HIV/AIDS: Use of Ryan White CARE Act and Other Assistance Grant Funds
(Letter Report, 03/01/2000, GAO/HEHS-00-54).

This report discusses the following three programs: the Ryan White
Comprehensive AIDS Resources Emergency Act (CARE) of 1990 run by the
Department of Housing and Human Services, the Centers for Disease
Control and Prevention's (CDC) HIV/AIDS prevention grants, and the
Department of Housing and Urban Development's Housing Opportunities for
Persons Living With AIDS. GAO found that funds provided by the CARE Act
serve vulnerable groups in higher proportions than their representation
in the AIDS population and that its drug assistance services are
reaching the rural AIDS population in proportion to the AIDS cases in
rural areas. Most CARE Act funds go to medical treatment and
medications. About two-thirds of CDC's fiscal year 1998 HIV prevention
funds to states, localities, schools, and organizations were used for
health education and risk reduction, public information, evaluation
research, capacity building and infrastructure development, and
community planning. About two-thirds of the HUD program's funds were
used in 1994-98 for housing assistance. Urban areas generally receive
higher funding per AIDS case when an area is designated as an eligible
metropolitan area. GAO found that the compensation for administrators of
organizations that received federal HIV/AIDS funds was generally
comparable to that of administrators of similar nonprofit organizations.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-00-54
     TITLE:  HIV/AIDS: Use of Ryan White CARE Act and Other Assistance
	     Grant Funds
      DATE:  03/01/2000
   SUBJECT:  Acquired immunodeficiency syndrome
	     Blacks
	     Women
	     Disadvantaged persons
	     Federal aid programs
	     Health care services
	     Health services administration
	     Health insurance
	     Health resources utilization
	     Federal grants
IDENTIFIER:  HUD Housing Opportunities for Persons with AIDS Program
	     Medicaid Program
	     Supplemental Security Income Program
	     SSI
	     AIDS
	     CDC HIV/AIDS Prevention Grants Program

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GAO/HEHS-00-54

Appendix I: CARE Act Criteria for Counseling and HUD Policies
on Illicit Drug Use in Housing

34

Appendix II: Methodology and Information on Administrators' Compensation

36

Appendix III: Dates When States and Territories Began Reporting HIV
Infection

42

Appendix IV: CARE Act Title I Awards, Fiscal Year 1999

43

Appendix V: CARE Act Title II HIV Grants, Fiscal Year 1999

46

Appendix VI: HOPWA Formula Grantees, Fiscal Year 1999

48

Appendix VII: Characteristics of CARE Act Clients and Persons Living With
AIDS at Seven Locations

51

Table 1: The Ryan White CARE Act's Programs Described 9

Table 2: Selected CDC HIV Prevention Program Funding,
Fiscal Year 1998 10

Table 3: Characteristics of Individuals Who Receive Services From Providers
Funded and Not Funded by the CARE Act 13

Table 4: Average Percentage of CARE Act Title I and Title II Funds
Spent on Services, Fiscal Year 1998 18

Table 5: Available CARE Act Title I and Title II Funds per AIDS Case
in Six States, Fiscal Year 1997 23

Table 6: Distribution of HOPWA Funds in Six States and Their
EMSAs, Fiscal Year 1997 25

Table 7: Compensation Characteristics at Nonprofit Organizations 31

Table 8: Organizations in Five Locations Funded by CARE Act Title I,
Fiscal Year 1998 39

Table 9: Compensation by Type of Nonprofit Organization 41

Figure 1: Federal HIV/AIDS Funding, Fiscal Year 1999 6

Figure 2: Distribution of CARE Act Title I-III Funds, Fiscal Year 1998 16

Figure 3: Distribution of Selected CDC HIV Prevention Program
Funds, Fiscal Year 1998 20

Figure 4: Distribution of HOPWA Funds, 1994-98 22

Figure 5: ADAP Clients and AIDS Cases in Non-MSA Areas, 1998-99 28

Figure 6: Distribution of AIDS Cases and CARE Act Clients in
Michigan, 1998 29

Figure 7: Distribution of AIDS Cases and CARE Act Clients in
Virginia, 1998 30

ADAP AIDS Drug Assistance Program

AHRQ Agency for Healthcare Research and Quality

AIDS acquired immunodeficiency syndrome

CARE Act Ryan White Comprehensive AIDS Resources Emergency Act of 1990

CBC Congressional Black Caucus

CBO Congressional Budget Office

CDC Centers for Disease Control and Prevention

EMA eligible metropolitan area

EMSA eligible metropolitan statistical area

HCSUS HIV Cost and Services Utilization Study

HHS Department of Health and Human Services

HIV human immunodeficiency virus

HOPWA Housing Opportunities for Persons Living With AIDS

HRSA Health Resources and Services Administration

HUD Department of Housing and Urban Development

IRS Internal Revenue Service

MSA metropolitan statistical area

NCCS National Center for Charitable Statistics

SSI Supplemental Security Income

Health, Education, and
Human Services Division

B-282771

March 1, 2000

The Honorable Dick Armey, Majority Leader
House of Representatives

The Honorable Thomas J. Bliley, Jr., Chairman
Committee on Commerce
House of Representatives

The Honorable Tom Coburn, Vice Chairman
Subcommittee on Health and Environment
Committee on Commerce
House of Representatives

Since the first cases of acquired immunodeficiency syndrome (AIDS) were
identified in 1981, more than 700,000 persons in the United States have been
diagnosed with AIDS. Recent developments in medical and pharmacological
therapies have improved the survival of AIDS patients. At the end of 1998,
an estimated 300,000 persons were living with AIDS. In addition, it is
estimated that hundreds of thousands of people are infected with the human
immunodeficiency virus (HIV) but have not progressed to AIDS.

