reporting systems were
    established. 100 This divergence can be illustrated by comparing Wisconsin
    and Delaware, two states with similar numbers of AIDS cases. Wisconsin
    began reporting HIV cases in 1985 while Delaware began in 2001. In
    Wisconsin, as of June 2003, there were about 50 percent more reported HIV
    cases than AIDS cases, or 2,287 HIV cases and 1,507 AIDS cases. As of June
    2003, the 909 reported HIV cases in Delaware were about 40 percent less
    than the 1,518 ELCs. This variability could be reduced as Delaware
    identifies more preexisting HIV cases. However, the variability between
    HIV cases and ELCs would remain if there was a difference in the actual
    number of HIV cases.

    Table 10: Reported HIV Cases and ELCs as of June 2003

    HIV case-reporting system      Number of jurisdictionsa Ratio of HIV cases
    start date                                                         to ELCs
    1985-1991                                            21               1.42
    1992-1998                                            11               1.01
    1999-2002                                            17               0.68

    Source: GAO analysis of CDC, HRSA, and state data.

    aGeorgia, Kentucky, and Puerto Rico are not included in this table because
    they established their HIV-reporting systems after 2002. Connecticut and
    New Hampshire established their name-based HIV-reporting system in 2005.
    However, in this table, Connecticut is classified as having established
    its reporting system in 2001 (and so is included in the 1999-2002 time
    period) since state officials provided us HIV case counts based on the
    system in operation as of June 2003. New Hampshire is classified as having
    established its reporting system in 1990 (and so is included in the
    1985-1991 time period), because state officials provided us HIV case
    counts based on the system in operation as of June 2003.

    Under either approach, grantees might receive increased funding because
    other grantees did not yet have an accurate measure of HIV case counts.
    IOM has reported that it could take from 18 months to several years after
    the implementation of an HIV-reporting system before there would be valid
    estimates of the number of people living with HIV. 101

    The maturity of the HIV-reporting systems can be linked to whether a
    jurisdiction has a name- or code-based system. As discussed earlier, CDC
    does not currently accept HIV case reports from code-based systems.
    However, even if code-based data were incorporated into the CDC case
    counts, the age of the code-based systems could still be a factor since
    the code-based systems tend to be newer than the name-based systems. As of
    December 2005, twelve of the 13 code-based systems were implemented in
    1999 or later, compared with 10 of the 39 name-based systems. The effect
    of the maturity of the code-based systems could be increased if, as CDC
    believes, name-based systems can be executed with more complete coverage
    of cases in much less time than code-based systems. As a result,
    jurisdictions with code-based systems could find themselves with
    undercounts of HIV cases for longer periods of time than jurisdictions
    with name-based systems.

    The use of HIV cases in CARE Act funding formulas could result in
    fluctuations in funding over time because of newly identified preexisting
    HIV cases. Grantees with more mature HIV-reporting systems have generally
    identified more of their HIV cases. Therefore, if HIV cases were used to
    distribute funding, these grantees would tend to receive more funds. As
    grantees with newer systems identify and report a higher percentage of
    their HIV cases, their proportion of the total number of ELCs and HIV
    cases in the country would increase and funding that had shifted away from
    states with newer HIV-reporting systems would shift back, creating
    potentially significant additional shifts in program funding. Without
    corresponding increases in CARE Act funding, this increase in identified
    HIV cases could cause grantees with more mature systems to experience
    funding decreases. Hold-harmless provisions would protect grantees with
    older reporting systems from funding losses. However, grantees with newer
    systems could receive less funding per case because funds would be needed
    to cover hold-harmless provisions.

    Conclusions

    The funding provided under the CARE Act and HOPWA has filled important
    gaps in communities throughout the country, but as Congress reviews these
    programs, it is important to understand how much funding can vary across
    communities with comparable numbers of persons living with AIDS. While
    provisions in the formulas have served specific purposes, such as
    maintaining consistent funding from year to year, it is clear that the
    level of funding available per AIDS case is quite variable because of
    these provisions:

               o  The use of ELCs-AIDS cases reported over the past 10 years
               weighted by survival rates-and the use of 2- and 5-year cumulative
               reported AIDS cases for CARE Act funding results in AIDS case
               counts that do not reflect the number of persons who could be
               served by the program because many persons with AIDS live longer
               than 10 years after their disease is reported, deceased cases are
               included in the case counts, and cases diagnosed prior to the
               reporting period are not included.
               o  Considerably more CARE Act funding has gone to some grantees
               than others even though they have similar numbers of cases because
               of the counting of ELCs in EMAs for both Title I base funding and
               Title II base funding, hold-harmless provisions that protect Title
               I, Title II, and ADAP base grant funding levels, the
               grandfathering of EMAs so that metropolitan areas designated as
               EMAs for fiscal year 1996 continue to be eligible for Title I
               funding, and the division of Emerging Communities into two tiers
               with equal funding of each tier without regard to the number of
               communities or the number of reported AIDS cases in each tier.
               o  The use of cumulative AIDS cases to determine eligibility for
               HOPWA formula grants, including for bonus grants, and the amount
               of HOPWA base grants has led to disproportionate funding per
               living AIDS case because the formula counts deceased cases in
               addition to living cases, thereby resulting in increased funding
               for areas with early outbreaks.

               The CARE Act Title II hold-harmless provision that is funded from
               amounts that would otherwise be available for ADAP Severe Need
               grants has had little effect so far as the amounts needed to fund
               this provision have been comparatively small. However, reducing
               funds to be made available for qualifying states could adversely
               affect the states with severe need in the future if the amounts
               needed to fund the hold-harmless provision increase.

               Congress recognized in the 2000 CARE Act amendments that the CARE
               Act benefits many people whose HIV infection has not progressed to
               AIDS when it required that HIV case counts be used in the
               distribution of funds. The inclusion of HIV cases in the CARE Act
               funding formulas by fiscal year 2007 could eventually improve the
               targeting of funding to needy individuals with HIV disease.
               However, it could result in significant shifts in program funding
               that may not be related to the geographic distribution of HIV/AIDS
               cases because of differences in the type and maturity of the
               reporting system used in each state.

    Matters for Congressional Consideration

    While only AIDS case counts are currently used for determining CARE Act
    formula funding, Congress has required that HIV case counts be
    incorporated into the funding formulas not later than fiscal year 2007.
    Regardless of when HIV case counts are incorporated, issues will still
    exist regarding how AIDS cases are used in the formulas and the effect
    various provisions have on funding. If Congress wishes CARE Act funding to
    more closely reflect the distribution of persons living with AIDS, and to
    more closely reflect the distribution of persons living with HIV/AIDS when
    HIV cases are incorporated into the funding formulas, it should take the
    following five actions:

               o  revising the funding formulas used to determine grantee
               eligibility and grant amounts using a measure of living AIDS cases
               that does not include deceased cases and reflects the longer lives
               of persons living with AIDS,
               o  eliminating the counting of cases in EMAs for Title I base
               grants and again for Title II base grants,
               o  modifying the hold-harmless provisions for Title I, Title II,
               and ADAP base grants to reduce the extent to which they prevent
               funding from shifting to areas where the epidemic has been
               increasing,
               o  modifying the Title I grandfather clause, which protects the
               eligibility of metropolitan areas that no longer meet the
               eligibility criteria, and
               o  eliminating the two-tiered structure of the Emerging
               Communities program.

               If Congress wishes to preserve funding for the ADAP Severe Need
               grants, it should revise the Title II hold-harmless provision that
               is funded with amounts set aside for ADAP Severe Need Grants.

               If Congress wishes HOPWA funding to more closely reflect the
               distribution of persons living with AIDS, it should change the
               program so that HOPWA formula grant eligibility, including for
               bonus grants, and base grant funding allocations are based on a
               measure of living AIDS cases.

    Agency Comments and Our Evaluation

    HHS and HUD provided written comments on a draft of this report. HHS and
    HUD generally agreed with our identification of issues in the funding
    formulas. Their comments are reprinted in appendixes XV and XVI. HHS
    commended us for its comprehensive approach and ambitious analysis that
    pulled together data from many disparate sources. HUD noted that it
    appreciated that the report seeks to improve the targeting of federal
    resources to better assist those with HIV/AIDS.

    HHS noted that we identified various deficiencies in the current HIV data.
    However, HHS suggested that we did not examine the distribution
    differences that would result from incorporating HIV cases into the CARE
    Act funding formulas. HHS noted that we did not assess the potential
    usefulness of HIV data in funding formulas if all jurisdictions
    participated in the national reporting system coordinated by CDC using
    standardized methods of reporting. Such a determination was beyond the
    scope of our work. However, as noted in the draft report, we present
    analyses showing the impact of using HIV cases on fiscal year 2004 funding
    for Title I, Title II, and ADAP base grants, which comprise the bulk of
    CARE Act funding.

    While HHS generally agreed with our matters for congressional
    consideration, HHS made several comments on the issues these matters
    address. HHS noted that our matters for congressional consideration focus
    only on potential changes to the use of AIDS cases in formulas but not to
    the use of HIV cases. The matters for consideration are based on current
    funding formula provisions that require the use of AIDS cases. Our
    discussion should not be interpreted as endorsing the superiority of using
    living AIDS cases instead of HIV/AIDS cases.

    Regardless of whether HIV case counts are used, the funding formula
    provisions we identified will continue to affect proportional funding per
    case if they are maintained. We believe that the use of AIDS case counts
    that include deceased cases and do not reflect the current life spans of
    persons living with AIDS will continue to be of concern. Also, various
    provisions, such as allocating funding for Emerging Communities by tier
    and hold-harmless provisions, will affect the distribution of funding
    regardless of whether HIV cases are used in the formulas.

    HHS pointed out that our assessment of the impact of hold-harmless
    provisions on CARE Act formula funding appears accurate. HHS noted
    disparities in funding per AIDS case that can result from counting cases
    in EMAs once for Title I funding, and once again for Title II funding. HHS
    also agreed with our analysis of the Emerging Communities provision; we
    deleted our reference to a population threshold as an eligibility
    requirement for Emerging Communities in response to its comment on this
    issue. HHS concurred with our suggestion that the Title II hold-harmless
    provision should be revised to preserve funding for ADAP Severe Need
    grants.

    HHS raised concerns that our discussion of the Title I grandfather clause
    in the CARE Act could be interpreted as suggesting EMAs that continue to
    receive grants because of this provision need not be funded. HHS noted
    that a cessation of funding could lead to a decline in these areas'
    systems of care and, by extension, a decline in the progress made in
    fighting the epidemic. However, we note that these areas could receive
    funding through their respective states or territories, which receive
    funds under Title II. In addition, much of the improvement in care for
    those with HIV/AIDS is due to the improvement in drugs, which, as
    indicated in Appendix III, are primarily provided through Title II ADAP
    grants. HHS noted that without Title II minimum grant amounts for states
    and territories, the number of reported AIDS cases in low prevalence areas
    would not be sufficient to sustain state-of-the-art HIV/AIDS care and
    treatment services.

    HHS also noted that we do not have a specific matter for congressional
    consideration regarding the use of OMB's revised definitions of
    metropolitan boundaries for determining Title I EMAs. HHS stated that the
    report suggests that the revised definitions be accepted for determining
    such boundaries. In the report, we discuss the methods used in our
    analysis and the results of this analysis, but take no position on whether
    the new definitions should be used in determining the EMA boundaries.

    HHS commented that the draft report lacked specificity regarding the
    process by which CDC receives HIV case counts from the states. We have
    modified our report to include a discussion of this process. HHS also
    stated in its comments that it would not be appropriate to use the
    code-based case counts in monitoring HIV/AIDS nationally. An assessment of
    whether code-based data should be used for monitoring HIV/AIDS is beyond
    the scope of our work. Our purpose was to provide Congress with an
    indication of the impact of using HIV cases in the CARE Act and HOPWA
    funding formulas in light of the statutory requirement that HIV cases be
    used in CARE Act funding formulas not later than fiscal year 2007. We have
    added text to the report discussing HHS's concerns about code-based data.

    HUD concurred with our matter for congressional consideration that
    cumulative AIDS cases no longer be used in the HOPWA formula. HUD pointed
    out that incorporation of a more current estimate of persons living with
    HIV/AIDS would be more effective in targeting these HOPWA funds to
    grantees. HUD stated in its comments that we did not take into account
    differing housing costs across jurisdictions in the draft report. In
    response to this comment, we revised the report to note that housing costs
    are not currently part of the HOPWA funding formula, and consideration of
    housing costs was not within the scope of our work. However, we have
    clarified the draft report to note that if housing costs were included in
    the funding formulas, they could justify deviations from proportional
    funding per case.

    HUD suggested that we not use the terms base grant and bonus grant. We
    have added a note to our report to reflect that our terminology differs
    from HUD's, but retained the use of bonus and base grants in order to
    differentiate between the two formula funding components.

    HUD expressed concern that the full effect of incorporating HIV case
    counts may not be apparent by only stating the amount of funding that
    would shift among grantees. We have added text to note that the changes
    could result in some grantees more than doubling their funding. HUD
    suggested that these analyses could be done based solely on data from
    jurisdictions with CDC-accepted HIV case counts, or those jurisdictions
    with mature HIV-reporting systems. However, as noted in the draft report,
    we present analyses showing the impact of using only CDC-accepted HIV data
    on fiscal year 2004 HOPWA base grants. We do not include an analysis using
    only jurisdictions with mature HIV-reporting systems because it would
    exclude many jurisdictions and we determined that such an analysis would
    not be appropriate. HUD also pointed out that the draft report did not
    describe the incremental effect on HOPWA allocations of using HIV cases
    with living AIDS cases rather than living AIDS cases only. The draft
    report provided information on this in appendix V, and we have added text
    to the report to refer the reader to this appendix. HUD suggested that we
    expand a footnote to further describe our analysis of HIV cases in funding
    formulas. However, this information is already presented in detail in
    appendix I and is also described in the text of the report.

    In its comments HUD noted bonus funding can provide a significant amount
    of resources to those eligible and that this funding can have a large
    effect on formula funding per AIDS case. As noted in the draft report, we
    show the amount of base funding and bonus funding that each grantee
    received in fiscal year 2004 and state that funding differences per case
    are due in part to the bonus grants. HUD suggested that we revise our
    conclusion to reflect the importance of the bonus grants. However, our
    conclusion focuses on the base grants because of the use of cumulative
    AIDS cases in determining these grants. HUD also noted that not all
    grantees that receive bonus grants sustain the funding from year to year.
    We have added text to note the instability of the bonus funding and that,
    with respect to fiscal year 2006 funding, HUD's appropriation act included
    a provision to mitigate the variability of incidence data by using data
    reported over a 3-year period.

    HUD also suggested that we use different terms to categorize how HOPWA
    funding was allocated by grantees and provided us with updated information
    on how grantees allocated fiscal year 2003 HOPWA grants. We have revised
    the report based on this information.

    HHS and HUD also provided technical comments, which we have incorporated
    where appropriate.

    We are sending copies of this report to the Secretary of Health and Human
    Services, the Secretary of Housing and Urban Development, the Director of
    the Centers for Disease Control and Prevention, the Administrator of the
    Health Resources and Services Administration, and to interested
    congressional committees. We will also make copies available to others
    upon request. In addition, the report will be available on GAO's Web site
    at http://www.gao.gov .

    If you or your staff have any questions about this report, please contact
    me at (202) 512-7119 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 major contributions to this report
    are listed in appendix XVII.

    Marcia Crosse Director, Health Care

    Appendix I: Objectives, Scope, and Methodology

    Objectives

    We assessed the distribution of funding for human immunodeficiency virus
    (HIV) and acquired immunodeficiency syndrome (AIDS) under the Ryan White
    Comprehensive AIDS Resources Emergency Act of 1990 (CARE Act) and the AIDS
    Housing Opportunity Act's Housing Opportunities for Persons with AIDS
    program (HOPWA). Specifically, we are reporting on (1) how CARE Act and
    HOPWA funds are allocated by grantees among the types of services each
    program supports; (2) the extent of funding distribution differences among
    CARE Act and HOPWA grantees, and how CARE Act and HOPWA funding-formula
    provisions contribute to these difference; and (3) what distribution
    differences would result from using HIV cases in CARE Act and HOPWA
    funding formulas.