In addition to increasing, the AIDS population has changed over time, with
minorities and women representing a larger proportion of cases. For example,
for the 12 months ending June 1993, African Americans accounted for 35
percent of reported AIDS cases, women 15 percent. For the 12 months ending
June 1999, the figures were 46 percent African Americans and 23 percent
women. The AIDS population by exposure category, or how HIV was contracted,
has also changed. Men who have sex with men accounted for 48 percent of the
reported AIDS cases during the 12 months ending June 1993. This group,
however, accounted for only 34 percent of the reported AIDS cases for the
period ending June 1999.

A number of federal HIV/AIDS programs provide for research, prevention,
health care, and support services to reduce the risk of contracting the
disease and to assist those who are infected with the virus. You asked us to
provide information on three programs that fund prevention activities,
health care, and other assistance: the Ryan White Comprehensive AIDS
Resources Emergency Act of 1990 (P.L. 101-381) (CARE Act), which is
administered by the Department of Health and Human Services' (HHS) Health
Resources and Services Administration (HRSA); the Centers for Disease
Control and Prevention's (CDC) HIV/AIDS prevention grants; and the
Department of Housing and Urban Development's (HUD) Housing Opportunities
for Persons Living With AIDS (HOPWA). You asked us to determine (1) the
characteristics of the persons who are served under the CARE Act; (2) how
CARE Act, CDC prevention, and HOPWA funds are distributed to treatment,
support services, housing, prevention, and program administration; (3)
whether the current approach to funding under the CARE Act leads to
advantages or disadvantages in particular areas; (4) whether CARE Act
services are reaching rural areas; and (5) how the salaries of
administrators of organizations providing HIV/AIDS services compare with the
salaries of administrators of other similar nonprofit organizations. We also
provide information related to your questions about CARE Act requirements
for counseling and HUD's policies regarding illicit drug use in HUD-funded
housing (see app. I).

To conduct our work, we interviewed officials at HUD and at HHS, including
HRSA, CDC, and the Agency for Healthcare Research and Quality (AHRQ). We
obtained and analyzed data from these federal agencies. We obtained funding
and other data from six states and public tax records on a sample of
nonprofit organizations. We reviewed federal legislation and regulations and
relevant HIV/AIDS literature. We conducted our work between June 1999 and
January 2000 in accordance with generally accepted government auditing
standards. Appendix II provides detailed information on our methodology for
comparing administrators' compensation for AIDS service organizations and
similar nonprofit organizations.

The CARE Act funds appear to be reaching groups of infected individuals that
have generally been found to be underserved, including the uninsured and the
poor. African Americans, Hispanics, and women are served by the CARE Act in
higher proportions than their representation in the AIDS population. These
vulnerable groups make up the majority of CARE Act clients.

The CARE Act funds both health care and support services, such as case
management, housing, transportation, and nutrition. Most of the funds,
however, are used for medical treatment and medications. CDC supports a wide
range of state and local HIV prevention activities. About two-thirds of
CDC's fiscal year 1998 HIV prevention funds to states, localities, schools,
and organizations were used for health education and risk reduction, public
information, evaluation and research, capacity building and infrastructure
development, and community planning. About one-third was used for counseling
about the risks of contracting HIV and the need to notify partners about
potential HIV infection, testing for the virus, and referring persons who
test positive to appropriate care. HOPWA helps low-income people with
HIV/AIDS and their families secure housing and provides other services.
HOPWA funds may be used for a variety of housing-related expenses, social
services, and program development. Between 1994 and 1998, about two-thirds
of HOPWA funds were used for housing assistance. All the programs have
limitations on how program funds can be used for administrative purposes.

The levels of funding differ in different areas, with urban areas generally
receiving higher funding per AIDS case when an area is designated as an
eligible metropolitan area (EMA). EMAs receive funds directly from the
federal government under title I of the CARE Act, in addition to the funds
provided through the states under title II. While HOPWA funds also vary
between states and their eligible metropolitan statistical areas (EMSA),
HOPWA state awards are allocated to provide assistance in areas of the state
that are outside any qualifying metropolitan area that receives a HOPWA
allocation.

While the vast majority of people with AIDS reside in urban areas, the
number of AIDS cases is growing in rural areas, which may offer more limited
medical and social services. CARE Act drug assistance services are reaching
the rural AIDS population in proportion to the AIDS cases in rural areas.
Other services under the CARE Act are being provided to individuals who
reside in rural areas, although data do not exist to show where the
individuals receive the services.

The compensation for administrators of organizations that received federal
HIV/AIDS funds was generally comparable to that of administrators of similar
nonprofit organizations. The median compensation for administrators at
organizations that received CARE Act or CDC HIV prevention funds was
$78,000, and the median at organizations that serve only HIV/AIDS clients
was $64,878. The median for other nonprofit organizations providing such
services as health care, family planning, and substance abuse prevention and
treatment services was $74,203.

The CARE Act, CDC HIV prevention programs, and HOPWA accounted for about 20
percent of the estimated $10 billion in federal spending on HIV/AIDS
programs for fiscal year 1999. For that period, estimated federal spending
for HIV/AIDS included $2 billion for research, $0.8 billion for prevention
activities, $5.8 billion for treatment, and $1.4 billion for income and
support. (See fig. 1.)

Figure 1: Federal HIV/AIDS Funding, Fiscal Year 1999
Note: CARE Act funds are assigned to "Treatment." Some funds are used for
support services. "Other" includes primarily Medicaid, Medicare, Social
Security Disability Insurance, Supplemental Security Income, and National
Institutes of Health research.

Source: Congressional Research Service.

Medicaid is the largest source of federal assistance for health care for
AIDS patients.1 In 1998, Medicaid was estimated to cover 50 percent of adult
AIDS patients and about 90 percent of pediatric AIDS patients. States vary
in their Medicaid eligibility requirements. Most adults with AIDS or HIV
infection become eligible for Medicaid by meeting the disability criteria of
the federal Supplemental Security Income (SSI) program but usually not until
they have developed AIDS and have become too disabled by their disease to
work.2 Within broad federal guidelines, states have flexibility in
developing their Medicaid programs, including eligibility, services to be
covered by the program, and the scope of the prescription drug benefit, if
any.