    Scope and Methodology

    To report on these three objectives, we reviewed the CARE Act of 1990, as
    well as the 1996 and 2000 CARE Act amendments, the AIDS Housing
    Opportunity Act, Health Resources and Services Administration (HRSA) and
    Department of Housing and Urban Development (HUD) documents on CARE Act
    and HOPWA funding, HUD memoranda, Institute of Medicine reports on the
    CARE Act, and other related reports. We interviewed officials from HRSA,
    the Centers for Disease Control and Prevention (CDC), HUD, and the
    National Alliance of State and Territorial AIDS Directors. We received
    information from state government officials regarding their HIV
    case-reporting systems. Details on the scope of our work and the methods
    to address each objective follow.

    Allocation of CARE Act and HOPWA Funds among Service Categories

    To determine how grantees allocate CARE Act and HOPWA funds by types of
    service, we obtained information on the allocation of these funds from
    HRSA and HUD. 1 HRSA provided information on grantees' allocation of CARE
    Act Titles I and II funds for fiscal year 2003, and Title III allocations
    for fiscal year 2002. HRSA also provided funding amounts for its HIV/AIDS
    Dental Reimbursement Program, Community-Based Dental Partnership grants,
    Special Projects of National Significance, and AIDS Education and Training
    Centers program for fiscal year 2003. HUD provided HOPWA allocation data
    for fiscal year 2003, these being the most recently available data. We
    analyzed these data and, where available, calculated the percentage of the
    total amount each service category represented. To assess the reliability
    of HRSA and HUD data on the allocations of CARE Act and HOPWA grant funds,
    we interviewed agency officials about the data and reviewed relevant
    documentation. We determined that the data were sufficiently reliable for
    the purposes of our report.

    Funding-formula Provisions

    We examined the effect of specific funding-formula provisions on CARE Act
    and HOPWA grants. We first assessed the use of 2- and 5-year cumulative
    counts of AIDS cases and the use of estimated living AIDS cases (ELC) in
    CARE Act programs by comparing these measures with living AIDS case counts
    received from CDC. 2 We then examined the following CARE Act formula
    provisions: the counting of ELCs in eligible metropolitan areas (EMA) for
    both Title I and Title II funding, the tiered allocation of Emerging
    Communities funding, the Title I hold-harmless provision, the Title I
    grandfathering clause, and the Title II hold-harmless provision funded
    from amounts available for Severe Need grants. 3 To examine the effect of
    each provision on the CARE Act and HOPWA grant amounts, we measured
    differences on a per case basis, by the amount of funding received, or
    both. We calculated each grantee's percentage of the total number of AIDS
    cases in all relevant jurisdictions, and we used these percentages to
    determine the funding each grantee would have received. We then compared
    these amounts with what was actually received to show the effect of a
    provision in the formula. In addition, we examined the effect of using
    living AIDS cases instead of cumulative cases in making HOPWA base grant
    distributions by comparing the actual funding distributions with simulated
    distributions using living AIDS cases. We also assessed the effect of
    HOPWA bonus grants on funding for eligible metropolitan statistical areas
    (EMSA) by examining the size of these grants and which EMSAs received
    them.

    To conduct our analyses of the effect of funding-formula provisions on
    CARE Act and HOPWA funding and programs in the states, including the
    District of Columbia, Puerto Rico, and metropolitan areas, we obtained
    fiscal year 2004 funding data and AIDS case counts from HRSA and HUD, and
    supplemented this information with additional AIDS case-count data from
    CDC. Fiscal year 2004 data were the latest data available at the time of
    our review. We limited our CARE Act analyses to Titles I and II because
    grants under other parts of the Act are not formula-driven. Similarly, our
    HOPWA analyses are also limited to the parts of the program that are
    formula-based, namely, the base and bonus grants.

    Our analyses of funding provisions take into consideration that CARE Act
    and HOPWA formula grants use different measures of the number of AIDS
    cases to determine grant amounts. There are three measures used for CARE
    Act grants-reported AIDS cases over 2 years, reported AIDS cases over 5
    years, and ELCs. HRSA calculates a jurisdiction's ELCs by using data from
    CDC on the reported AIDS case counts for the last 10 years and weighting
    those numbers to account for the likelihood of deaths. HOPWA uses two
    measures-total AIDS cases reported in the jurisdiction since the beginning
    of the epidemic in 1981 and AIDS incidence rates.

    In our analyses of the funding formulas, we used the measure of AIDS cases
    that is used to determine funding in a particular grant program in order
    to show the effect of different formula provisions on fund distribution.
    We also compared the AIDS data used for funding formulas with data on
    living AIDS cases to assess the effect of not using living AIDS cases on
    funding allocations. For the CARE Act, we used the measure of living AIDS
    cases that is required by law to be used by the program when distributing
    Title I, Title II, and ADAP base grants, that is, the number of ELCs based
    on 10 years of reported cases and survival rates. In the absence of a
    measure of living AIDS cases for HOPWA funding, we used a measure of
    living AIDS cases calculated by subtracting the number of reported deaths
    among AIDS cases in a jurisdiction from the number of reported cases. This
    measure of living AIDS cases is used for illustrative purposes only.

    In our analysis of counting ELCs in EMAs for both Title I and Title II
    CARE Act funding, we aggregated Title I and Title II funding received by
    each of the states and Puerto Rico. Because some EMAs cross state
    boundaries, we apportioned Title I funding among states according to the
    proportionate share of an EMA's ELCs in each state. For example,
    approximately 96 percent of the ELCs in the Boston EMA are in
    Massachusetts and 4 percent are in New Hampshire. Consequently, we
    allocated 96 percent of the Boston EMA's funding to Massachusetts and 4
    percent to New Hampshire. We then compared the combined total Title I and
    Title II funding received by all Title II grantees.

    To examine the effect of using living AIDS case counts on funding for
    HOPWA base grants, we estimated the amount of funding grantees would have
    received by determining the number of living AIDS cases in each
    jurisdiction. CDC provided us with living AIDS cases counts for states,
    Puerto Rico, and EMSAs. To determine each grantee's number of living AIDS
    cases, we subtracted the number of living AIDS cases in EMSAs in a state
    from the total number of living AIDS cases in the state. 4 When an EMSA
    crossed state boundaries, we used information from CDC to determine the
    number of living AIDS cases in each state within the EMSA. For example,
    the Memphis EMSA covers parts of Arkansas, Mississippi, and Tennessee. We
    obtained the living AIDS case counts for each of the states in the Memphis
    EMSA. We then subtracted the number of living AIDS cases from Arkansas in
    the Memphis EMSA from the Arkansas state total, and did comparable
    calculations for the cases from the other two states. After doing similar
    calculations for all EMSAs that crossed state boundaries, we had living
    AIDS case counts for all HOPWA grantees. We then calculated each grantee's
    percentage of the total number of living AIDS cases in all jurisdictions
    and simulated the HOPWA base grant funding allocations according to this
    percentage. We then compared the base funding received using cumulative
    AIDS case counts with the simulated funding allocations using living AIDS
    cases.

    The dates of the AIDS case counts used in our analyses varied by program.
    Depending on the grant, formula allocations under the CARE Act are based
    on the number of ELCs in a jurisdiction as of June 30 preceding the start
    of the fiscal year for which the award is to be made or on the number of
    reported AIDS cases in either the most recent 2 or 5 calendar years. HOPWA
    eligibility is based on the number of cumulative AIDS cases as of March 31
    preceding the start of the fiscal year. Where appropriate, we used ELCs as
    of June 30, 2003, to estimate the effect of formula provisions on CARE Act
    funding for fiscal year 2004, which began on October 1, 2003. For other
    CARE Act grants, we used reported cases for the appropriate calendar-year
    period. We used AIDS case counts as of March 31, 2003, to estimate the
    effect of formula provisions on HOPWA funding for fiscal year 2004.

    We used funding per AIDS case 5 to illustrate the effect of certain
    funding-formula provisions on the distribution of CARE Act and HOPWA
    funds. There are other considerations that could be included in funding
    formulas. For example, differing health care and housing costs across
    regions and differences in grantees' capacities to fund services from
    local resources could be used as bases for distributing program funds and
    to justify deviations from proportional funding per case. 6 Without such
    considerations, regions with the same funding and the same number of AIDS
    cases could not treat the same number of patients. Currently, these
    considerations are not taken into account when awarding formula grants
    under either the CARE Act or HOPWA.

    To analyze the effect of retaining the current EMA boundaries, we reviewed
    documents pertaining to the Office of Management and Budget's (OMB) 2004
    metropolitan boundary definitions. In particular, we relied on information
    generated in our June 2004 report on metropolitan statistical areas (MSA)
    that reported on the process used to develop the 2000 standards and how
    the 2000 standards differ from the 1990 standards. 7 Before each decennial
    census, OMB reviews the standards used in defining the boundaries of these
    statistical areas to ensure their continued usefulness and relevance and,
    if warranted, revises them. OMB had determined that a more fundamental
    examination of the standards was required for 2000, and advisory groups
    were formed to look at the standards. These groups suggested OMB consider
    defining less-populated areas, which had been statistically unrecognized.
    The 2000 standards differ from the 1990 standards in many ways, and the
    Census Bureau and OMB have stated that the new standards are simpler and
    more transparent.

    To demonstrate the effect on the current boundaries of the 51 CARE Act
    Title I EMAs if OMB's 2004 definitions of MSAs were used to establish EMA
    boundaries, we compared the boundaries of existing EMAs with the new MSA
    boundaries that could be created using the new definitions. Because most
    EMA boundaries include portions of more than one new metropolitan area,
    for our analysis we chose two decision rules to serve as a basis for
    selecting new metropolitan areas to be compared with the existing EMAs. 8
    First, we assumed there would be no change in eligibility of the current
    51 Title I EMAs. Second, since the number of ELCs within an EMA would
    change if its boundaries were revised, we chose whatever combination of
    the newly defined metropolitan areas 9 would result in the least change to
    the numbers of ELCs within the EMA's boundaries. The results of our method
    are shown in appendix VII, which lists each of the existing EMAs together
    with the corresponding new areas, the number of counties constituting the
    metropolitan areas, and the number of ELCs contained within those areas.

    To assess the reliability of the data on HRSA's and HUD's distribution of
    CARE Act and HOPWA funds, we asked agency officials about how the data
    were developed and reported. We also reviewed relevant documentation. We
    determined the data were sufficiently reliable for the purposes of our
    report.

    Use of HIV Cases in Formulas

    We examined how CARE Act and HOPWA fiscal year 2004 allocations would have
    been affected by using HIV cases in addition to living AIDS cases to
    determine funding. We undertook our analyses in light of the statutory
    requirement that HIV cases be used in CARE Act funding formulas not later
    than fiscal year 2007. 10 We examined the effect of using HIV cases in
    addition to living AIDS cases on formula funding for CARE Act Title I,
    Title II, and ADAP base grants, and HOPWA base grants in the states,
    Puerto Rico, and metropolitan areas. 11 We limited our analyses to these
    grants because they constitute the majority of the CARE Act and HOPWA
    formula funding. For the CARE Act, we used the measure of living AIDS
    cases that is required by law to be used by the program when distributing
    Title I, Title II, and ADAP base grants, that is, the number of ELCs based
    on 10 years of reported cases and survival rates. In the absence of a
    measure of living AIDS cases for HOPWA funding, we used a measure of
    living AIDS cases calculated by subtracting the number of reported deaths
    among AIDS cases in a jurisdiction from the number of reported cases. This
    measure of living AIDS cases is used for illustrative purposes only. We
    used fiscal year 2004 allocations, which were based on case counts
    reported as of June 30, 2003, for the CARE Act and as of March 31, 2003,
    for HOPWA. As of these dates there were 35 jurisdictions 12 from which CDC
    accepted HIV data and 17 without CDC-approved HIV data. CDC will only
    accept name-based case counts as no code-based system has yet met CDC's
    quality criteria. 13

    Because CDC did not accept HIV case counts from 17 jurisdictions, we
    conducted our analysis using two approaches to measure total HIV/AIDS
    cases for purposes of formula calculations. Under the first approach, we
    used HIV and live AIDS case counts for the 35 jurisdictions from which CDC
    accepted HIV data. 14 Because CDC did not accept the HIV case counts from
    the other 17 jurisdictions, we used only the live AIDS case counts
    received by CDC for these grantees. Consequently, for some grantees we
    used HIV and AIDS case counts, but for others we used only AIDS case
    counts. This approach reflects the data that would have been used if
    funding allocations were based on the HIV and AIDS case counts received by
    CDC in time for determining fiscal year 2004 allocations. Under the second
    approach, we used the same HIV and AIDS case counts as our first approach,
    but supplemented these data with the code-based HIV case counts collected
    by the grantees from which CDC did not receive HIV data. 15 We obtained
    these HIV case counts directly from these jurisdictions. 16 These case
    counts were collected and reported to us by public health authorities. We
    also received information from them regarding their HIV case-reporting
    systems.

    For both approaches, we calculated the grantee's percentage of the total
    number of HIV/AIDS cases relative to all grantees for that program and
    estimated the fiscal year 2004 grants that each would have received. 17
    CARE Act formula allocations were calculated both with certain
    hold-harmless and minimum-grant provisions and again without those
    provisions. 18 Eliminating hold-harmless and minimum-grant provisions was
    done to show the full effect of distributing fiscal year 2004 funding
    solely according to HIV/AIDS data available at that time. We also
    estimated the effect of using HIV cases and living AIDS cases for HOPWA
    base funding.

    In our analyses of how the use of HIV cases would affect funding by
    region, we use U.S. Census Bureau definitions to define regions of the
    country. The Census Bureau divides the country into four regions:
    Northeast, Midwest, South, and West. 19 Table 11 lists the four regions
    and the jurisdictions that constitute them.

    Table 11: U.S. Census Bureau Regions

    Northeast
    Connecticut          New York
    Maine                Pennsylvania
    Massachusetts        Rhode Island
    New Hampshire        Vermont
    New Jersey
    Midwest
    Illinois             Missouri
    Indiana              Nebraska
    Iowa                 North Dakota
    Kansas               Ohio
    Michigan             South Dakota
    Minnesota            Wisconsin
    South
    Alabama              Mississippi
    Arkansas             North Carolina
    Delaware             Oklahoma
    District of Columbia South Carolina
    Florida              Tennessee
    Georgia              Texas
    Kentucky             Virginia
    Louisiana            West Virginia
    Maryland
    West
    Alaska               Nevada
    Arizona              New Mexico
    California           Oregon
    Colorado             Utah
    Hawaii               Washington
    Idaho                Wyoming
    Montana

    Source: U.S. Census Bureau.

    Our analyses of the effect of using HIV case counts for determining CARE
    Act and HOPWA funding rely on data whose reliability has been questioned.
    In June 2004, the Secretary of Health and Human Services determined that
    because of the problems associated with these data, they should not
    currently be used in determining CARE Act funding. We used these data in
    our analyses to give a general indication of the effect of using HIV cases
    in future formula allocations as required by the CARE Act. By using
    HIV/AIDS counts in determining CARE Act and HOPWA funding, the number of
    persons on which funding is based would increase. The effect on individual
    grantees would depend on the number of reported HIV cases in the
    jurisdiction compared with the number reported in other jurisdictions. The
    extent to which the use of HIV cases could affect formula allocations
    cannot be determined by these analyses because jurisdictions use different
    methods to identify HIV cases, and it is unclear to what degree the
    resulting case counts are comparable. However, we think our approaches in
    these analyses are informative in light of the statutory requirement that
    HIV cases be used in CARE Act funding formulas not later than fiscal year
    2007.

    To assess the reliability of the HIV and AIDS case-count data, we asked
    HRSA, HUD, CDC, state, and local officials a series of questions about how
    the data were collected and the methods used to ensure their accuracy. We
    asked state and local officials about their HIV data only when they were
    not accepted by CDC. On the basis of the information provided regarding
    the verification of the reliability of these data, we determined these
    data to be sufficiently reliable for the purposes of our analyses.

    Our analyses do not include the different costs of treating patients with
    HIV and AIDS. The cost of serving persons who have HIV and AIDS can vary
    substantially, depending on the stage of the disease. Patients whose
    disease has progressed to AIDS often require more expensive drug therapies
    and more intensive care than those whose disease has not progressed to
    AIDS. One study found that the average annual cost of treating an HIV
    patient was about $18,000 per year. However, the cost ranged from about
    $14,000 per year for well patients with HIV to $34,000 per year for
    patients with advanced-stage AIDS. 20

    We performed our work from July 2004 through February 2006, in accordance
    with generally accepted government auditing standards.