The incidence of AIDS varies from state to state. AIDS cases reported for
the 12 months ending June 1999 ranged from less than one case per 100,000
people in North Dakota to 143.4 cases per 100,000 people in the District of
Columbia. The rates of AIDS cases also vary within states. For example, for
the 12 months ending June 1999, the rate of AIDS cases reported in New York
was 42.1 per 100,000 people. A large portion of this was accounted for by
the New York City metropolitan area, where the rate was 74.9 per 100,000
people for the same period. A comparison of Florida and Miami shows similar
differences. The rate of reported cases in Florida was 38.1 per 100,000
people while in Miami it was 72.5.

Rural areas still account for only a small portion of AIDS cases, according
to CDC information. AIDS rates have increased in nonmetropolitan statistical
areas but do not indicate that the epidemic is increasing rapidly there.3 Of
the reported cases, 83 percent were from large metropolitan statistical
areas (MSA), where 62 percent of the population lived. Medium-sized MSAs
accounted for 10 percent of the AIDS cases and 18 percent of the population.
Non-MSAs accounted for 7 percent of the AIDS cases and 20 percent of the
population.4

The pattern of HIV cases is not as clear as the pattern of AIDS cases
because not all states report HIV cases. While information on people with
HIV is important in planning for surveillance purposes, only 33 states had
implemented HIV reporting as of June 30, 1999. Additionally, the states'
reporting practices vary. For example, states began HIV reporting on
different dates, and some states reported previously diagnosed cases along
with new cases, while others reported only newly diagnosed cases. Two states
report only pediatric cases. Appendix III lists the states that have
initiated HIV reporting.

The CARE Act was enacted to improve the quality and availability of medical
and support services for individuals with HIV disease and their families.
The act was reauthorized in 1996. HRSA administers it. Appropriations for
fiscal year 1999 were $1.4 billion. Title I provides funds to EMAs with
substantial numbers of AIDS cases. Title II provides funds to states and
territories by formula, including for the AIDS Drug Assistance Program
(ADAP). Discretionary grants to community health centers and other related
entities are available under title III for providing primary medical care,
HIV counseling and testing, and a variety of support services. Other
discretionary grants are available under title IV for services for women,
children, and families. (See table 1.)

Table 1: The Ryan White CARE Act's Programs Described

Continued from Previous Page

      Program             Grantee         Fiscal year       Purpose and
                                         1999 funding      requirements
 Title
                                                       Provides HIV/AIDS
                                                       outpatient health
                                                       care, including
                                                       medications, and a
                                                       range of support
                                                       services, including
                                                       case management,
                                                       substance abuse
                                                       treatment, housing,
                                                       mental health
                                                       treatment,
                    51 EMAs in fiscal                  transportation, and
 I. HIV Emergency   year 1999 with at                  nutritional
 Relief Grant       least 500,000       $485.8         services, among
 Program (formula   population and      milliona       others. Each EMA has
 and supplemental   2,000 AIDS cases                   to establish a
 grants)            reported in the                    planning council of
                    most recent 5 years                representatives of
                                                       health care
                                                       agencies,
                                                       community-based
                                                       providers, health
                                                       care planning
                                                       agencies, and
                                                       persons with HIV
                                                       disease, among
                                                       others. The planning
                                                       councils establish
                                                       priorities for
                                                       allocating funds.
                                                       In addition to ADAP,
                                                       services include
                                                       home and
                                                       community-based
                                                       health care and
                                                       support and health
                                                       insurance
                                                       continuation. States
                                                       provide the services
 II. HIV Care       50 states, the      $710 million,  directly or through
 Grants (formula    District of         of which $461  consortia of service
 grants)            Columbia, and U.S.  million was    providers. States
                    territories         for ADAP       are required to
                                                       periodically convene
                                                       people living with
                                                       HIV disease,
                                                       grantees, providers,
                                                       and public health
                                                       agencies to develop
                                                       a statewide
                                                       coordinated
                                                       statement of need.
                    198 grantees,
 III. Early         including community                Services include
 Intervention       and migrant health                 risk reduction,
 Services           centers, hospital   $94.3 million  counseling, testing,
 (discretionary     or university-based                clinical care,
 grants)            medical centers,                   medications, and
                    and city and county                case management.
                    health departments

 IV. Coordinated    55 grantees and
 Services and       projects in fiscal                 Health care and
 Access to Research year 1998,                         social services that
 for Women,         including health                   benefit children,
 Infants, Children, care facilities,    $46 million    youths, and women
 and Youth          public health                      living with HIV and
 (discretionary     agencies, and                      their families.
 grants)            community-based
                    organizations
 Other
                                        Funded by
                                        set-asides     Supports the
 Special Projects                       from titles    development and
 of National                            I-IV not to    evaluation of
 Significance                           exceed $25     innovative models of
                                        million        HIV/AIDS care.
                                        annually
                                                       A national network
                                                       of 15 centers that
 AIDS Education and                                    conduct training and
 Training Centers                       $20 million    education for health
 Program                                               care providers in
                                                       designated
                                                       geographic areas.
                                                       Assists accredited
                                                       dental schools and
                                                       postdoctoral dental
 Dental                                                programs with
 Reimbursement                          $7.8 million   uncompensated costs
 Program                                               incurred in
                                                       providing oral
                                                       health treatment to
                                                       HIV- positive
                                                       patients.

aAdditional funds were available to some EMAs. HHS in collaboration with the
Congressional Black Caucus (CBC) provided funds to target and enhance
effective HIV/AIDS efforts that directly benefit racial and ethnic minority
communities: technical assistance and infrastructure support, increasing
access to prevention and care, and building stronger linkages to address the
needs of specific populations. For fiscal year 1999, CBC funds to the EMAs
totaled $5 million.