    Appendix II: CARE Act Title I Awards, Fiscal Year 2004 Appendix II: CARE
    Act Title I Awards, Fiscal Year 2004

    Eligible metropolitan area             Base award    Supplemental award     Minority AIDS  Total Title I award   Total Title I
                                                                             Initiative award                       award per ELCa
    Atlanta, Ga.                           $9,268,937            $7,518,391        $1,552,404          $18,339,732          $2,417
    Austin, Tex.                            2,016,473             1,559,617           224,430            3,800,520           2,302
    Baltimore, Md.                         10,195,952             7,615,994         1,898,933           19,710,879           2,361
    Bergen-Passaic, N.J.b                   2,605,497             2,002,220           206,987            4,814,704           2,306
    Boston, Mass.b, c                       7,434,884             6,630,052           783,761           14,848,697           2,459
    Caguas, P.R.                              935,565               735,726           145,356            1,816,647           2,372
    Chicago, Ill.                          12,801,123            10,363,895         2,261,742           25,426,760           2,426
    Cleveland, Ohiob                        1,850,098             1,379,848           256,990            3,486,936           2,308
    Dallas, Tex                             6,425,600             5,378,653         1,016,330           12,820,583           2,437
    Denver, Colo.b                          2,440,655             1,843,081           245,361            4,529,097           2,273
    Detroit, Mich.                          4,382,256             3,427,753           780,272            8,590,281           2,394
    District of Columbiac                  14,431,645             9,840,164         2,679,205           26,951,014           2,281
    Dutchess County, N.Y.                     639,995               512,173            79,074            1,231,242           2,350
    Fort Lauderdale, Fla.                   7,330,631             6,349,097         1,069,822           14,749,550           2,457
    Fort Worth, Tex.                        1,805,177             1,386,868           181,405            3,373,450           2,282
    Hartford, Conn.                         2,386,547             1,899,397           266,293            4,552,237           2,330
    Houston, Tex.                           9,416,722             8,472,252         1,239,598           19,128,572           2,481
    Jacksonville, Fla.b                     2,517,844             1,873,132           472,117            4,863,093           2,371
    Jersey City, N.J.b                      3,022,562             2,548,825           312,807            5,884,194           2,424
    Kansas City, Mo.b, c                    1,716,152             1,358,374           166,287            3,240,813           2,503
    Las Vegas, Nev.c                        2,375,554             1,832,717           265,130            4,473,401           2,300
    Los Angeles, Calif.                    18,540,316            16,153,706         1,950,099           36,644,121           2,414
    Miami, Fla.                            12,806,009            10,268,761         2,465,241           25,540,011           2,436
    Middlesex-Somerset-Hunterdon,           1,520,364               988,206           215,127            2,723,697           2,200
    N.J.b
    Minneapolis-St. Paul, Minn.b,           1,587,346             1,328,653           177,916            3,093,915           2,432
    c
    Nassau-Suffolk, N.Y.b                   3,182,104             2,402,225           367,460            5,951,789           2,300
    New Haven, Conn.b                       3,639,492             3,012,393           417,463            7,069,348           2,400
    New Orleans, La.                        3,852,184             2,239,460           695,384            6,787,028           2,152
    New York, N.Y.                         60,276,790            52,106,068         9,720,259          122,103,117           2,474
    Newark, N.J.b                           8,151,371             6,076,957         1,083,776           15,312,104           2,297
    Norfolk, Va.c                           2,732,193             1,639,148           448,860            4,820,201           2,155
    Oakland, Calif.b                        3,534,076             2,614,717           462,814            6,611,607           2,318
    Orange County, Calif.                   2,666,239             2,282,192           284,898            5,233,329           2,397
    Orlando, Fla.                           4,021,954             3,028,863           770,969            7,821,786           2,375
    Philadelphia, Pa.c                     12,038,992            10,407,066         2,002,427           24,448,485           2,480
    Phoenix, Ariz.                          3,480,889             2,975,380           358,158            6,814,427           2,391
    Ponce, P.R.                             1,414,340             1,002,813           301,178            2,718,331           2,347
    Portland, Oreg.c                        1,889,451             1,572,205           105,819            3,567,475           2,306
    Riverside-San Bernardino,               3,913,252             2,613,404           296,527            6,823,183           2,130
    Calif.
    Sacramento, Calif.b                     1,558,276             1,328,376            81,399            2,968,051           2,382
    St. Louis, Mo.c                         2,412,195             1,646,152           312,807    4,371,154Appendix           2,213
                                                                                                VI: Total CARE Act
                                                                                              Title I and Title II
                                                                                              Funding by State and
                                                                                                 Territory, Fiscal
                                                                                                         Year 2004
    San Antonio, Tex. Total Title 2,097,083ELCsaELCsa   1,400,297Percent of      336,063Total            3,833,443    2,233Alabama
    I and Title II awards Total                        ELCs in EMAs Percent Title I and Title
    Title I and Title II awards                             of ELCs in EMAs     II awards per
                                                                             ELCTotal Title I
                                                                                 and Title II
                                                                               awards per ELC
    San Diego, Calif. 3,320               5,201,7920%       4,554,583$3,657           531,422    10,287,797Alaskab    2,416974,705
    San Francisco, Calif.b0           16,171,6074,351            13,199,079    479,094Arizona 29,849,78018,635,537      4,1373,978
    San Jose, Calif.b4,685                  1,411,781     1,069,179Arkansas  175,5904,933,831       2,656,5501,466          2,3180
    San Juan, P.R.b               8,139,880California  5,255,408223,607,373   1,337,27742,479       14,732,56588.9      2,2225,264
    Santa Rosa, Calif.bColorado     611,31212,949,158          469,3702,658        26,74675.0       1,107,4284,872           2,298
    Seattle, Wash.b26,797,308          3,024,1725,363         2,605,64291.4      212,8014,997            5,842,615   2,367Delaware
    Tampa-St. Petersburg,                  4,777,6960        3,348,9203,518           593,053 8,719,669District of 2,25033,288,417
    Fla.b1,518                                                                                            Columbia
    Vineland-Millville-Bridgeton,        473,8895,074               297,261     76,748Florida   847,898182,771,752     2,18538,101
    N.J. 100.0
    West Palm Beach, Fla.b4,797             4,577,648      3,964,724Georgia 866,32354,483,301      9,408,69511,226       2,51567.6
    Totald                         $305,704,561Hawaii $246,379,4373,298,130    $43,258,002988        $595,342,0000           3,338

    Source: GAO analysis of HRSA data. Idahob

    Notes: HRSA has awarded Minority AIDS Initiative grants to EMAs. HRSA
    characterizes Minority AIDS Initiative grants to EMAs as Title I grants.
    1,019,352

    aHRSA calculates a jurisdiction's ELCs by using data from CDC on the
    reported AIDS case counts for the last 10 years and weighting those
    numbers to account for the likelihood of death. The average total Title I
    award per ELC was $2,380. 220

    bEMA received hold-harmless funding that is included in base award. 0

    cEMA boundaries include jurisdictions in more than one state. 4,633

    dIndividual entries may not sum to totals because of rounding.

                                                  State/territory State/territory

                                                                      $12,142,447

                                                                              224

                                                                             73.5

                                                                            3,366

                                                                      Connecticut

                                                                        5,340,795

                                                                            6,561

                                                                             77.3

                                                                            4,853

    Illinois

    Appendix III: CARE Act Title II Awards, Fiscal Year 2004 Appendix III:
    CARE Act Title II Awards, Fiscal Year 2004 60,837,359

    12,203

    Grantee                      Base grant award         ADAP base grant award                   Minority AIDS Initiative award          Emerging            ADAP Severe Need award                    Total Title II award           Total Title II award per ELCa
                                                                                                                                 Communities award
    Alabama Iowa             $4,042,811 2,067,375                 $7,004,635619                                         $77,8280     $192,2603,340                          $824,913                       $12,142,447Kansas                         $3,6573,881,999
    Alaskab34.2                     500,000 4,048                       472,602                                    2,103Kentucky             1,937                          974,7050                              4,3513,702                               7,170,005
    Arizona Louisiana        3,201,547 29,740,454                8,392,9036,555                                       54,16448.1                                    11,648,614Maineb                          2,9281,333,909                                   4,537
    Arkansas 0                    1,785,169 3,377                     3,116,716                                   31,946Maryland            12,203                     4,933,83193.6                              3,3665,018                              61,230,030
    California              31,236,233 34,432,147               89,623,4656,960                                      565,82983.2                                 121,425,527Michigan                         2,85824,046,130                                   4,947
    Massachusetts
    Colorado 68.8                 2,117,525 4,611                     5,607,928                                  34,181Minnesota     660,427 1,427                     8,420,06188.7                              3,1685,003                               7,139,028
    Connecticut               3,779,591 9,454,950               11,315,0182,747                                          81,1140                                  15,175,723Missouri                         2,83016,501,234                                   3,442
    Mississippi
    Delaware 76.8                 1,848,490 4,699                     3,202,722                                   39,177Montanab    250,406847,196                               147                              5,340,7950                              3,5185,763
    District of Columbia      4,305,124 1,887,660                 13,842,594525                                         175,7700                                    18,323,488Nevada                         2,79310,757,214                                   3,596
    Nebraska
    Florida 83.3                 29,860,865 4,789                    80,386,630                            893,442New Hampshireb  528,0111,864,452                               358                         111,668,94869.0                              2,9315,208
    Georgia New Jersey       9,408,492 80,222,837              23,684,95116,531                                      260,82884.8         2,789,298              36,143,569New Mexico                          3,2203,338,463                                   4,853
    Hawaii 0                      1,203,101 3,400                     2,084,512                                   10,517New York            59,226                     3,298,13088.6                              3,3385,041                             298,549,361
    IdahobNorth Carolina       500,000 22,668,734                  464,1636,083                                           5260.1            54,663            1,019,352North Dakotac                            4,633292,543                                   3,727
    Illinois 0                    8,837,193 6,803                    25,746,254                                      287,121Ohio             5,171                    34,870,56829.2                              2,8583,916                              20,249,202
    Indiana Oklahoma          3,768,825 6,343,022                6,529,9241,687                                          47,1960    1,057,0053,760                                                          11,402,950Oregon                          3,6849,084,990
    Iowa 68.9                       753,765 4,536                     1,305,985                                7,625Pennsylvania            12,840                     2,067,37567.4                              3,3404,655                              59,766,256
    Kansas Puerto Rico       1,007,120 53,026,882               2,045,49510,711                                        8,54579.9                               3,061,160Rhode Island                          3,1923,189,276                                   4,951
    Kentucky 0                    2,358,712 3,520                     4,086,741                             22,875South Carolina 220,39520,705,328                     481,282 5,563                              7,170,0050                              3,7023,722
    Louisiana South             6,211,002 705,706                  13,829,93597                                         192,0720    1,091,7127,275                         1,628,705                     22,953,426Tennessee                         3,50221,178,234
    Dakotab
    Maineb0                         500,000 4,169                       833,383                                         526Texas     36,525 23,922                     1,370,43474.5                              3,4694,973                             118,965,938
    Maryland Utah             8,446,358 3,235,191                 25,746,254882                                         317,3590                                  34,509,971Vermontb                            2,828883,059                                   3,668
    Massachusetts 0               5,223,382 4,879                    14,684,416                                   99,257Virginia 183,81932,149,863                             6,872                          20,190,87463.2                              2,9014,678
    Michigan Washington      4,335,555 17,349,313               11,002,7633,776                                      117,53169.8                             15,455,849West Virginia                          2,9642,335,062                                   4,595
    Minnesota 11.3                1,026,762 3,778                     3,010,727                                  22,218Wisconsin             1,507                      4,059,7070.4                              2,8453,718                               5,603,506
    Mississippi Wyomingc        3,345,060 360,347                   5,795,70376                                          88,4770      225,7104,741                                     9,454,950Source: GAO analysis of HRSA  3,442Notes: Our analysis is limited to
                                                                                                                                                                                                                       data.             the states and Puerto Rico.
    Missouri bState              2,783,489 cState                     7,409,723                                           56,925    Table 12: EMAs 10,250,137HRSA 2004 EMA HRSA 2004      2,919GAO-identified comparable OMB      Appendix VII: HRSA's Title I EMAs,
    received a Title II  received a Title II base                                                                                with Service Area                               EMA            newly defined 2004 MSA(s) or   GAO-Identified Set of Comparable 2004
    base award of          award of $200,000, the                                                                                          Changes                                     MDIV(s)aGAO-identified comparable OMB     OMB-Defined Metropolitan Areas, and
    $500,000, the        minimum it could receive                                                                                                                                      newly defined 2004 MSA(s) or MDIV(s)a    Changes Appendix VII: HRSA's Title I
    minimum it could       based on the number of                                                                                                                                                                             EMAs, GAO-Identified Set of Comparable
    receive based on the       ELCs in the state.                                                                                                                                                                               2004 OMB-Defined Metropolitan Areas,
    number of ELCs in                                                                                                                                                                                                                                    and Changes
    the state.
    Montanab              500,000 OMB's 1993 full  310,145Number of counties in                     526ELCs in EMAs ELCs in EMAs         Number of  810,671ELCs in EMAs ELCs in EMAs   5,515Decrease in counties Decrease in   OMB's 2004 full title of metropolitan
                            title of metropolitan EMA Number of counties in EMA                                                    counties in EMA                                                                  counties        area(s) OMB's 2004 full title of
                             area OMB's 1993 full                                                                                        Number of                                                                                              metropolitan area(s)
                            title of metropolitan                                                                                  counties in EMA
                                             area
    Nebraska Change in                    639,300     1,107,661Atlanta, Ga. MSA                                         10,25420           130,445                       1,887,66028                              3,5967,663                                   7,589
    ELCs (percent)Change                                                                                                             Atlanta-Sandy
    in ELCs (percent)                                                                                                                  Springs-Ga.
                                                                                                                                 Marietta, Ga. MSA
    Nevada 8                         1,684,896 1%                     4,738,678 32,735Boston-Worcester-Lawrence-Lowell-Brockton,             6,038 6,456,309Boston-Cambridge-Quincy,                                  2,8759                                      10
                                                                                                                Mass.-N.H. NECMA                     Mass-N.H. MSA; Worcester, Mass.
                                                                                                                                                    MSA; and Manchester-Nashua, N.H.
                                                                                                                                                                                 MSA
    New Hampshireb1                     500,000 0                     755,319-9                                            1,709                 9                   1,257,02810,481    3,511Chicago-Naperville-Joliet, Ill.                      Chicago, Ill. PMSA
                                                                                                                                                                                       MDIV; and Lake County-Kenosha County,
                                                                                                                                                                                                              Ill.-Wis. MDIV
    New Jersey 10,534                12,302,631 0                   34,877,5981                                         279,3651           181,943     Cleveland-Lorain-Elyria, Ohio                             47,641,5376                              2,8821,511
                                                                                                                                                                                PMSA
    New Mexico 5                  1,195,795 1,484                    2,127,0241                                          15,6440                          3,338,463Dallas, Tex. PMSA                                  3,4008                                      -2
    New York                         42,659,431 8              124,956,7845,229                                       1,252,4751          394,5231                                -1                             169,263,213                 2,858Denver, Colo. PMSA
    Dallas-Plano-Irving,
    Tex. MDIV
    North Carolina 1,993 7,403,985 Denver-Aurora,                  12,834,09510                                     197,5932,017          708,7030                       1,511,429 5                             22,655,8051                                   3,724
                                       Colo./ MSA
    North Dakotac6                  200,000 3,588 92,543Detroit-Warren-Livonia,                                               07             3,601                                 0                                292,5431                                 6,8030b
                                                    Mich. MSA and Monroe, Mich.
                                                                            MSA
    Ohio Dutchess                     5,448,305 1                 10,909,930524 67,968Poughkeepsie-Newburgh-Middletown, N.Y. MSA          336,0632                             1,010                             16,762,2660                                  3,2421
    County, N.Y. PMSA
    Oklahoma                       2,054,284 Fort                    3,655,7074                                      23,7951,478       190,071Fort                         419,165 4                          6,343,0221,475                                  3,7601
                            Worth-Arlington, Tex.                                                                                 Worth-Arlington,
                                             PMSA                                                                                        Tex. MDIV
    Oregon 0b                           1,664,149   4,225,989Houston, Tex. PMSA                                          12,4896             7,710  Houston-Sugar Land-Baytown, Tex.                             5,902,62710                              2,9478,106
                                                                                                                                                                                 MSA
    Pennsylvania 4                   10,779,206 5                    27,090,216                    258,856Jacksonville, Fla. MSA          188,1964                             2,051        38,316,474Jacksonville, Fla. MSA                                  2,9845
    Puerto Rico 0                     8,238,917 1                   22,598,3881                                          260,697      Kansas City,                      2,661,337 11                         33,759,3391,295         3,152Kansas City, Mo.-Kans. MSA
                                                                                                                                     Mo.-Kans. MSA
    Rhode Island 1,305                1,103,249 0                    1,911,5064                                          14,4611           160,060         Las Vegas, Nev.-Ariz. MSA                              3,189,2763                              3,5201,945
    South Carolina 1              6,774,143 1,857                   11,736,9842                                         164,8580         647,118-5                         1,382,225 20,705,328Middlesex-Somerset-Hunterdon,                                  3,7223
                                                                                                                                                                                                                   N.J. PMSA
    South DakotabEdison,                500,000 4                  204,6542,217                                           1,0521                 2                                79                                 705,706               7,275New Orleans, La. MSA
    N.J. MDIV
    Tennessee 3,154                 6,185,987 New                   12,018,4387                                     122,5263,130        2,851,2831                                 0                            21,178,234-1                                   4,169
                         Orleans-Metairie-Kenner,
                                          La. MSA
    Texas 5                      19,125,106 6,665       50,471,351Newark-Union,                                         469,0706             6,735                       5,943,843 1                             76,009,3702                                  3,1771
                                                                  N.J.-Pa. MDIV
    Utah                             1,074,024 15                1,980,5652,237        7,099Virginia Beach-Norfolk-Newport News,         173,50316                             2,240                              3,235,1910                                  3,6681
    Norfolk-Virginia                                                                                                Va.-N.C. MSA
    Beach-Newport News,
    VA-N.C. MSA
    Vermontb                500,000 Philadelphia,                      382,0079                                       1,0529,857 Philadelphia, Pa.                                 8                            883,0599,782                                  4,8791
                                    Pa.-N.J. PMSA                                                                                 MDIV and Camden,
                                                                                                                                         N.J. MDIV
    Virginia -1                         5,929,341     14,498,751Ponce, P.R. MSA                                         145,0076      244,7791,158     1,707,470 Ponce, P.R. MSA and                             22,525,3487                              3,2781,202
                                                                                                                                                                     Yauco, P.R. MSA
    Washington 1                      3,118,978 4                     7,966,718       35,890Portland-Vancouver, Oreg.-Wash. PMSA                 6                             1,547 11,121,586Portland-Vancouver-Beaverton,                                  2,9457
                                                                                                                                                                                                             Oreg.-Wash. MSA
    West Virginia 0                     713,239 1                   1,303,8750b                                            4,733       Sacramento,                         153,553 3                          2,175,4001,246 3,520Sacramento-Arden-Arcade-Roseville,
                                                                                                                                       Calif. PMSA                                                                                                        Calif. MSA
    Wisconsin 1,321                   1,831,726 0                    3,179,5141                                          28,7916           174,440   374,441 St. Louis, Mo.-Ill. MSA                             5,588,91212                              3,7091,975
    Wyomingc16                      200,000 1,993                      160,3470                                               04                 1                                              360,347San Antonio, Tex. MSA                                  4,7414
    Total San Antonio,             $284,712,863 8             $727,320,9291,750                                      $6,903,7970      $10,000,0004                     $20,759,721 2                          $1,049,697,310                   San Jose, Calif. PMSA
    Tex. MSA