Appendix IV lists the EMAs for fiscal year 1999 and title I award amounts;
appendix V shows the title II awards to the states, the District of
Columbia, and the territories.

CDC's role includes vaccine research, research on HIV infection and disease
progression, surveillance programs, prevention research, prevention program
evaluations, state and local prevention activities, school-based prevention
activities, and prevention in occupational settings. In this report, we
focus on CDC-funded HIV prevention programs through state and local health
departments; national and regional minority organizations; national
business, labor, and faith partnerships; and other community-based
organizations. State, territory, District of Columbia, and local education
agencies also receive funding for prevention activities. The major grantees
received $289.8 million in fiscal year 1998, as shown in table 2.

Table 2: Selected CDC HIV Prevention Program Funding, Fiscal Year 1998

 Type of grantee                          Number of grantees Funding
 State, territorial, and local health
 departments                              65                 $252,824,319a
 State and local education agencies       75                 19,414,850
 Community-based organizations            93                 17,553,983

aExcludes funding for surveillance activities.

HOPWA provides housing assistance and supportive services for low-income
persons with HIV/AIDS and their families. Formula grants to states and
metropolitan areas that exceed thresholds for population and AIDS cases
constitute 90 percent of the funding. The remaining 10 percent of funds are
awarded competitively. Fiscal year 1999 funding of $200.5 million was
distributed to 63 metropolitan areas and 34 states, and $24.5 million in
competitive awards went to 24 projects. States, localities, and other
grantees provide emergency shelter, shared housing, apartments, single room
occupancy units, group homes, and housing combined with support services.
Grantees can also use HOPWA funds for a variety of housing-related expenses,
social services, and program development costs such as housing information
and resource identification, purchase, repair, and construction. HOPWA funds
are also used for health care, mental health services, substance abuse
treatment, nutritional services, case management, and help with daily
living.5 Appendix VI identifies grantees and fiscal year 1999 award amounts.

African Americans, Hispanics, and women are served by the CARE Act in higher
proportions than their representation in the AIDS population. These
vulnerable groups, including the uninsured and poor, are the majority of
CARE Act clients. According to a recent HIV study, they generally receive
less appropriate health care for their disease when assessed in terms of
physician visits, emergency room visits, hospitalizations, and
antiretroviral and prophylactic drug therapies.

According to the HIV Cost and Services Utilization Study (HCSUS)--a study of
a nationally representative sample of HIV/AIDS patients--African Americans,
Hispanics, women, the uninsured, and people insured by Medicaid are likely
to visit physicians less frequently and to take fewer anti-HIV medications
for their HIV disease than other HIV-infected people.6 HCSUS analyzed usage
patterns for six measures of health care: physician visits, emergency room
visits, hospitalizations, prophylaxis against Pneumocystis carinii
pneumonia, antiretroviral medication, and new classes of pharmaceuticals
that include protease inhibitors and nonnucleoside reverse transcriptase
inhibitors. The analysis showed that compared with whites, African Americans
and Hispanics received less appropriate care for their HIV disease. Types of
public and private health insurance coverage also affected care. People who
lacked health insurance fared worse on most measures. Also, Medicaid
recipients received less care than privately insured persons. Women also did
not fare as well as men on most of the measures. Finally, exposure category
was a significant factor; those who had acquired their infection by
injecting drugs or through heterosexual sex had less favorable patterns of
care than did men who had sex with men.7

of Minorities, Uninsured, and Poor

Analyses of the HCSUS data to determine the characteristics of persons
served under the CARE Act show that CARE Act clients are more likely to be
African American, have no insurance or rely on public insurance, and have a
lower income than other HIV/AIDS patients.8 (See table 3.)

Table 3: Characteristics of Individuals Who Receive Services From Providers
Funded and Not Funded by the CARE Act

                Characteristic                 Funded  Not funded
 Gender
 Male                                          74%     82%
 Female                                        26      18
 Race
 White                                         40      62
 African American                              42      19
 Hispanic                                      15      16
 Other                                         3       3
 Exposure category
 Men who have sex with men                     44      55
 Persons who inject drugs                      17      14
 Men who have sex with men and inject drugs    8       8
 Persons who have heterosexual contact         22      13
 Other                                         3       4
 Insurance status
 No insurance                                  30      6
 Medicaid only                                 33      23
 Medicare and Medicaid                         19      18
 Private insurance                             19      54
 Income (highest income ever, in 1996 dollars)
 $0−$5,000                               25      12
 $5,001−$10,000                          30      20
 $10,001−$25,000                         27      23
 More than $25,000                             18      45

Also, a greater percentage of women (26 percent) are served under the CARE
Act than are not (18 percent). A greater percentage of persons contracting
the disease by injecting drugs or through heterosexual contact were seen by
providers funded by the CARE Act. A greater percentage of men who contracted
the disease through sexual contact with other men were seen by providers not
funded by the CARE Act.

Representation in the AIDS Population

Using separate data, we also compared the estimated number of people living
with AIDS and people receiving CARE Act-funded services in two states and
five metropolitan areas: Los Angeles, San Francisco, and Orange County,
California; Middlesex, New Jersey; Michigan; Virginia; and Washington, D.C.
These locations were selected because HRSA was able to provide data on the
unduplicated population of persons served under the CARE Act.9 We compared
the AIDS population as of June 30, 1998, with the client population
receiving services under the CARE Act in 1998.10

We found that women were receiving services funded by the CARE Act at rates
greater than their representation in the AIDS population as a whole. At all
seven locations, a greater percentage of women received such services than
their percentage in the AIDS population. Analyses also indicate that
minorities and individuals contracting the virus through heterosexual
contact are represented at higher rates among those served under the CARE
Act than in the AIDS population as a whole. While there is variation across
locations in the proportion of African Americans and Hispanics in both the
AIDS and client populations, at all seven locations a greater percentage of
African Americans are among the CARE Act clients than in the AIDS
population. This is also true for Hispanics at two of the seven locations.
In three locations, the percentages of Hispanics among CARE Act clients were
slightly higher than their representation in the AIDS population. In two
locations, they were slightly lower.