    Source: GAO analysis of HRSA data. 1,146

    Notes: HRSA has awarded grants for Minority AIDS Initiative grants to
    states and territories. HRSA characterizes Minority AIDS Initiative grants
    to states and territories as Title II grants. San Jose-Sunnyvale-Santa
    Clara, Calif. MSA

    In addition to the grantees listed, American Samoa, the Federated States
    of Micronesia, Guam, the Republic of the Marshall Islands, the
    Commonwealth of the Northern Mariana Islands, the Republic of Palau, and
    the Virgin Islands also received Title II funding ranging from a total of
    $50,000 to $1,048,657. 2

    aHRSA calculates a jurisdiction's ELCs by using data from CDC on the
    reported AIDS case counts for the last 10 years and weighting those
    numbers to account for the likelihood of death. The average total Title II
    award per ELC was $3,559. 1,163

    bState received a Title II base award of $500,000, the minimum it could
    receive based on the number of ELCs in the state. 0

    cState received a Title II base award of $200,000, the minimum it could
    receive based on the number of ELCs in the state. 1

                                                                              959

                                                                              395

                                                                            5,215

                                                                            3,512

                                                                            2,246

                                                                              982

                                                                               43

                                                                            2,003

                                                                              906

                                                                            5,080

                                                                              181

                                                                              618

             aHRSA calculates a jurisdiction's ELCs by using data from CDC on the
              reported AIDS case counts for the last 10 years and weighting those
                                  numbers to account for the likelihood of death.

                                                                  Changes Changes

                                         Increase in countiesIncrease in counties

                                                                                0

                                                                            5,484

                                                                               10

                                                Cleveland-Elyria-Mentor, Ohio MSA

                                                                            5,261

                                                                                5

                                                              Detroit, Mich. PMSA

                                                                               93

                                                                                1

                                                                                0

                                                                            2,080

                                                                               15

                                                     Las Vegas-Paradise, Nev. MSA

                                                                            1,238

                                                                                8

                                                                Newark, N.J. PMSA

                                                                               0b

                                                                                0

                                                                                0

                                                                            1,548

                                                                                4

                                                          St. Louis, Mo.-Ill. MSA

                                                                            1,717

                                                                                1

    1

    Appendix IV: HOPWA Formula Grantees and Award Amounts, Fiscal Year 2004
    Appendix IV: HOPWA Formula Grantees and Award Amounts, Fiscal Year 2004

    Seattle-Bellevue-Everett, Wash. PMSA

    Grantee        Base funding        Bonus fundinga Total formula Total formula funding per cumulative     Total formula
                                                            funding                           AIDS caseb       funding per
                                                                                                         living AIDS casec
    Alabama -1       $1,139,000          $1,139,00025   $230 11,816 $444Washington-Arlington-Alexandria,       Washington,
                                                                                        D.C.-Va.-Md. MSA D.C.-Md.-Va-W.Va.
                                                                                                                      PMSA
    Albany, N.Y.      429,000 3             429,000-1           230         497Bergen-Passaic, N.J. PMSA                 0
    11,732
    Arizona 2,088   164,000 New         164,00053,867         230 0                                 4740                11
                     York-White
                  Plains-Wayne,
                      N.Y.-N.J.
                           MDIV
    Arkansas            752,000          752,0002,427           230                                  418                 1
                   Jersey City,
                      N.J. PMSA
    Atlanta, Ga.      4,262,000              $637,000     4,899,000         264 New York City, N.Y. PMSA              5738
    Augusta, Ga.        373,000               373,000           230                                  455
    Austin, Tex.      988,000 5            988,000San        230 41                             5207,724               766
    Caguas, P.R.                Juan-Caguas-Guaynabo,
    PMSA                                     P.R. MSA
    Baltimore,      3,940,000 4             3,996,000  7,936,000San                               463 30        1,0396,631
    Md. 9                                             Juan-Bayamon,
                                                          P.R. PMSA
    Baton Rouge,        666,000             1,147,000     1,813,000                                  626             1,290
    La.
    Birmingham,         520,000            520,000275   230 160,694                                46117    Not applicable
    Ala. 239            158,952
    Boston, Mass.     1,829,000           1,829,00057    230 84,768                    563Not applicable       Subtotal of
    1                                                                                                      unchanged areas
                                                                                                            (see table 13)
    Bridgeport,       752,000 0               27,0000      779,0000                                  238          476Total
    Conn. 84,768
    Buffalo, N.Y.   472,000 Not        472,000245,462        230 17                                52353               332
    243,720          applicable
    California        3,042,000    3,042,000aWe chose  230 bPercent                                  518     Notes: HRSA's
                   Sources: GAO  whatever combination   change that                                       Title I EMAs are
                    analysis of  of the newly defined     rounds to                                         based on OMB's
                     CDC, HRSA,    metropolitan areas     zero, but                                      1993 metropolitan
                  and OMB data.  that would result in      does not                                                   area
                                  the least change to    equal zero                                       definitions.This
                                  the numbers of ELCs      percent.                                       table uses OMB's
                                     within the EMA's                                                      terminology for
                                          boundaries.                                                    classifying types
                                                                                                           of metropolitan
                                                                                                                    areas.
                                                                                                          Specifically, it
                                                                                                                  includes
                                                                                                              metropolitan
                                                                                                          statistical area
                                                                                                            (MSA), primary
                                                                                                              metropolitan
                                                                                                          statistical area
                                                                                                               (PMSA), New
                                                                                                            England county
                                                                                                         metropolitan area
                                                                                                              (NECMA), and
                                                                                                              metropolitan
                                                                                                          division (MDIV).
                                                                                                            The terms used
                                                                                                            and meaning of
                                                                                                               those terms
                                                                                                                    differ
                                                                                                           between1993 and
                                                                                                           2004 because of
                                                                                                         OMB's fundamental
                                                                                                              revisions of
                                                                                                              metropolitan
                                                                                                             concepts. For
                                                                                                                   further
                                                                                                          explanation, see
                                                                                                               GAO-04-758.
    Cambridge,          659,000               659,000           230                                  518
    Mass.
    Camden, N.J.        657,000               657,000           230                                  567
    Charleston,         411,000                 7,000       418,000                                  234               480
    S.C.
    Charlotte,          571,000               571,000           230                                  450
    N.C.
    Chicago, Ill.     5,622,000             2,716,000     8,338,000                                  341               805
    Cincinnati,         550,000               550,000           230                                  523
    Ohio
    Cleveland,          854,000               854,000           230                                  479
    Ohio
    Colorado            366,000               366,000           230                                  462
    Columbia,           626,000               644,000     1,270,000                                  466               824
    S.C.
    Columbus,           584,000               584,000           230                                  619
    Ohio
    Connecticut         251,000               251,000           230                                  479
    Dallas, Tex.      3,192,000             3,192,000           230                                  496
    Delaware            164,000               164,000           230                                  463
    Denver, Colo.     1,424,000             1,424,000           230                                  547
    Detroit,          1,624,000               355,000     1,979,000                                  280               749
    Mich.
    District of       5,626,000             6,176,000    11,802,000                                  482               939
    Columbia
    Florida           4,063,000             4,063,000           230                                  489
    Fort              3,337,000             2,903,000     6,240,000                                  430               954
    Lauderdale,
    Fla.
    Fort Worth,         835,000               835,000           230                                  500
    Tex.
    Gaithersburg,       535,000               535,000           230                                  467
    Md.
    Georgia           1,515,000              HIV/AIDS     1,515,000                                  230               469
                                      FundingHIV/AIDS
                                      FundingHIV/AIDS
                                      FundingHIV/AIDS
                                      FundingHIV/AIDS
                                      FundingHIV/AIDS
                                      FundingHIV/AIDS
                                      FundingHIV/AIDS
                                      FundingHIV/AIDS
                                      FundingHIV/AIDS
                                      FundingHIV/AIDS
                                      FundingHIV/AIDS
                                              Funding
    Hartford,         1,023,000             1,023,000           230                                  460
    Conn.
    Hawaii              181,000               181,000           230                                  439
    Honolulu,           452,000               452,000           230                                  571
    Hawaii
    Houston, Tex.     5,068,000             5,068,000           230                                  591
    Illinois            864,000               864,000           230                                  466
    Indiana             836,000               836,000           230                                  500
    Indianapolis,       759,000               759,000           230                                  476
    Ind.
    Iowa                347,000               347,000           230                                  511
    Islip, N.Y.       1,660,000             1,660,000           230                                  577
    Jackson,            449,000               275,000       724,000                                  371               728
    Miss.
    Jacksonville,     1,195,000               369,000     1,564,000                                  301               623
    Fla.
    Kansas              363,000               363,000           230                                  562
    Kansas City,        978,000               978,000           230                                  506
    Mo.
    Kentucky            423,000               423,000           230                                  418
    Las Vegas,          916,000               916,000           230                                  455
    Nev.
    Los Angeles,     10,476,000            10,476,000           230                                  622
    Calif.
    Louisiana           940,000               940,000           230                                  488
    Louisville,         462,000               462,000           230                                  443
    Ky.
    Maryland            345,000               345,000           230                                  453
    Massachusetts       525,000               525,000           230                                  521
    Memphis,            920,000             1,214,000     2,134,000                                  533             1,000
    Tenn.
    Miami, Fla.       6,149,000             4,566,000    10,715,000                                  400               934
    Michigan            911,000               911,000           230                                  546
    Milwaukee,          512,000               512,000           230                                  511
    Wis.
    Minneapolis,        839,000               839,000           230                                  508
    Minn.
    Minnesota           110,000               110,000           230                                  529
    Mississippi         756,000               756,000           230                                  484
    Missouri            496,000               496,000           230                                  471
    Nashville,          737,000               737,000           230                                  387
    Tenn.
    Nevada              238,000               238,000           230                                  499
    New Haven,          937,000               295,000     1,232,000                                  302               605
    Conn.
    New Jersey        1,106,000                           1,106,000                                  230               593
    New Mexico          533,000               533,000           230                                  501
    New Orleans,      1,785,000             1,207,000     2,992,000                                  385               887
    La.
    New York          1,776,000             1,776,000           230                                  500
    New York,        33,487,000            26,868,000    60,355,000                                  414             1,099
    N.Y.
    Newark, N.J.      4,297,000               885,000     5,182,000                                  277               828
    North             2,082,000             2,082,000           230                                  437
    Carolina
    Oakland,          2,006,000             2,006,000           230                                  595
    Calif.
    Ohio              1,041,000             1,041,000           230                                  524
    Oklahoma            518,000               518,000           230                                  521
    Oklahoma            466,000               466,000           230                                  509
    City, Okla.
    Orlando, Fla.     1,660,000             1,529,000     3,189,000                                  441               913
    Pennsylvania      1,540,000             1,540,000           230                                  445
    Philadelphia,     4,340,000             3,292,000     7,632,000                                  404               799
    Pa.
    Phoenix,          1,434,000             1,434,000           230                                  490
    Ariz.
    Pittsburgh,         626,000               626,000           230                                  568
    Pa.
    Portland,         1,006,000             1,006,000           230                                  523
    Oreg.
    Poughkeepsie,       604,000               604,000           230                                  556
    N.Y.
    Providence,         807,000               807,000           230                                  498
    R.I.
    Puerto Rico       1,748,000             1,748,000           230                                  584
    Richmond, Va.       692,000               692,000           230                                  527
    Riverside,        1,772,000             1,772,000           230                                  462
    Calif.
    Rochester,          597,000               597,000           230                                  460
    N.Y.
    Sacramento,         844,000               844,000           230                                  574
    Calif.
    St. Louis,        1,217,000             1,217,000           230                                  491
    Mo.
    Salt Lake           386,000               386,000           230                                  455
    City, Utah
    San Antonio,      1,027,000             1,027,000           230                                  480
    Tex.
    San Diego,        2,683,000             2,683,000           230                                  522
    Calif.
    San               6,698,000             1,864,000     8,562,000                                  294             1,130
    Francisco,
    Calif.
    San Jose,           792,000               792,000           230                                  538
    Calif.
    San Juan,         4,585,000             2,555,000     7,140,000                                  358             1,000
    P.R.
    Santa Ana,        1,436,000             1,436,000           230                                  489
    Calif.
    Sarasota,           397,000               397,000           230                                  501
    Fla.
    Seattle,          1,688,000             1,688,000           230                                  524
    Wash.
    South             1,387,000             1,387,000           230                                  446
    Carolina
    Springfield,        461,000               461,000           230                                  535
    Mass.
    Tampa, Fla.       2,221,000               168,000     2,389,000                                  247               569
    Tennessee           739,000               739,000           230                                  438
    Texas             2,736,000             2,736,000           230                                  454
    Tucson, Ariz.       402,000               402,000           230                                  515
    Utah                120,000               120,000           230                                  467
    Virginia            640,000               640,000           230                                  499
    Virginia          1,022,000             1,022,000           230                                  505
    Beach, Va.
    Wake County,        345,000                 7,000       352,000                                  234               408
    N.C.
    Warren, Mich.       405,000               405,000           230                                  571
    Washington          652,000               652,000           230                                  480
    West Palm         2,019,000             1,817,000     3,836,000                                  436               933
    Beach, Fla.
    Wilmington,         566,000               232,000       798,000                                  325               624
    Del.
    Wisconsin           405,000               405,000           230                                  509
    Woodbridge,       1,462,000             1,462,000           230                                  627
    N.J.
    Worcester,          369,000               369,000           230                                  480
    Mass.
    Total          $197,288,000           $65,751,000  $263,039,000

    Sources: GAO analysis of CDC and HUD data.

    aBonus grants were awarded to EMSAs that have a higher-than-average per
    capita incidence of AIDS over the previous year.

    bThe average formula funding per cumulative AIDS case was $260.

    cThe number of living AIDS cases was calculated by subtracting the number
    of reported deaths among AIDS cases in a jurisdiction from the number of
    reported cases. The average formula funding per living AIDS case was $573.

                                                                                0

                                                                               22

                                                                                2

                                                                                0

                                                                           49,352

                                                                                3

                                                        Subtotal of changed areas

                                                                               53

                                                                               57

                                                                              296

                                                                                1

    Appendix V: HOPWA Base Funding Allocations Using Cumulative and Living
    AIDS Cases, Fiscal Year 2004 Appendix V: HOPWA Base Funding Allocations
    Using Cumulative and Living AIDS Cases, Fiscal Year 2004

    Grantee        Base funding Cumulative        Percent of  Living AIDS casesa  Percent          Funding if      Difference in
                                AIDS cases   cumulative AIDS                           of     allocated using           fundingb
                                                       cases                       living   living AIDS cases
                                                                                     AIDS
                                                                                    cases
    Alabama          $1,139,000      4,969             0.58%               2,568    0.70%          $1,378,278          -$239,278
    Albany, N.Y.        429,000      1,867              0.22                 864     0.24             463,720            -34,720
    Arizona             164,000        712              0.08                 346     0.09             185,703            -21,703
    Arkansas            752,000      3,274              0.38               1,799     0.49             965,546           -213,546
    Atlanta, Ga.      4,262,000     18,554              2.16               8,557     2.33           4,592,649           -330,649
    Augusta, Ga.        373,000      1,623              0.19                 819     0.22             439,568            -66,568
    Austin, Tex.        988,000      4,302              0.50               1,899     0.52           1,019,217            -31,217
    Baltimore,        3,940,000     17,150              2.00               7,641     2.08           4,101,020           -161,020
    Md.
    Baton Rouge,        666,000      2,898              0.34               1,405     0.38             754,081            -88,081
    La.
    Birmingham,         520,000      2,265              0.26               1,127     0.31             604,875            -84,875
    Ala.
    Boston, Mass.     1,829,000      7,960              0.93               3,248     0.88           1,743,242             85,758
    Bridgeport,         752,000      3,275              0.38               1,637     0.45             878,598           -126,598
    Conn.
    Buffalo, N.Y.       472,000      2,053              0.24                 902     0.25             484,115            -12,115
    California        3,042,000     13,240              1.54               5,870     1.60           3,150,502           -108,502
    Cambridge,          659,000      2,868              0.33               1,271     0.35             682,162            -23,162
    Mass.
    Camden, N.J.        657,000      2,861              0.33               1,159     0.32             622,050             34,950
    Charleston,         411,000      1,788              0.21                 870     0.24             466,940            -55,940
    S.C.
    Charlotte,          571,000      2,486              0.29               1,269     0.35             681,088           -110,088
    N.C.
    Chicago, Ill.     5,622,000     24,471              2.85              10,362     2.82           5,561,415             60,585
    Cincinnati,         550,000      2,394              0.28               1,051     0.29             564,085            -14,085
    Ohio
    Cleveland,          854,000      3,718              0.43               1,784     0.49             957,495           -103,495
    Ohio
    Colorado            366,000      1,595              0.19                 792     0.22             425,076            -59,076
    Columbia,           626,000      2,727              0.32               1,541     0.42             827,074           -201,074
    S.C.
    Columbus,           584,000      2,542              0.30                 944     0.26             506,657             77,343
    Ohio
    Connecticut         251,000      1,092              0.13                 524     0.14             281,237            -30,237
    Dallas, Tex.      3,192,000     13,895              1.62               6,436     1.75           3,454,282           -262,282
    Delaware            164,000        716              0.08                 354     0.10             189,996            -25,996
    Denver, Colo.     1,424,000      6,200              0.72               2,602     0.71           1,396,526             27,474
    Detroit,          1,624,000      7,068              0.82               2,641     0.72           1,417,458            206,542
    Mich.
    District of       5,626,000     24,490              2.85              12,570     3.42           6,746,476         -1,120,476
    Columbia
    Florida           4,063,000     17,686              2.06               8,306     2.26           4,457,934           -394,934
    Fort              3,337,000     14,527              1.69               6,541     1.78           3,510,636           -173,636
    Lauderdale,
    Fla.
    Fort Worth,         835,000      3,635              0.42               1,670     0.45             896,310            -61,310
    Tex.
    Gaithersburg,       535,000      2,328              0.27               1,146     0.31             615,073            -80,073
    Md.
    Georgia           1,515,000      6,593              0.77               3,233     0.88           1,735,192           -220,192
    Hartford,         1,023,000      4,455              0.52               2,222     0.60           1,192,575           -169,575
    Conn.
    Hawaii              181,000        786              0.09                 412     0.11             221,126            -40,126
    Honolulu,           452,000      1,966              0.23                 791     0.22             424,540             27,460
    Hawaii
    Houston, Tex.     5,068,000     22,063              2.57               8,579     2.33           4,604,457            463,543
    Illinois            864,000      3,761              0.44               1,855     0.50             995,602           -131,602
    Indiana             836,000      3,638              0.42               1,673     0.46             897,920            -61,920
    Indianapolis,       759,000      3,302              0.38               1,595     0.43             856,056            -97,056
    Ind.
    Iowa                347,000      1,509              0.18                 679     0.18             364,428            -17,428
    Islip, N.Y.       1,660,000      7,226              0.84               2,877     0.78           1,544,122            115,878
    Jackson,            449,000      1,953              0.23                 994     0.27             533,492            -84,492
    Miss.
    Jacksonville,     1,195,000      5,202              0.61               2,509     0.68           1,346,612           -151,612
    Fla.
    Kansas              363,000      1,582              0.18                 646     0.18             346,716             16,284
    Kansas City,        978,000      4,256              0.50               1,933     0.53           1,037,465            -59,465
    Mo.
    Kentucky            423,000      1,841              0.21               1,011     0.28             542,616           -119,616
    Las Vegas,          916,000      3,986              0.46               2,014     0.55           1,080,939           -164,939
    Nev.
    Los Angeles,     10,476,000     45,601              5.31              16,834     4.58           9,035,018          1,440,982
    Calif.
    Louisiana           940,000      4,091              0.48               1,926     0.52           1,033,708            -93,708
    Louisville,         462,000      2,011              0.23               1,044     0.28             560,328            -98,328
    Ky.
    Maryland            345,000      1,501              0.17                 762     0.21             408,975            -63,975
    Massachusetts       525,000      2,287              0.27               1,007     0.27             540,469            -15,469
    Memphis,            920,000      4,006              0.47               2,133     0.58           1,144,808           -224,808
    Tenn.
    Miami, Fla.       6,149,000     26,766              3.12              11,477     3.12           6,159,849            -10,849
    Michigan            911,000      3,966              0.46               1,669     0.45             895,773             15,227
    Milwaukee,          512,000      2,228              0.26               1,001     0.27             537,249            -25,249
    Wis.
    Minneapolis,        839,000      3,654              0.43               1,650     0.45             885,576            -46,576
    Minn.
    Minnesota           110,000        480              0.06                 208     0.06             111,636             -1,636
    Mississippi         756,000      3,291              0.38               1,563     0.43             838,882            -82,882
    Missouri            496,000      2,157              0.25               1,053     0.29             565,158            -69,158
    Nashville,          737,000      3,208              0.37               1,902     0.52           1,020,827           -283,827
    Tenn.
    Nevada              238,000      1,034              0.12                 477     0.13             256,012            -18,012
    New Haven,          937,000      4,077              0.47               2,036     0.55           1,092,747           -155,747
    Conn.
    New Jersey        1,106,000      4,778              0.56               1,864     0.51           1,000,432            105,568
    New Mexico          533,000      2,319              0.27               1,064     0.29             571,062            -38,062
    New Orleans,      1,785,000      7,769              0.90               3,374     0.92           1,810,868            -25,868
    La.
    New York          1,776,000      7,730              0.90               3,553     0.97           1,906,940           -130,940
    New York,        33,487,000    145,769             16.97              54,900    14.94          29,465,516          4,021,484
    N.Y.
    Newark, N.J.      4,297,000     18,704              2.18               6,262     1.70           3,360,894            936,106
    North             2,082,000      9,065              1.06               4,761     1.30           2,555,288           -473,288
    Carolina
    Oakland,          2,006,000      8,731              1.02               3,374     0.92           1,810,868            195,132
    Calif.
    Ohio              1,041,000      4,533              0.53               1,985     0.54           1,065,374            -24,374
    Oklahoma            518,000      2,254              0.26                 995     0.27             534,029            -16,029
    Oklahoma            466,000      2,027              0.24                 916     0.25             491,629            -25,629
    City, Okla.
    Orlando, Fla.     1,660,000      7,228              0.84               3,494     0.95           1,875,273           -215,273
    Pennsylvania      1,540,000      6,702              0.78               3,463     0.94           1,858,635           -318,635
    Philadelphia,     4,340,000     18,890              2.20               9,546     2.60           5,123,457           -783,457
    Pa.
    Phoenix,          1,434,000      6,244              0.73               2,924     0.80           1,569,347           -135,347
    Ariz.
    Pittsburgh,         626,000      2,723              0.32               1,103     0.30             591,994             34,006
    Pa.
    Portland,         1,006,000      4,378              0.51               1,925     0.52           1,033,172            -27,172
    Oreg.
    Poughkeepsie,       604,000      2,630              0.31               1,087     0.30             583,406             20,594
    N.Y.
    Providence,         807,000      3,514              0.41               1,622     0.44             870,548            -63,548
    R.I.
    Puerto Rico       1,748,000      7,608              0.89               2,995     0.81           1,607,454            140,546
    Richmond, Va.       692,000      3,012              0.35               1,312     0.36             704,167            -12,167
    Riverside,        1,772,000      7,714              0.90               3,834     1.04           2,057,756           -285,756
    Calif.
    Rochester,          597,000      2,599              0.30               1,297     0.35             696,116            -99,116
    N.Y.
    Sacramento,         844,000      3,676              0.43               1,470     0.40             788,967             55,033
    Calif.
    St. Louis,        1,217,000      5,297              0.62               2,481     0.67           1,331,584           -114,584
    Mo.
    Salt Lake           386,000      1,680              0.20                 849     0.23             455,669            -69,669
    City, Utah
    San Antonio,      1,027,000      4,469     0.52Change in      2,138Change in     0.58    1,147,491Grantee     -120,491Dollar
    Tex. Appendix                              Title II base        Title I base                      Grantee      changebDollar
    XII:                                          funding if funding if HIV case                                         changeb
    Estimated                               CDC-accepted HIV     counts from all
    CARE Act                                 case counts and   grantees and ELCs
    Title II Base                          ELCs were used to        were used to
    Funding                                       distribute  distribute funding
    Changes from                             funding without             without
    Use of HIV                             hold-harmless and   hold-harmless and
    Case Counts                                minimum-grant       minimum-grant
    and ELCs                               provisions Change   provisionsaChange
    without                                 in Title II base     in Title I base
    Hold-harmless                                 funding if funding if HIV case
                                            CDC-accepted HIV     counts from all
                                             case counts and   grantees and ELCs
                                           ELCs were used to        were used to
                                                  distribute  distribute funding
                                             funding without             without
                                           hold-harmless and   hold-harmless and
                                               minimum-grant       minimum-grant
                                                  provisions         provisionsa
    San Diego,        2,683,000     11,677       1.36Alabama     5,136$2,550,000  1.4063% 2,756,555$2,010,000         -73,55550%
    Calif. Dollar       Percent
    changebDollar changePercent
    changeb              change
    San               6,698,000  29,156-54      3.40-290,000            7,577-58     2.06    4,066,671Arizona 2,631,3291,220,000
    Francisco,         -270,000
    Calif.
    Alaskac
    San Jose,        792,000 25      3,446      0.40Arkansas        1,472870,000   0.4049      790,041650,000            1,95937
    Calif.
    810,000
    San Juan,         4,585,000  19,960-38    2.32-4,980,000            7,141-16     1.94   3,832,664Colorado   752,3362,100,000
    P.R.            -11,750,000
    California
    Santa Ana,     1,436,000 81      6,250   0.73Connecticut     2,939-1,360,000  0.80-36 1,577,398-1,410,000        -141,398-37
    Calif.
    1,700,000
    Sarasota,           397,000   1,730-40      0.20-220,000              792-12     0.22  425,076District of  -28,076-1,520,000
    Fla. Delaware      -740,000                                                                      Columbia
    Seattle,      1,688,000 -42      7,347       0.86Florida      3,2212,970,000   0.8810   1,728,751-110,000          -40,7510d
    Wash.
    -1,800,000
    South             1,387,000   6,039-38    0.70-4,060,000            3,108-43     0.85     1,668,102Hawaii   -281,102-480,000
    Carolina         -3,530,000
    Georgia
    Springfield,    461,000 -14      2,005        0.23Idahoc          861-80,000  0.23-16     462,109-110,000          -1,109-23
    Mass.
    -170,000
    Tampa, Fla.       2,221,000   9,670-36       1.13-60,000             4,201-1     1.14    2,254,729Indiana   -33,7291,210,000
    Illinois         -3,200,000
    Tennessee        739,000 21      3,218          0.37Iowa         1,68930,000    0.463      906,507-40,000         -167,507-5
    810,000
    Texas Kansas      2,736,000   11,91121       1.39110,000             6,02411     1.64   3,233,156Kentucky   -497,156-940,000
                        210,000
    Tucson, Ariz.   402,000 -45      1,749     0.20Louisiana        7802,110,000   0.2134    418,6361,380,000          -16,63622
    -1,060,000
    Utah Mainec         120,000     524-42        0.0650,000               25710     0.07     137,935Maryland  -17,935-3,020,000
                       -210,000
    Virginia         640,000 35      2,788 0.32Massachusetts     1,282-1,910,000  0.35-37      688,065530,000          -48,06510
    2,980,000
    Virginia          1,022,000    4,45027       0.52680,000             2,02416     0.55  1,086,306Minnesota     -64,306650,000
    Beach, Va.        1,180,000
    Michigan
    Wake County,     345,000 48      1,502   0.17Mississippi        8631,630,000   0.2349    463,1831,220,000         -118,18337
    N.C. 490,000
    Warren, Mich.       405,000    1,76345       0.21880,000               70932     0.19     380,529Montanac     24,471-390,000
    Missouri          1,260,000
    Washington      652,000 -33      2,839      0.33Nebraska        1,357150,000   0.3724       728,31990,000          -76,31914
    -170,000
    West Palm         2,019,000    8,78950       1.02600,000             4,11236     1.12        2,206,962New   -187,962-310,000
    Beach, Fla.         840,000                                                                    Hampshirec
    Nevada
    Wilmington,     566,000 -24      2,459    0.29New Jersey      1,2782,140,000   0.3517      685,919760,000          -119,9196
    Del. -120,000
    Wisconsin New       405,000     1,7615       0.21-50,000               795-4     0.22     426,686New York    -21,686-600,000
    Mexico               60,000
    Woodbridge,   1,462,000 -11      6,363         0.74North      2,3325,030,000   0.6368  1,251,6144,020,000          210,38654
    N.J.                                            Carolina
    -4,640,000
    Worcester,          369,000   1,607-62      0.19-130,000              768-65     0.21         412,195Ohio   -43,1952,420,000
    Mass. North        -120,000
    Dakotae
    Total          $197,288,000    858,752  367,5861,010,000 $197,288,000760,000 Oklahoma                  49                 37
    1,750,00                 32