We also found that persons who contracted the HIV virus through heterosexual
contact were more likely to receive services funded by the CARE Act.11 In
the HCSUS data, we saw that a greater percentage of people who injected
drugs receive their services from providers funded under the CARE Act.
However, individuals who contracted HIV by injecting drugs had less
representation among individuals served under the CARE Act than in the AIDS
population at five of the locations. (See app. VII for detailed results for
each location.)

Services

While the CARE Act funds both health care and support services, most of the
funds are used for medical treatment and medications. Included in CDC
prevention activities are counseling about the risks of contracting HIV and
the need to notify partners about potential HIV infection, testing for the
virus, and referring those who test positive to appropriate care. About
one-third of fiscal year 1998 funds were used for these purposes. HOPWA
funds are used primarily for housing assistance; about two-thirds of the
funds between 1994 and 1998 were used for this purpose. All the programs
have limitations on the administrative use of program funds.

To determine the distribution of CARE Act funds, we focused on titles I-III.
These titles accounted for 95 percent of the act's fiscal year 1999
appropriations.12 About 56 percent of title I funds were used for health
care and medications in fiscal year 1998. For the same year, 34 percent of
the funds were used for case management and support services and 10 percent
were used for administration, planning councils, and program support. (See
fig. 2.)

Figure 2: Distribution of CARE Act Title I-III Funds, Fiscal Year 1998

Most title II funds are also used for medications and medical services.
About 66 percent of title II funds were devoted to ADAP services in fiscal
year 1998. Health services other than ADAP accounted for 12 percent of the
funds in the same year. Case management and support services accounted for
12 percent of the funds. Grantees used 10 percent of the funds for
administration as well as planning and evaluation.

Most title III funds were also used for health care. In fiscal year 1998,
health care services, including medications and laboratory services,
accounted for 74 percent of the funds. Another 12 percent were used for case
management and other services. About 8 percent were used for testing and
counseling, referral, and outreach. The remaining 6 percent went to
administration activities.

The Distribution of Funds Has Changed With New Treatment Approaches

Decreases in the number of new AIDS diagnoses and death rates have been
greatly influenced by new drug therapies generally administered in
combinations of three or more agents. These medications, however, are
expensive, with estimated annual costs of $10,000 and more per patient.
While the distribution of title I funds among various services has remained
relatively constant, title II money is increasingly supporting
pharmaceuticals.

Title II's ADAP component provides funds to the states for providing
medications to HIV-infected individuals. In response to these expensive
therapies, federal funding for ADAP increased from $52 million in fiscal
year 1996 to about $461 million in fiscal year 1999, accounting for an
increasing proportion of the title II funds. ADAP represented 20 percent of
title II funding in fiscal year 1996 and 65 percent in fiscal year 1999.
Title II funds used for other health care services remained about the
same--$59.3 million in fiscal year 1996 and $60.4 million in fiscal year
1998--but represented a decreasing proportion of title II spending.

States With EMAs Spend Proportionately Less on Medications

The proportions of CARE Act funds spent on services for their HIV-infected
populations vary from state to state. For example, the percentage of CARE
Act funds devoted to health care services other than medications ranged from
5 percent in one state to 41 percent in another for fiscal year 1998. One
state did not use any of its CARE Act funds for health care services. With
the majority of title II funds earmarked for ADAPs, states without EMAs have
most of their CARE Act funding allocated for medications. In states with
EMAs, and therefore title I funding, greater proportions of CARE Act funds
are spent, on average, for other services such as health care and support
services. Table 4 shows the average percentage of title I and title II funds
spent on different services for fiscal year 1998.

Table 4: Average Percentage of CARE Act Title I and Title II Funds Spent on
Services, Fiscal Year 1998

 Service                         All states  States with   States without
                                             EMAs          EMAs
 Medications                     49.9%       38.5%         58.4%
 Health care                     20.4        24.4          17.6
 Administration, planning, and
 evaluation                      9.4         9.7           8.6
 Case management                 8.9         12.3          6.5
 Support services                8.6         14.2          4.5
 Health insurance continuation   2.4         0.9           3.5

Source: HHS, HRSA, Ryan White CARE Act State Profiles (Washington, D.C.:
HHS, 1999).

The CARE Act Limits the Use of Funds That Can Be Used for Administrative
Purposes

As shown in figure 2, under each title, not more than 10 percent was used
for administrative purposes. Each title contains limitations on the use of
funds for administrative activities. The portion of fiscal year 1998 title
I-III funds used for administrative purposes was within these limitations.

The CARE Act defines administrative activities as routine grant
administration and monitoring, including the development of applications for
funds, the receipt and disbursal of program funds, the development and
establishment of reimbursement and accounting systems, the preparation of
routine program and financial reports, and compliance with grant conditions
and audit requirements. Also considered administrative activities are all
activities associated with a grantee's contract award procedures, including
the development of requests for proposals, contract proposal review
activities, the negotiation and awarding of contracts, monitoring contracts
through telephone consultation, written documentation of onsite visits,
reporting on contracts, and funding reallocation activities.

Grantees may not use more than 5 percent of awarded title I funds for
administrative activities. In addition, title I EMAs may use funds for
carrying out planning council support, program support, and service-related
activities that are subject to a 10 percent aggregate administrative cost
cap. While subcontractors are not included in the 10 percent aggregate cap,
HRSA strongly recommends that all subcontractors include a cap on
administrative expenses.

The states may use title II funds to conduct administrative activities
similar to those under title I. The combined costs for administration,
planning, and evaluation cannot exceed 15 percent of a state's award.13 For
title III, grantees may not use more than 7.5 percent of the grant amount
for administrative costs, including planning and evaluation.