    Sources: GAO analysis of CDC and HUD data. Oregon

    Notes: By law HOPWA base grants are distributed according to cumulative
    AIDS case counts. -620,000

    aThe number of living AIDS cases was calculated by subtracting the number
    of reported deaths among AIDS cases in a jurisdiction from the number of
    reported cases. -37

    bThis was calculated by subtracting the amount that would have been
    received if living AIDS cases had been used from the amount that was
    received using cumulative AIDS cases. A positive value indicates that the
    jurisdiction received more funding using cumulative AIDS cases than it
    would have received if living AIDS cases had been used. A negative value
    indicates that the jurisdiction would have received more funding if living
    AIDS cases had been used. -280,000

                                                     Percent changePercent change

                                                                               38

                                                                               99

                                                                              -35

                                                                              -40

                                                                               32

                                                                              -40

                                                                              -36

                                                                               64

                                                                              -79

                                                                              -63

                                                                               -1

                                                                               45

    -17

    Appendix VI: Total CARE Act Title I and Title II Funding by State and
    Territory, Fiscal Year 2004

    Pennsylvania

    -2,320,000                    -22    -3,080,000              -29
    -2,950,000                    -36    -3,450,000              -42
    -440,000                      -40      -170,000              -15
    2,370,000                      35     1,620,000               24
    -290,000                      -58      -310,000              -62
    2,250,000                      36     1,550,000               25
    870,000                         5      -990,000               -5
    110,000                        10        10,000                1
    -370,000                      -74      -260,000              -52
    2,370,000                      40     1,620,000               27
    -1,170,000                    -37       170,000                5
    150,000                        21        80,000               11
    940,000                        51       710,000               39
    -90,000                       -46      -100,000              -51
    Notes: HRSA              aIn some   bRounded to  cState received  dPercent
    calculates a       jurisdictions,       nearest  a Title II base    change
    jurisdiction's      HIV cases are      $10,000.         award of      that
    ELCs by using        collected by                  $500,000, the rounds to
    data from CDC on    name while in               minimum it could zero, but
    the reported     others HIV cases               receive based on  does not
    AIDS case counts    are collected                  the number of     equal
    for the last 10     using a coded                    ELCs in the      zero
    years and          identifier. We                     state. The  percent.
    weighting those   used both name-                      estimated
    numbers to         and code-based                changes compare
    account for the   case counts for               this amount with
    likelihood of      this estimate.                 what the state
    death.           CDC only accepts                     would have
                         name-based case                received if HIV
                            counts as no                case counts and
                              code-based                  ELCs had been
                          system has yet                        used to
                         met its quality                      determine
                               criteria.                 funding and if
                                                         there had been
                                                       no hold-harmless
                                                                    and
                                                          minimum-grant
                                                            provisions.
         Appendix XIII:                                  Change in ADAP
         Estimated CARE                                 base funding if
          Act ADAP Base                                CDC-accepted HIV
        Funding Changes                                 case counts and
        from Use of HIV                                  ELCs were used
        Case Counts and                                   to distribute
           ELCs without                                 funding without
          Hold-harmless                                   hold-harmless
         Appendix XIII:                                provision Change
         Estimated CARE                                    in ADAP base
          Act ADAP Base                                      funding if
        Funding Changes                                CDC-accepted HIV
        from Use of HIV                                 case counts and
        Case Counts and                                  ELCs were used
           ELCs without                                   to distribute
          Hold-harmless                                 funding without
                                                          hold-harmless
                                                              provision
        Grantee Grantee           Dollar       Percent           Dollar
                           changebDollar changePercent    changebDollar
                                 changeb        change          changeb
                Alabama       $5,190,000           74%       $3,970,000
                 Alaska          -50,000           -10          -90,000
                Arizona        3,550,000            42        2,370,000
               Arkansas        1,820,000            59        1,330,000
             California      -32,150,000           -36      -12,590,000
               Colorado        5,970,000           106        4,820,000
            Connecticut       -4,060,000           -36       -4,240,000
               Delaware       -1,150,000           -36         -250,000
            District of       -4,970,000           -36       -5,850,000
               Columbia
                Florida       10,400,000            13        1,390,000
                Georgia       -8,500,000           -36      -10,010,000
                 Hawaii         -750,000           -36         -210,000
                  Idaho          310,000            68          240,000
               Illinois       -9,240,000           -36         -250,000
                Indiana        2,690,000            41        1,770,000
                   Iowa          140,000            10          -10,000
                 Kansas          650,000            32          390,000
               Kentucky       -1,470,000           -36       -1,730,000
              Louisiana        5,440,000            39        3,530,000
                  Maine         -300,000           -36          160,000
               Maryland       -9,240,000           -36        7,700,000
          Massachusetts       -5,270,000           -36        1,530,000
               Michigan        3,150,000            29        1,740,000
              Minnesota        1,910,000            63        1,420,000
            Mississippi        3,410,000            60        2,490,000
               Missouri        3,600,000            49        2,510,000
                Montana         -110,000           -36          300,000
               Nebraska          360,000            32          210,000
                 Nevada        2,400,000            51        1,700,000
          New Hampshire         -270,000           -36          210,000
             New Jersey        6,500,000            19        2,390,000
             New Mexico          250,000            12           20,000
               New York       -1,110,000            -1      -13,400,000
         North Carolina       10,190,000            79        7,900,000
           North Dakota           50,000            57           40,000
                   Ohio        5,520,000            51        3,890,000

                                                                      Puerto Rico

                                                                     Rhode Island

                                                                   South Carolina

                                                                    South Dakotac

                                                                        Tennessee

                                                                            Texas

                                                                             Utah

                                                                         Vermontc

                                                                         Virginia

                                                                       Washington

                                                                    West Virginia

                                                                        Wisconsin

                                                                         Wyominge

                       Sources: GAO analysis of CDC, HRSA, state, and local data.

          eState received a Title II base award of $200,000, the minimum it could
          receive based on the number of ELCs in the state. The estimated changes
          compare this amount with what the state would have received if HIV case
         counts and ELCs had been used to determine funding and if there had been
                                   no hold-harmless and minimum-grant provisions.

        Change in ADAP base funding if HIV case counts from all grantees and ELCs
        were used to distribute funding without hold-harmless provisionaChange in
        ADAP base funding if HIV case counts from all grantees and ELCs were used
                           to distribute funding without hold-harmless provisiona

                                                     Percent changePercent change

                                                                              57%

                                                                              -19

                                                                               28

                                                                               43

                                                                              -14

                                                                               86

                                                                              -38

                                                                               -8

                                                                              -42

                                                                                2

                                                                              -42

                                                                              -10

                                                                               51

                                                                               -1

                                                                               27

                                                                               -1

                                                                               19

                                                                              -42

                                                                               26

                                                                               19

                                                                               30

                                                                               10

                                                                               16

                                                                               47

                                                                               43

                                                                               34

                                                                               95

                                                                               19

                                                                               36

                                                                               28

                                                                                7

                                                                                1

                                                                              -11

                                                                               62

                                                                               41

                                                                               36

    Oklahoma

    2,100,000

    59

    1,540,000

    43

    Table 13: EMAs with No Service Area Changes

                           HRSA 2004 EMA                         GAO-identified comparable OMB Changes
                                                                 newly defined 2004 MSA(s) or
                                                                           MDIV(s)a
    OMB's 1993 full title of metropolitan area     Number   ELCs OMB's 2004 full title of        Number   ELCs Decrease Increase Change in
                                                       of     in metropolitan area(s)                of     in       in       in      ELCs
                                                 counties   EMAs                               counties   EMAs counties counties (percent)
                                                   in EMA                                        in EMA
    Austin-San Marcos, Tex. MSA                         5  1,651 Austin-Round Rock, Tex. MSA          5  1,651        0        0        0%
    Baltimore, Md. PMSA                                 7  8,348 Baltimore-Towson, Md. MSA            7  8,348        0        0         0
    Fort Lauderdale, Fla. PMSA                          1  6,002 Fort Lauderdale-Pompano              1  6,002        0        0         0
                                                                 Beach-Deerfield Beach, Fla.
                                                                 MDIV
    Hartford, Conn. NECMA                               3  1,954 Hartford-West Hartford-East          3  1,954        0        0         0
                                                                 Hartford, Conn. MSA
    Los Angeles-Long Beach, Calif. PMSA                 1 15,180 Los Angeles-Long                     1 15,180        0        0         0
                                                                 Beach-Glendale, Calif. MDIV
    Miami, Fla. PMSA                                    1 10,485 Miami-Miami Beach-Kendall,           1 10,485        0        0         0
                                                                 Fla. MDIV
    Minneapolis-St. Paul, Minn.-Wis. MSA               13  1,272 Minneapolis-St.                     13  1,272        0        0         0
                                                                 Paul-Bloomington, Minn.-Wis.
                                                                 MSA
    Nassau-Suffolk, N.Y. PMSA                           2  2,588 Nassau-Suffolk, N.Y. MDIV            2  2,588        0        0         0
    New                                                 2  2,945 Bridgeport-Stamford-Norwalk,         2  2,945        0        0         0
    Haven-Bridgeport-Stamford-Waterbury-Danbury,                 Conn. MSA and New
    Conn. NECMA                                                  Haven-Milford, Conn. MSA
    Oakland, Calif. PMSA                                2  2,852 Oakland-Fremont-Hayward,             2  2,852        0        0         0
                                                                 Calif. MDIV
    Orange County, Calif. PMSA                          1  2,183 Santa Ana-Anaheim-Irvine,            1  2,183        0        0         0
                                                                 Calif. MDIV
    Orlando, Fla. MSA                                   4  3,293 Orlando-Kissimmee, Fla. MSA          4  3,293        0        0         0
    Phoenix-Mesa, Ariz. MSA                             2  2,850 Phoenix-Mesa-Scottsdale,             2  2,850        0        0         0
                                                                 Ariz. MSA
    Riverside-San Bernardino, Calif. PMSA               2  3,204 Riverside-San                        2  3,204        0        0         0
                                                                 Bernardino-Ontario, Calif.
                                                                 MSA
    San Diego, Calif. MSA                               1  4,259 San Diego-Carlsbad San               1  4,259        0        0         0
                                                                 Marcos, CA MSA
    San Francisco, Calif. PMSA                          3  7,216 San Francisco-San                    3  7,216        0        0         0
                                                                 Mateo-Redwood City, Calif.
                                                                 MDIV
    Santa Rosa, Calif. PMSA                             1    482 Santa Rosa-Petaluma, Calif.          1    482        0        0         0
                                                                 MSA
    Tampa-St. Petersburg-Clearwater, Fla. MSA           4  3,875 Tampa-St.                            4  3,875        0        0         0
                                                                 Petersburg-Clearwater, Fla.
                                                                 MSA
    Vineland-Millville-Bridgeton, N.J. PMSA             1    388 Vineland-Millville-Bridgeton,        1    388        0        0         0
                                                                 N.J. MSA
    West Palm Beach-Boca Raton, Fla. MSA                1  3,741 West Palm Beach-Boca                 1  3,741        0        0         0
                                                                 Raton-Boynton Beach, Fla.
                                                                 MDIV
    Total                                              57 84,768 Not applicable                      57 84,768        0        0         0

         HIV/AIDS FundingHIV/AIDS FundingHIV/AIDS FundingHIV/AIDS FundingHIV/AIDS
                  FundingHIV/AIDS FundingHIV/AIDS FundingHIV/AIDS FundingHIV/AIDS
                  FundingHIV/AIDS FundingHIV/AIDS FundingHIV/AIDS FundingHIV/AIDS
                                          FundingHIV/AIDS FundingHIV/AIDS Funding

    Sources: GAO analysis of CDC, HRSA, and OMB data.

    Notes: This table uses OMB's terminology for classifying types of
    metropolitan areas. Specifically, it includes metropolitan statistical
    area (MSA), primary metropolitan statistical area (PMSA), New England
    county metropolitan area (NECMA), and metropolitan division (MDIV). The
    terms used and meaning of those terms differs between1993 and 2004 because
    of OMB's fundamental revisions of metropolitan concepts. For further
    explanation, see GAO-04-758 .

    aWe chose whatever combination of the newly defined metropolitan areas
    that would result in the least change to the numbers of ELCs within the
    EMA's boundaries.

    Oregon

    -1,520,000

                          -36                          -600,000       -14
    Pennsylvania -6,540,000        -24 -8,540,000              -32    Puerto Rico     -7,890,000      -35
    -41               Rhode -690,000             -36      -210,000            -11        South Carolina
                     Island
    44            3,510,000         30  South Dakota       180,000             90        150,000       71
    Tennessee     4,880,000         46 3,330,000                31          Texas      3,440,000        7
    -4                 Utah 330,000               18       110,000              6               Vermont
    -36              50,000         14      Virginia     6,260,000             43      4,200,000       29
    Washington   -2,860,000        -36 720,000                   9  West Virginia        380,000       29
    16            Wisconsin 1,950,000             61     1,440,000             45               Wyoming
    24               20,000         12  Sources: GAO    Notes: The           HRSA       aIn some bRounded
                                         analysis of     ADAP base   calculates a jurisdictions,       to
                                          CDC, HRSA, grant funding jurisdiction's  HIV cases are  nearest
                                          state, and        levels  ELCs by using   collected by $10,000.
                                         local data.   reported to  data from CDC  name while in
                                                       us included         on the     others HIV
                                                               any  reported AIDS      cases are
                                                     hold-harmless    case counts      collected
                                                      funding that   for the last  using a coded
                                                             would   10 years and identifier. We
                                                      otherwise be      weighting      used both
                                                     used for ADAP  those numbers      name- and
                                                       Severe Need to account for     code-based
                                                       grants. The the likelihood    case counts
                                                         estimated      of death.       for this
                                                        dollar and                 estimate. CDC
                                                           percent                  only accepts
                                                           changes                    name-based
                                                         presented                case counts as
                                                          here are                 no code-based
                                                     based on what                system has yet
                                                          grantees                       met its
                                                       received in                       quality
                                                        their ADAP                     criteria.
                                                       base grants
                                                      without this
                                                     hold-harmless
                                                          funding.
    Appendix                           Change in         Change in        Grantee Dollar changeb  Percent
    XIV:                               HOPWA base       HOPWA base                                 change
    Estimated                          funding if   funding if HIV
    HOPWA Base                         CDC-accepted    case counts
    Funding                            HIV case           from all
    Changes from                       counts and     grantees and
    Use of HIV                         living AIDS     living AIDS
    and Living                         case counts     case counts
    AIDS Case                          were used to   were used to
    Counts,                            distribute       distribute
    Fiscal Year                        funding            fundinga
    2004
    Appendix
    XIV:
    Estimated
    HOPWA Base
    Funding
    Changes from
    Use of HIV
    and Living
    AIDS Case
    Counts,
    Fiscal Year
    2004
    Percent         Alabama $1,150,000          101%      $960,000            84%          Albany, N.Y.
    change
    18               30,000          8       Arizona        60,000             39         40,000       27
    Arkansas        630,000         84 520,000                  69   Atlanta, Ga.     -1,160,000      -27
    -33            Augusta, 10,000                 3       -20,000             -6          Austin, Tex.
                        Ga.
    7               -20,000         -2    Baltimore,    -1,170,000            -30      1,770,000       45
                                                 Md.
    Baton Rouge,    470,000         71 370,000                  56    Birmingham,        550,000      106
    La.                                                                      Ala.
    89              Boston, -650,000             -36       110,000              6     Bridgeport, Conn.
                      Mass.
    -21            -180,000        -24 Buffalo, N.Y.        30,000              6        -10,000       -3
    California   -1,150,000        -38 -600,000                -20     Cambridge,       -200,000      -30
                                                                            Mass.
    16              Camden, 180,000               27       110,000             16      Charleston, S.C.
                       N.J.
    72              230,000         57    Charlotte,       900,000            158        780,000      137
                                                N.C.
    Chicago,     -1,860,000        -33 -10,000                  0c    Cincinnati,        200,000       36
    Ill.                                                                     Ohio
    24           Cleveland, 410,000               48       300,000             35              Colorado
                       Ohio
    97              290,000         80     Columbia,       600,000             96        490,000       80
                                                S.C.
    Columbus,       360,000         61 280,000                  48    Connecticut        -60,000      -24
    Ohio
    -28             Dallas, 590,000               19       270,000              9              Delaware
                       Tex.
    -22              30,000         18 Denver, Colo.     1,210,000             85        990,000       69
    Detroit,        270,000         17 110,000                   7    District of       -230,000       -4
    Mich.                                                                Columbia
    0c              Florida -660,000             -16      -950,000            -23           Fort
                                                                                     Lauderdale,
                                                                                            Fla.
    24              460,000         14   Fort Worth,       110,000             13         30,000          3
                                                Tex.