In fiscal year 1998, CDC provided $289.8 million to state and local health
departments and education agencies and community-based organizations for HIV
prevention activities. Major HIV prevention interventions include
counseling, testing, referral, and partner notification; health education
and risk reduction; school health; and public information. Evaluation and
research, capacity building and infrastructure development, and community
planning are support activities. About 62 percent of the fiscal year 1998
funds were used for health education and risk reduction, school health,
public information, and support activities. Another 31 percent was devoted
to counseling and testing and partner counseling and referral services.
Grantees' administrative expenses or indirect costs averaged 7 percent for
fiscal year 1998.14 (See fig. 3.)

Figure 3: Distribution of Selected CDC HIV Prevention Program Funds, Fiscal
Year 1998
CDC places several requirements on its grantees, including requirements
related to counseling and testing, and partner counseling and referral
services. Public health agencies that receive CDC HIV/AIDS prevention funds
are required to offer HIV prevention counseling and testing services to
persons potentially infected with HIV, their partners, and others who have
high-risk behaviors. CDC criteria require HIV prevention program managers to
ensure the confidentiality of the persons who use HIV counseling and testing
services. Additionally, persons who seek HIV testing and others who have
been determined to be at risk of infection are offered counseling services,
regardless of their ability to pay.

These programs must also refer clients who test either positive or negative
for HIV to appropriate services that may include medical care, drug
treatment, and support. Additionally, the grantees' counselors are to assist
the client in developing a plan that ensures that all partners are counseled
about their exposure to HIV.

According to reports filed with HUD between 1994 and 1998 that accounted for
more than $302 million in HOPWA funds, most HOPWA money (64 percent) was
spent on housing assistance. Support services accounted for 22 percent of
the funds in those years. Support services include case management, adult
care and personal assistance, health care, alcohol and drug abuse treatment,
and child care, among others. Housing information services accounted for 4
percent of the funds, while program development services and administration
expenses were 10 percent of the total. (See fig. 4.) Administrative costs
may not exceed 3 percent of the grant amount for grantees and 7 percent for
program sponsors.15 HOPWA grantees reported that 3 percent of grant funds
were spent for their administrative expenses and 5 percent were spent for
program sponsors' administrative expenses.

Figure 4: Distribution of HOPWA Funds, 1994-98
In general, metropolitan areas designated EMAs and therefore receiving title
I funds receive more money per person living with AIDS than non-EMA areas.
While we are examining funding formulas in greater detail for you, we
include here some analyses of fiscal year 1997 title I and title II funding
for EMAs and states.16

The level of funding per person living with AIDS differs among states, among
EMAs, and between EMAs and states. In general, EMAs, with about
three-fourths of all AIDS cases, receive more funding per case. For those
areas, the additional money provided through title I is the primary
component of the greater availability of funds. (See table 5.)

Table 5: Available CARE Act Title I and Title II Funds per AIDS Case in Six
States, Fiscal Year 1997

                                                           Funds per person
      Location       Estimated number living with AIDS at
                               the end of 1997               living with
                                                                AIDSa
 Arizona            2,430                                  $2,830
 Phoenixb           1,670                                  3,133
 Rest of Arizona    760                                    2,164
 Georgia            8,776                                  2,846
 Atlantab           6,119                                  3,081
 Rest of Georgia    2,657                                  2,303
 Michigan           4,050                                  2,939
 Detroitb           2,765                                  3,296
 Rest of Michigan   1,285                                  2,170
 Texas              20,685                                 2,555
 Austinb            1,408                                  3,462
 Dallasb            4,639                                  2,769
 Fort Worthb        1,347                                  2,514
 Houstonb           7,258                                  2,457
 San Antoniob       1,626                                  2,940
 Rest of Texas      4,407                                  2,072
 Virginiac          4,710                                  1,723
 Washington         3,562                                  2,914
 Seattleb           2,463                                  3,053
 Rest of Washington 1,099                                  2,603

aFunds do not include state match.

b Designated an EMA as of 1997.

cParts of Northern Virginia are included in the Washington, D.C., EMA. Those
funds are not reflected in the Virginia totals.

Sources: CDC, HIV/AIDS Surveillance Supplemental Report No. 1 (Atlanta: CDC,
1999); HHS, HRSA, Ryan White CARE Act State Profiles (Washington, D.C.: HHS,
1999); HHS, HRSA, Division of HIV Services, data on title I contributions to
state ADAPs.

The states have discretion in how they distribute their title II funds.
States with EMAs may elect to give more title II money to non-EMA areas or
may choose to distribute title II funds without regard to title I funding.
Depending on how the title II funds are distributed, this can increase or
decrease the disparity in funding per case between EMA and non-EMA areas.
Also, EMAs may contribute a portion of their title I funds to their state
ADAP to fund drug assistance services.

For example, in Michigan, some title II money is set aside for consortia
while the ADAP and nonconsortia funds are available statewide. Detroit,
which has about two-thirds of the estimated persons living with AIDS in the
state, got $950,000, or about 37 percent, of the title II money Michigan
earmarked for its consortia in fiscal year 1997. However, Detroit is an EMA,
so this title II funding was in addition to the title I money of $6 million
for the same year. The Detroit EMA transferred $300,000 of its title I funds
to the state ADAP in fiscal year 1997. Thus, with the 2,765 people estimated
to be living with AIDS at the end of 1997 in the Detroit metropolitan area,
the title I and title II money going to Detroit amounts to about $3,296 per
AIDS case. This compares with funding of about $2,170 per case for the
non-EMA areas in Michigan for fiscal year 1997.

Georgia also has one EMA, Atlanta, that received $12.6 million in title I
funds. Unlike Detroit, only 2.5 percent of the title II consortium money
went to Atlanta, although 70 percent of the state's persons living with AIDS
are in the Atlanta area. Georgia thus allocated its title II consortium
funds to areas that do not receive title I funding. In addition, the Atlanta
EMA transferred $1.2 million to the state ADAP in fiscal year 1997. However,
funding for persons outside the metropolitan area was still below
metropolitan area funding. In Georgia, fiscal year funding per AIDS case was
estimated at $3,081 for Atlanta and $2,303 for the rest of the state.
Virginia, which did not have a designated EMA in 1997, had only title II
money to distribute. The funding per person living with AIDS in Virginia was
$1,723.

This comparison does not consider the state's rationale for distributing its
title II money among EMA and non-EMA areas. States' funding decisions may
take into account the incidence of HIV infection as well as AIDS prevalence
and the degree of unmet need. Such factors as a state's Medicaid benefit
package and the infrastructure investment required for some types of
services may also play a role. Further, individuals living outside the EMA
may travel to the EMA to receive certain services that would be paid for out
of title I funds.

An analysis of the distribution of HOPWA funds in the same six states shows
that HOPWA funds also generally vary by AIDS case among EMSAs and the rest
of the state. Table 6 shows HOPWA awards per person living with AIDS at the
end of 1997.

Table 6: Distribution of HOPWA Funds in Six States and Their EMSAs, Fiscal
Year 1997

                       Estimated number living
       Location        with AIDS at the end of   Awarda    Funds per person
                                1997                      living with AIDS
 Arizona
 Phoenix              1,670                     $851,000  $510
 Rest of Arizona      222                       0         0
 Georgia
 Atlanta              6,119                     4,090,000 668
 Rest of Georgia      2,657                     1,106,000 416
 Michigan
 Detroit              2,765                     1,374,000 497
 Rest of Michigan     861                       603,000   700
 Texas
 Austin               1,408                     704,000   500
 Dallas               4,639                     2,640,000 569
 Fort Worth           1,347                     582,000   432
 Houston              7,258                     3,316,000 457
 San Antonio          1,626                     709,000   436
 Rest of Texas        3,856                     1,709,000 443
 Virginia
 Richmond             930                       429,000   461
 Virginia
 Beach-Norfolk        1,496                     556,000   372
 Rest of Virginia     2,284                     0         0
 Washington
 Seattle              2,463                     1,317,000 535
 Rest of Washington   789                       434,000   550

aWe assume that the HOPWA awards for the EMSAs and states were spent in the
award year.

Sources: CDC, HIV/AIDS Surveillance Supplemental Report No. 1 (Atlanta: CDC,
1999), and HUD data on HOPWA formula awards for fiscal year 1997.

Awards per AIDS case in Texas ranged from $432 in Fort Worth to $569 in
Dallas. The average award in Texas was $443 per AIDS case. Washington and
Seattle were very similar, at $550 and $535, respectively. Other states had
a wider range of awards per case--for example, Michigan at $700 and Detroit
at $497. However, unlike the CARE Act title II funds, the HOPWA state awards
are allocated to provide assistance in areas of the state that are outside
any qualifying metropolitan area that receives a HOPWA allocation.

While the vast majority of people with AIDS reside in urban areas, HIV
infection and AIDS are growing in rural areas, especially in the southern
states. The CARE Act is assisting in providing services for HIV-infected
populations living in rural areas. Although data on HIV/AIDS services in
rural areas are limited, it appears that both drug assistance services and
other services are reaching rural residents.

Rural areas, with smaller populations, may offer more limited medical and
social services, although access to medical care and support services is
critical for the well-being of both the HIV-infected populations and
individuals with other medical conditions in these areas. In some instances,
rural residents may be traveling to urban areas to receive services.

Our analysis of Arizona, Georgia, Michigan, Texas, Virginia, and Washington
showed that the incidence of AIDS cases in rural areas was proportionately
smaller than in metropolitan areas. In three of these states, 4 percent of
the AIDS cases were in non-MSA areas as of June 30, 1998. The 1990 non-MSA
populations for these states ranged from about 13 percent to 16 percent of
the states' populations. In the three other states, AIDS cases in non-MSAs
accounted for 7, 10, and 14 percent, and their 1990 non-MSA populations were
about 16, 25, and 33 percent.

Coverage for expensive combination drug therapies under the CARE Act is
available primarily through the ADAPs. Our analysis of AIDS cases and ADAP
clients in the six states shows that CARE Act drug assistance services are
reaching the rural AIDS population generally in proportion to AIDS cases. We
found that in five states the percentages of ADAP clients in non-MSA areas
were the same as or greater than the percentages of people living with AIDS
in non-MSA areas. In one state, there were 1 percent fewer ADAP clients than
the estimated number of people living with AIDS, while in another state
there were 8 percent more.17 (See fig. 5.)

Figure 5: ADAP Clients and AIDS Cases in Non-MSA Areas, 1998-99
We were able to take a closer look at Michigan and Virginia because
client-level data (unduplicated counts of clients) exist for them. We
compared individuals receiving CARE Act services in 1998 with the estimated
numbers of persons living with AIDS as of June 30, 1998. As figures 6 and 7
show, the distributions of the AIDS populations and CARE Act clients appear
to be reasonably similar.18 However, these data show where the clients lived
and do not necessarily reflect where the services were provided. Rural
clients may be traveling to urban areas to receive certain services.

Figure 6: Distribution of AIDS Cases and CARE Act Clients in Michigan, 1998

Figure 7: Distribution of AIDS Cases and CARE Act Clients in Virginia, 1998

Our analysis shows that compensation to administrators of organizations
serving persons with HIV/AIDS is generally comparable in similar nonprofit
organizations. The median compensation for administrators for all
organizations that received CARE Act or CDC funds was $78,000, and the
median at organizations that serve only HIV/AIDS clients was $64,878. The
median for other nonprofit organizations was $74,203.

The organizations vary by services provided, funds available to provide
these services, and the salaries and benefits provided to their
administrators. These nonprofit organizations provided health care, drug
treatment services, counseling, nutritional services, and legal and other
assistance to a diverse group of clients, including people with HIV/AIDS.
Revenues, as an indicator of organization size, varied from $206,000 to more
than $30 million. Compensation also varied, ranging from $23,434 to
$527,807.19 The average compensation among organizations that received
federal HIV/AIDS funds and other nonprofit organizations also varied. (See
table 7.)