                                                                       -9,350,000

                                                                        5,190,000

                                                                       -1,920,000

                                                                         -140,000

                                                                          210,000

                                                                           40,000

                                                                   Dollar changeb

                                                                           80,000

                                                                       -1,420,000

                                                                           70,000

                                                                          460,000

                                                                         -160,000

                                                                          110,000

                                                                          290,000

                                                                          130,000

                                                                          350,000

                                                                          -70,000

                                                                          -40,000

                                                                           20,000

                                                                          820,000

    Appendix VIII: Estimated CARE Act Title I Funding Changes from Use of HIV
    Case Counts and ELCs with Hold-harmless Appendix VIII: Estimated CARE Act
    Title I Funding Changes from Use of HIV Case Counts and ELCs with
    Hold-harmless

                                     Change in Title I  Change in Title I
                                      base funding if    base funding if
                                      CDC-accepted HIV   HIV case counts
                                      case counts and   from all grantees
                                     ELCs were used to    and ELCs were
                                     distribute funding      used to
                                     with hold-harmless    distribute
                                         provision        funding with
                                                          hold-harmless
                                                           provisiona
    Eligible metropolitan area        Dollar Percent    Dollar changeb Percent
                                        changeb  change                    change
    Atlanta, Ga.                   -$210,000     -2%         -$210,000     -2%
    Austin, Tex.                     260,000      13           -10,000      0c
    Baltimore, Md.                  -240,000      -2         3,210,000      32
    Bergen-Passaic, N.J.             600,000      23           210,000       8
    Boston, Mass.                          0       0         1,180,000      16
    Caguas, P.R.                     -50,000      -5           -50,000      -5
    Chicago, Ill.                   -950,000      -7           510,000       4
    Cleveland, Ohio                  940,000      51           610,000      33
    Dallas, Tex.                   1,630,000      25           660,000      10
    Denver, Colo.                  3,210,000     132         2,530,000     104
    Detroit, Mich.                 1,520,000      35           810,000      19
    District of Columbia            -750,000      -5          -750,000      -5
    Dutchess County, N.Y.             40,000       7           -30,000      -5
    Fort Lauderdale, Fla.          2,060,000      28           940,000      13
    Fort Worth, Tex.                 350,000      19            90,000       5
    Hartford, Conn.                  -80,000      -3           -80,000      -3
    Houston, Tex.                  1,130,000      12           -20,000      0c
    Jacksonville, Fla.               570,000      23           200,000       8
    Jersey City, N.J.                590,000      20           160,000       5
    Kansas City, Mo.                 870,000      51           560,000      32
    Las Vegas, Nev.                1,460,000      61         1,000,000      42
    Los Angeles, Calif.              -10,000      0c           -10,000      0c
    Miami, Fla.                    3,580,000      28         1,620,000      13
    Middlesex-Somerset-Hunterdon,    400,000      26           170,000      11
    N.J.
    Minneapolis-St. Paul, Minn.    1,130,000      71           810,000      51
    Nassau-Suffolk, N.Y.              40,000       1            40,000       1
    New Haven, Conn.                       0       0                 0       0
    New Orleans, La.               1,950,000      51         1,250,000      33
    New York, N.Y.                 5,660,000       9          -310,000      -1
    Newark, N.J.                   2,360,000      29         1,100,000      14
    Norfolk, Va.                   1,560,000      57         1,040,000      38
    Oakland, Calif.                        0       0                 0       0
    Orange County, Calif.            -30,000      -1           -30,000      -1
    Orlando, Fla.                  1,190,000      30           570,000      14
    Philadelphia, Pa.               -230,000      -2          -230,000      -2
    Phoenix, Ariz.                 2,020,000      58         1,360,000      39
    Ponce, P.R.                      -30,000      -2           -30,000      -2
    Portland, Oreg.                  -20,000      -1           -20,000      -1
    Riverside-San Bernardino,        -90,000      -2           -90,000      -2
    Calif.
    Sacramento, Calif.                     0       0                 0       0
    St. Louis, Mo.                 1,120,000      47           830,000      34
    San Antonio, Tex.                180,000       8           -20,000      -1
    San Diego, Calif.               -120,000      -2           800,000      15
    San Francisco, Calif.                  0       0                 0       0
    San Jose, Calif.                       0       0                 0       0
    San Juan, P.R.                         0       0                 0       0
    Santa Rosa, Calif.                     0       0                 0       0
    Seattle, Wash.                         0       0           640,000      21
    Tampa-St. Petersburg, Fla.     1,000,000      21           310,000       7
    Vineland-Millville-Bridgeton,    130,000      28            60,000      12
    N.J.
    West Palm Beach, Fla.            530,000      12                 0       0

    Sources: GAO analysis of CDC, HRSA, state, and local data.

    Notes: The estimated dollar and percent changes are based on what the EMAs
    received in their base grants, including any hold-harmless funding, and
    what they would have received if HIV cases and ELCs had been used to
    allocate funding. In fiscal year 2004, the amount of hold-harmless funding
    was $8,033,563. Because the amounts needed to fund the Title I
    hold-harmless provision are taken from funds that would otherwise be
    available for supplemental grants, the total funding actually allocated as
    base grants and our estimated base grant funding differ by the amounts
    necessary to fund the hold-harmless provision. The hold-harmless funding
    was $43,300,968 when only CDC-accepted HIV case counts and ELCs were used
    and $29,413,708 when the HIV case counts from all grantees were used.

    HRSA calculates a jurisdiction's ELCs by using data from CDC on the
    reported AIDS case counts for the last 10 years and weighting those
    numbers to account for the likelihood of death.

    aIn some jurisdictions, HIV cases are collected by name while in others
    HIV cases are collected using a coded identifier. We used both name- and
    code-based case counts for this estimate. CDC only accepts name-based case
    counts as no code-based system has yet met its quality criteria.

    bRounded to nearest $10,000.

    cPercent change that rounds to zero, but does not equal zero percent.

    Appendix IX: Estimated CARE Act Title II Base Funding Changes from Use of
    HIV Case Counts and ELCs with Hold-harmless Appendix IX: Estimated CARE
    Act Title II Base Funding Changes from Use of HIV Case Counts and ELCs
    with Hold-harmless

                        Change in Title II base   Change in Title II base
                      funding if CDC-accepted HIV   funding if HIV case
                       case counts and ELCs were      counts from all
                      used to distribute funding  grantees and ELCs were
                        with hold-harmless and      used to distribute
                       minimum-grant provisions        funding with
                                                     hold-harmless and
                                                       minimum-grant
                                                        provisionsa
    Grantee           Dollar changeb   Percent          Dollar changeb Percent
                                           change                          change
    Alabama               $1,170,000       29%              $1,000,000     25%
    Alaskac                        0         0                       0       0
    Arizona                  620,000        19                 410,000      13
    Arkansas                 320,000        18                 250,000      14
    California                     0         0                       0       0
    Colorado               1,540,000        73               1,340,000      63
    Connecticut             -150,000        -4                -150,000      -4
    Delaware                -410,000       -22                -410,000     -22
    District of             -940,000       -22                -940,000     -22
    Columbia
    Florida               -1,330,000        -4              -2,910,000     -10
    Georgia               -1,350,000       -14              -1,350,000     -14
    Hawaii                   -70,000        -6                 -70,000      -6
    Idahoc                         0         0                       0       0
    Illinois              -1,780,000       -20                -780,000      -9
    Indiana                  180,000         5                  50,000       1
    Iowa                     -90,000       -11                 -90,000     -11
    Kansas                         0         0                       0       0
    Kentucky                -400,000       -17                -400,000     -17
    Louisiana                700,000        11                 390,000       6
    Mainec                         0         0                       0       0
    Maryland              -1,650,000       -20               2,060,000      24
    Massachusetts           -620,000       -12                  20,000      0d
    Michigan                 370,000         9                 130,000       3
    Minnesota                460,000        45                 370,000      36
    Mississippi              590,000        18                 460,000      14
    Missouri                 720,000        26                 520,000      19
    Montanac                       0         0                       0       0
    Nebraska                 -10,000        -2                 -30,000      -5
    Nevada                   520,000        31                 400,000      24
    New Hampshirec                 0         0                       0       0
    New Jersey               370,000         3                       0       0
    New Mexico               -70,000        -6                 -70,000      -6
    New York              -1,730,000        -4              -1,730,000      -4
    North Carolina         2,440,000        33               2,120,000      29
    North Dakotae            300,000       150                 300,000     150
    Ohio                     940,000        17                 690,000      13
    Oklahoma                 370,000        18                 290,000      14
    Oregon                  -130,000        -8                -130,000      -8
    Pennsylvania          -1,840,000       -17              -1,840,000     -17
    Puerto Rico             -320,000        -4                -320,000      -4
    Rhode Island             -30,000        -2                 -30,000      -2
    South Carolina           470,000         7                 230,000       3
    South Dakotac                  0         0                       0       0
    Tennessee                490,000         8                 270,000       4
    Texas                 -1,140,000        -6              -1,140,000      -6
    Utah                     -60,000        -6                 -60,000      -6
    Vermontc                       0         0                       0       0
    Virginia               1,100,000        19                 750,000      13
    Washington              -200,000        -7                -170,000      -5
    West Virginia            -20,000        -3                 -50,000      -7
    Wisconsin                360,000        20                 290,000      16
    Wyominge                 300,000       150                 300,000     150

    Sources: GAO analysis of CDC, HRSA, state, and local data.

    Notes: HRSA calculates a jurisdiction's ELCs by using data from CDC on the
    reported AIDS case counts for the last 10 years and weighting those
    numbers to account for the likelihood of death.

    For purposes of this analysis, we considered the Title II hold-harmless
    provision that is funded by proportional reductions in Title II base
    grants. We did not include the Title II hold-harmless provision funded by
    amounts otherwise available for Severe Need grants.

    aIn some jurisdictions, HIV cases are collected by name while in others
    HIV cases are collected using a coded identifier. We used both name- and
    code-based case counts for this estimate. CDC only accepts name-based case
    counts as no code-based system has yet met its quality criteria.

    bRounded to nearest $10,000.

    cState received a Title II base award of $500,000, the minimum it could
    receive based on the number of AIDS cases in the state.

    dPercent change that rounds to zero, but does not equal zero percent.

    eState received a Title II base award of $200,000, the minimum it could
    receive based on the number of AIDS cases in the state.

    Appendix X: Estimated CARE Act ADAP Base Funding Changes from Use of HIV
    Case Counts and ELCs with Hold-harmless Appendix X: Estimated CARE Act
    ADAP Base Funding Changes from Use of HIV Case Counts and ELCs with
    Hold-harmless

                         Change in ADAP base       Change in ADAP base
                       funding if CDC-accepted     funding if HIV case
                       HIV case counts and ELCs      counts from all
                       were used to distribute   grantees and ELCs were
                      funding with hold-harmless   used to distribute
                              provision               funding with
                                                      hold-harmless
                                                       provisiona
    Grantee          Dollar changeb   Percent           Dollar changeb Percent
                                          change                           change
    Alabama              $4,810,000       69%              $3,860,000      55%
    Alaska                  -60,000       -13                 -90,000      -20
    Arizona               3,180,000        38               2,260,000       27
    Arkansas              1,670,000        54               1,290,000       42
    California          -18,530,000       -21             -13,400,000      -15
    Colorado              5,610,000       100               4,710,000       84
    Connecticut          -2,970,000       -26              -2,970,000      -26
    Delaware             -1,210,000       -38                -280,000       -9
    District of          -5,240,000       -38              -5,490,000      -40
    Columbia
    Florida               7,570,000         9                 530,000        1
    Georgia              -8,120,000       -34              -8,120,000      -34
    Hawaii                 -610,000       -30                -230,000      -11
    Idaho                   290,000        62                 230,000       49
    Illinois             -9,750,000       -38                -520,000       -2
    Indiana               2,400,000        37               1,690,000       26
    Iowa                     90,000         7                 -20,000       -2
    Kansas                  570,000        28                 360,000       18
    Kentucky             -1,550,000       -38              -1,550,000      -38
    Louisiana             4,840,000        35               3,350,000       24
    Maine                  -260,000       -32                 150,000       18
    Maryland             -9,750,000       -38               7,340,000       29
    Massachusetts        -4,760,000       -32               1,360,000        9
    Michigan              2,710,000        25               1,610,000       15
    Minnesota             1,750,000        58               1,370,000       46
    Mississippi           3,120,000        54               2,410,000       42
    Missouri              3,260,000        44               2,400,000       32
    Montana                 -80,000       -25                 290,000       93
    Nebraska                310,000        28                 200,000       18
    Nevada                2,180,000        46               1,630,000       34
    New Hampshire          -170,000       -22                 200,000       26
    New Jersey            5,210,000        15               2,000,000        6
    New Mexico              170,000         8                 -10,000       0c
    New York             -4,960,000        -4             -14,570,000      -12
    North Carolina        9,470,000        74               7,680,000       60
    North Dakota             50,000        52                  40,000       40
    Ohio                  5,010,000        46               3,730,000       34
    Oklahoma              1,930,000        54               1,490,000       42
    Oregon               -1,230,000       -29                -640,000      -15
    Pennsylvania         -7,180,000       -27              -8,780,000      -32
    Puerto Rico          -5,900,000       -26              -5,900,000      -26
    Rhode Island           -520,000       -27                -230,000      -12
    South Carolina        4,660,000        40               3,350,000       29
    South Dakota            170,000        84                 140,000       69
    Tennessee             4,400,000        41               3,180,000       30
    Texas                 1,760,000         4              -2,430,000       -5
    Utah                    260,000        14                  90,000        5
    Vermont                -130,000       -35                  50,000       12
    Virginia              5,610,000        39               4,000,000       28
    Washington           -2,220,000       -28                 630,000        8
    West Virginia           330,000        25                 200,000       15
    Wisconsin             1,790,000        56               1,400,000       44
    Wyoming                  30,000        20                  20,000       11

    Sources: GAO analysis of CDC, HRSA, state, and local data.

    Notes: The ADAP base grant funding levels reported to us included any
    hold-harmless funding that would otherwise be used for ADAP Severe Need
    grants. The estimated dollar and percent changes presented here are based
    on what grantees received in their ADAP base grants without this
    hold-harmless funding.

    HRSA calculates a jurisdiction's ELCs by using data from CDC on the
    reported AIDS case counts for the last 10 years and weighting those
    numbers to account for the likelihood of death.

    For purposes of this analysis, we considered the Title II hold-harmless
    provision that is funded by proportional reductions in ADAP base grants.
    We did not include the Title II hold-harmless provision funded by amounts
    otherwise available for Severe Need grants.

    aIn some jurisdictions, HIV cases are collected by name while in others
    HIV cases are collected using a coded identifier. We used both name- and
    code-based case counts for this estimate. CDC only accepts name-based case
    counts as no code-based system has yet met its quality criteria.

    bRounded to nearest $10,000.

    cPercent change that rounds to zero, but does not equal zero percent.

    Appendix XI: Estimated CARE Act Title I Base Funding Changes from Use of
    HIV Case Counts and ELCs without Hold-harmless Appendix XI: Estimated CARE
    Act Title I Base Funding Changes from Use of HIV Case Counts and ELCs
    without Hold-harmless

                                       Change in Title I     Change in
                                        base funding if     Title I base
                                     CDC-accepted HIV case funding if HIV
                                     counts and ELCs were   case counts
                                      used to distribute      from all
                                        funding without     grantees and
                                         hold-harmless     ELCs were used
                                           provision       to distribute
                                                              funding
                                                              without
                                                           hold-harmless
                                                             provisiona
    Eligible metropolitan area          Dollar  Percent Dollar changeb Percent
                                          changeb   change                 change
    Atlanta, Ga.                   -$2,830,000     -31%    -$3,600,000    -39%
    Austin, Tex.                       260,000       13        -10,000      0c
    Baltimore, Md.                  -3,110,000      -31      3,210,000      32
    Bergen-Passaic, N.J.               600,000       23        210,000       8
    Boston, Mass.                   -2,310,000      -31      1,180,000      16
    Caguas, P.R.                      -260,000      -28       -340,000     -37
    Chicago, Ill.                   -3,900,000      -31        510,000       4
    Cleveland, Ohio                    940,000       51        610,000      33
    Dallas, Tex.                     1,630,000       25        660,000      10
    Denver, Colo.                    3,210,000      132      2,530,000     104
    Detroit, Mich.                   1,520,000       35        810,000      19
    District of Columbia            -2,330,000      -16     -1,390,000     -10
    Dutchess County, N.Y.               40,000        7        -40,000      -6
    Fort Lauderdale, Fla.            2,060,000       28        940,000      13
    Fort Worth, Tex.                   350,000       19         90,000       5
    Hartford, Conn.                   -730,000      -31       -800,000     -34
    Houston, Tex.                    1,130,000       12       -140,000      -1
    Jacksonville, Fla.                 570,000       23        200,000       8
    Jersey City, N.J.                  590,000       20        160,000       5
    Kansas City, Mo.                   870,000       51        560,000      32
    Las Vegas, Nev.                  1,460,000       61      1,000,000      42
    Los Angeles, Calif.             -5,660,000      -31     -2,660,000     -14
    Miami, Fla.                      3,580,000       28      1,620,000      13
    Middlesex-Somerset-Hunterdon,      400,000       26        170,000      11
    N.J.
    Minneapolis-St. Paul, Minn.      1,130,000       71        810,000      51
    Nassau-Suffolk, N.Y.              -940,000      -29     -1,210,000     -38
    New Haven, Conn.                -1,140,000      -31     -1,270,000     -35
    New Orleans, La.                 1,950,000       51      1,250,000      33
    New York, N.Y.                   5,660,000        9     -2,240,000      -4
    Newark, N.J.                     2,360,000       29      1,100,000      14
    Norfolk, Va.                     1,560,000       57      1,040,000      38
    Oakland, Calif.                 -1,100,000      -32       -680,000     -19
    Orange County, Calif.             -810,000      -31       -190,000      -7
    Orlando, Fla.                    1,190,000       30        570,000      14
    Philadelphia, Pa.               -2,620,000      -22     -3,750,000     -31
    Phoenix, Ariz.                   2,020,000       58      1,360,000      39
    Ponce, P.R.                       -420,000      -29       -540,000     -38
    Portland, Oreg.                   -580,000      -31        -90,000      -5
    Riverside-San Bernardino,       -1,190,000      -31       -170,000      -4
    Calif.
    Sacramento, Calif.                -500,000      -32       -330,000     -21
    St. Louis, Mo.                   1,120,000       47        830,000      34
    San Antonio, Tex.                  180,000        8       -100,000      -5
    San Diego, Calif.               -1,590,000      -31        800,000      15
    San Francisco, Calif.          -10,050,000      -62     -8,470,000     -52
    San Jose, Calif.                  -440,000      -31        -30,000      -2
    San Juan, P.R.                  -2,430,000      -30     -3,120,000     -38
    Santa Rosa, Calif.                -200,000      -33        -30,000      -5
    Seattle, Wash.                    -930,000      -31        640,000      21
    Tampa-St. Petersburg, Fla.       1,000,000       21        310,000       7
    Vineland-Millville-Bridgeton,      130,000       28         60,000      12
    N.J.
    West Palm Beach, Fla.              530,000       12        -80,000      -2

    Sources: GAO analysis of CDC, HRSA, state, and local data.

    Notes: The estimated dollar and percent changes are based on what the EMAs
    actually received in their base grants, which includes hold-harmless
    funding, and what they would have received using HIV cases and ELCs if
    there had been no hold-harmless provision. Because hold-harmless funding
    is taken from amounts otherwise available for supplemental grants, the
    total funding actually allocated as base grants and our estimated funding
    differ by the amount of the hold-harmless funding ($8,033,563).

    HRSA calculates a jurisdiction's ELCs by using data from CDC on the
    reported AIDS case counts for the last 10 years and weighting those
    numbers to account for the likelihood of death.

    aIn some jurisdictions, HIV cases are collected by name while in others
    HIV cases are collected using a coded identifier. We used both name- and
    code-based case counts for this estimate. CDC only accepts name-based case
    counts as no code-based system has yet met its quality criteria.

    bRounded to nearest $10,000.

    cPercent change that rounds to zero, but does not equal zero percent.

    Appendix XII: Estimated CARE Act Title II Base Funding Changes from Use of
    HIV Case Counts and ELCs without Hold-harmless

                                   Change in HOPWA base      Change in
                                 funding if CDC-accepted     HOPWA base
                                HIV case counts and living funding if HIV
                                AIDS case counts were used  case counts
                                  to distribute funding       from all
                                                            grantees and
                                                            living AIDS
                                                            case counts
                                                            were used to
                                                             distribute
                                                              fundinga
    Grantee                     Dollar changeb  Percent Dollar changeb Percent
                                                    change                 change
    Gaithersburg, Md.                 -120,000      -22        190,000      35
    Georgia                           -340,000      -23       -440,000     -29
    Hartford, Conn.                   -220,000      -21       -230,000     -23
    Hawaii                             -30,000      -17         10,000       5
    Honolulu, Hawaii                  -160,000      -37        -70,000     -16
    Houston, Tex.                     -260,000       -5       -660,000     -13
    Illinois                          -190,000      -22        140,000      17
    Indiana                            470,000       56        360,000      43
    Indianapolis, Ind.                 420,000       56        320,000      42
    Iowa                                60,000       17         30,000       8
    Islip, N.Y.                       -300,000      -18       -410,000     -25
    Jackson, Miss.                     450,000       99        370,000      82
    Jacksonville, Fla.                 290,000       24        160,000      14
    Kansas                              90,000       25         50,000      15
    Kentucky                           -60,000      -13        -90,000     -21
    Kansas City, Mo.                   360,000       36        240,000      25
    Las Vegas, Nev.                    710,000       77        570,000      62
    Los Angeles, Calif.             -4,370,000      -42     -3,660,000     -35
    Louisiana                          580,000       62        460,000      49
    Louisville, Ky.                    -40,000       -9        -80,000     -17
    Maryland                           -70,000      -20        710,000     204
    Massachusetts                     -160,000      -30         60,000      12
    Memphis, Tenn.                     940,000      102        780,000      85
    Miami, Fla.                      1,140,000       19        520,000       9
    Michigan                           370,000       41        270,000      29
    Milwaukee, Wis.                    340,000       66        260,000      52
    Minneapolis, Minn.                 350,000       42        250,000      30
    Minnesota                           60,000       56         50,000      43
    Mississippi                        630,000       84        520,000      68
    Missouri                           270,000       55        210,000      42
    Nashville, Tenn.                   680,000       93        560,000      77
    Nevada                             130,000       55        100,000      41
    New Haven, Conn.                  -200,000      -21       -220,000     -24
    HIV/AIDS FundingNew               -770,000      -70       -800,000     -72
    Jersey HIV/AIDS
    FundingHIV/AIDS
    FundingHIV/AIDS
    FundingHIV/AIDS
    FundingHIV/AIDS
    FundingHIV/AIDS
    FundingHIV/AIDS
    FundingHIV/AIDS
    FundingHIV/AIDS
    FundingHIV/AIDS
    FundingHIV/AIDS
    FundingHIV/AIDS
    FundingHIV/AIDS
    FundingHIV/AIDS
    FundingHIV/AIDS
    FundingHIV/AIDS Funding
    New Mexico                         110,000       21         60,000      11
    New Orleans, La.                   760,000       43        550,000      31
    New York                           300,000       17        130,000       7
    New York, N.Y.                  -3,040,000       -9     -5,610,000     -17
    Newark, N.J.                        40,000        1       -330,000      -8
    North Carolina                   2,130,000      103      1,780,000      85
    Oakland, Calif.                   -780,000      -39       -670,000     -33
    Ohio                               500,000       49        370,000      36
    Oklahoma                           430,000       83        350,000      67
    Oklahoma City, Okla.               180,000       39        130,000      27
    Orlando, Fla.                      610,000       37        420,000      25
    Pennsylvania                       -50,000       -4       -180,000     -12
    Philadelphia, Pa.                 -730,000      -17     -1,040,000     -24
    Phoenix, Ariz.                     920,000       65        730,000      51
    Pittsburgh, Pa.                   -120,000      -19       -160,000     -26
    Portland, Oreg.                   -300,000      -30       -110,000     -11
    Poughkeepsie, N.Y.                 -30,000       -5        -80,000     -13
    Providence, R.I.                  -220,000      -27         40,000       5
    Puerto Rico                     -1,080,000      -62     -1,130,000     -65
    Richmond, Va.                      490,000       71        390,000      57
    Riverside, Calif.                 -380,000      -22        -90,000      -5
    Rochester, N.Y.                    170,000       29        110,000      18
    Sacramento, Calif.                -310,000      -37       -280,000     -33
    St. Louis, Mo.                     450,000       37        370,000      30
    Salt Lake City, Utah               120,000       32         80,000      21
    San Antonio, Tex.                  100,000       10            0 d       1
    San Diego, Calif.                 -820,000      -31         20,000       1
    San Francisco, Calif.           -3,950,000      -59     -3,420,000     -51
    San Jose, Calif.                  -260,000      -33       -100,000     -13
    San Juan, P.R.                  -1,990,000      -44     -2,210,000     -48
    Santa Ana, Calif.                 -370,000      -26       -130,000      -9
    Sarasota, Fla.                      40,000       11         10,000       1
    Seattle, Wash.                    -520,000      -31        170,000      10
    South Carolina                   1,040,000       75        840,000      61
    Springfield, Mass.                -150,000      -32         90,000      20
    Tampa, Fla.                        330,000       15        110,000       5
    Tennessee                          490,000       67        390,000      53
    Texas                              780,000       29        480,000      18
    Tucson, Ariz.                      210,000       53        160,000      40
    Utah                                30,000       26         20,000      15
    Virginia                           320,000       50        240,000      37
    Virginia Beach, Va.                720,000       71        580,000      56
    Wake County, N.C.                  360,000      105        300,000      88
    Warren, Mich.                      120,000       31         80,000      20
    Washington                        -160,000      -25         70,000      10
    West Palm Beach, Fla.              270,000       14         80,000       4
    Wilmington, Del.                   -70,000      -13        110,000      19
    Wisconsin                          220,000       54        170,000      41
    Woodbridge, N.J.                    50,000        4        -80,000      -5
    Worcester, Mass.                   -90,000      -25         80,000      22

    Sources: GAO analysis of CDC, HUD, state, and local data.

    Notes: The number of living AIDS cases was calculated by subtracting the
    number of reported deaths among AIDS cases in a jurisdiction from the
    number of reported cases.

    aIn some jurisdictions, HIV cases are collected by name while in others
    HIV cases are collected using a coded identifier. We used both name- and
    code-based case counts for this estimate. CDC only accepts name-based case
    counts as no code-based system has yet met its quality criteria.

    bRounded to nearest $10,000.

    cPercent change that rounds to zero, but does not equal zero.

    dDollar change that rounds to zero, but does not equal zero.

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

    Appendix XVI: Comments from the Department of Housing and Urban
    Development Appendix XVI: Comments from the Department of Housing and
    Urban Development

    Appendix XVII: GAO Contact and Staff Acknowledgments

    GAO Contact

    Marcia Crosse, (202) 512-7119 or crossem@gao.gov

    Acknowledgments

    In addition to the contact above, James McClyde, Assistant Director;
    Robert Copeland; Robert Dinkelmeyer; Louise Duhamel; Cathy Hamann; Opal
    Winebrenner; Craig Winslow; and Suzanne Worth made key contributions to
    this report.

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    Ryan White CARE Act of 1990: Opportunities Are Available to Improve
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    (290345)

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    Highlights of GAO-06-332 , a report to congressional requesters

    February 2006

    HIV/AIDS

    Changes Needed to Improve the Distribution of Ryan White CARE Act and
    Housing Funds

    Among federal efforts to address the HIV/AIDS epidemic are the CARE Act of
    1990 and the Housing Opportunities for Persons with AIDS program (HOPWA)
    administered by the Departments of Health and Human Services (HHS) and
    Housing and Urban Development (HUD), respectively. Both use formulas based
    upon a grantee's number of AIDS cases, rather than HIV and AIDS cases, to
    distribute funds to metropolitan areas, states, and territories. HIV cases
    must be incorporated with AIDS cases in CARE Act formulas not later than
    fiscal year 2007.

    GAO was asked to examine (1) how CARE Act and HOPWA funds are allocated
    among types of services, (2) the extent of funding distribution
    differences among CARE Act and HOPWA grantees, and how funding formula
    provisions contribute to these differences, and (3) what distribution
    differences could result from incorporating HIV case counts in CARE Act
    and HOPWA funding formulas.

    What GAO Recommends

    If Congress wishes CARE Act and HOPWA funding to more closely reflect the
    distribution of persons living with AIDS, it should consider taking
    actions that lead to more comparable funding per case by revising the
    funding formulas. HHS and HUD generally agreed with GAO's identification
    of issues in the funding formulas.

    CARE Act and HOPWA grants are allocated by grantees for health care,
    housing assistance, and a variety of services for people with HIV/AIDS.
    These grants provide services for persons who have been diagnosed with HIV
    that has not progressed to AIDS as well as those for whom it has. In
    fiscal year 2003, more than half of Title I CARE Act funds awarded to
    eligible metropolitan areas (EMAs) were allocated for health care services
    such as outpatient care and home health services, and over two-thirds of
    Title II CARE Act funds awarded to states and territories were allocated
    for medications. Two-thirds of HOPWA funds were used for direct housing
    costs for people with HIV/AIDS and their families.

    Multiple provisions in the CARE Act and HOPWA grant funding formulas as
    enacted result in funding not being comparable per AIDS case across
    grantees. First, both the CARE Act and HOPWA use measures of AIDS cases
    that do not accurately reflect the number of persons living with AIDS. For
    example, the statutory funding formulas require the use of cumulative AIDS
    case counts, which could include deceased cases. Second, AIDS cases within
    EMAs are counted once for determining funding under Title I of the CARE
    Act for EMAs and again under Title II for determining funding for the
    states and territories in which those EMAs are located. As a result,
    states with EMAs receive more total funding per case than states without
    EMAs. Third, CARE Act hold-harmless provisions under Titles I and II and
    the grandfather clause for EMAs under Title I sustain the funding and
    eligibility of CARE Act grantees on the basis of a previous year's
    measurements of the number of AIDS cases in these jurisdictions. For
    example, under Title I's hold-harmless provision, one EMA continues to
    have deceased AIDS cases factored into its allocation because its
    hold-harmless funding dates back to the mid-1990s when formula funding was
    based on a count of AIDS cases from the beginning of the epidemic.

    If HIV case counts had been incorporated along with AIDS case counts in
    allocating fiscal year 2004 CARE Act and HOPWA grants, funding would have
    shifted among jurisdictions. Grantees in the South and the Midwest
    generally would have received more funding, although there would have been
    grantees that would have received increased funding and grantees that
    would have received decreased funding in every region of the country.
    Although CARE Act and HOPWA grantees have established HIV case reporting
    systems, differences between these systems-in their maturity and reporting
    methods, for instance-would impact the appropriateness of using HIV case
    counts in distributing CARE Act and HOPWA funding. GAO found that CARE Act
    and HOPWA fiscal year 2004 funding would have shifted to jurisdictions
    with more mature HIV reporting systems.
    *** End of document. ***