Table 7: Compensation Characteristics at Nonprofit Organizations

                      Receiving CARE Act and CDC funds
                                               Serving HIV/AIDS Not receiving
 Item        All              Serving HIV/AIDS and other        CARE Act or CDC
             organizations    clients only
                                               clients          funds

 Revenue     $15,312-$27.7    $415,312-$17.6   $1.4             $206,142a -$30.9
 range       million          million          million-$27.7    million
                                               million
 Compensation
 as
 percentage  0.4−13     1−13       0.4−5      0.3−20
 of revenue
 Compensation
 range       $37,450-$223,804 $37,450-$197,014 $56,663-$223,804 $23,434-$527,807
 Compensation
 median      $78,000          $64,878          $89,783          $74,203
 Compensation
 mean        $92,490          $72,871          $104,751         $89,996

aWe limited our analysis to organizations with revenues of $300,000 or more.
However, in some cases, the Internal Revenue Service (IRS) file used to
identify the organizations had revenue amounts different from those in the
file used for the analysis.

Organizations that received CARE Act or CDC funds and served only HIV/AIDS
clients compensated their administrators $72,871 on average, while
organizations that served persons with HIV/AIDS and other clients paid their
administrators an average of $104,751. However, the average compensation at
all organizations that received either CARE Act or CDC funds was $92,490.
This compares with an average compensation of $89,996 for other nonprofit
organizations that did not receive CARE Act or CDC funds. A more complete
description of our analysis is in appendix II.

We provided HHS and HUD the opportunity to comment on a draft of this
report. HHS said that it agreed with most aspects of the report but thought
it should provide more information on the role of Medicare, Medicaid, and
State Children's Health Insurance in meeting the needs of HIV/AIDS patients.
We agree that these programs, especially Medicaid, do play important roles
in the care of HIV/AIDS patients. Our emphasis was on the CARE Act program,
however, although we do include some information on other programs that also
serve HIV/AIDS patients.

HUD provided technical comments, as did HHS, and we incorporated them where
appropriate.

As we agreed with your offices, unless you publicly announce the report's
contents earlier, we plan no further distribution of it until 30 days from
the date of this letter. We will then send copies to the Honorable Donna E.
Shalala, Secretary of Health and Human Services; the Honorable Claude Earl
Fox, Administrator of the Health Services and Resources Administration; the
Honorable Jeffrey P. Koplan, Director of the Centers for Disease Control and
Prevention; the Honorable Andrew M. Cuomo, Secretary of Housing and Urban
Development; and others who are interested. If you have any questions or
would like additional information, please call me at (202) 512-7114. Marcia
Crosse, Roy Hogberg, and Donna Bulvin made major contributions to this
report.

Janet Heinrich
Associate Director, Health Financing and
Public Health Issues

CARE Act Criteria for Counseling and HUD Policies on Illicit Drug Use in
Housing

This appendix briefly describes the Ryan White Comprehensive AIDS Resources
Emergency Act of 1990 (CARE Act) criteria for counseling people with human
immunodeficiency virus (HIV) and referring them to appropriate care and
federal policies related to substance abuse in federally subsidized housing.

Grantees receiving title III (early intervention services) money are
statutorily required to provide certain counseling services for persons who
test positive and negative for HIV. As stated earlier in this report, about
8 percent of fiscal year 1998 title III money was spent on counseling,
testing, referral, and outreach.

Counseling and testing services include pretest counseling and counseling
individuals with either negative or positive test results. Before testing
for HIV, counselors are to provide information on preventing HIV as well as
on how the virus is transmitted. They are also to convey information on the
accuracy and reliability of test results. Other information includes the
benefits of testing, the significance of test results, and encouragement to
undergo testing. Counselors should also stress the confidentiality of
receiving early intervention services, the availability of anonymous
testing, and laws related to discrimination against individuals with HIV
disease.

Post-test counseling for individuals who test negative for HIV should
contain information about reducing the risk of contracting the virus, the
accuracy and reliability of test results, and their significance. The
counseling should also include information on the appropriateness of further
HIV counseling, testing, and education and referral to HIV prevention
services.

People who test positive for the virus need counseling in addition to the
information on risk reduction and significance and the reliability of HIV
test results. Important information that should be conveyed is the
availability of appropriate health care, including antiretroviral therapies,
mental health care, and social and support services. In addition to telling
them about the availability of early intervention services and primary care,
counselors should make them aware of the benefits of counseling others whom
they may have exposed to HIV and assist them in locating those persons.

Federal law authorizes the secretary of the Department of Housing and Urban
Development (HUD) to make grants to public housing agencies, for-profit and
nonprofit owners of federally assisted low-income housing, and others for
use in eliminating drug related and violent crime (42 U.S.C. 11902(a)). The
grants may be used to employ security personnel, reimburse local law
enforcement agencies for additional security, make physical improvements for
security, conduct training and buy equipment for volunteer tenant patrols,
among other things (42 U.S.C. 11903(a)). The secretary is required to
establish a clearinghouse to respond to inquiries from the public requesting
assistance in investigating, studying, and working on substance abuse
problems. The clearinghouse is also to collect and disseminate information
on programs to assist the public in this area. Federal law also requires the
secretary to establish regional training programs to educate and prepare
officials to confront drug abuse in housing.

In addition, HUD has a zero tolerance policy regarding illegal activities in
HUD-funded programs. Housing Opportunities for Persons Living With AIDS
(HOPWA) is subject to all federal criminal statutes and procedures regarding
the sale, possession, and use of illegal substances. Grantees, project
sponsors, and other contracted agents are required to comply with them and
have no ability to waive or modify them in order to condone on-site use of
illegal substances. HUD may use established remedies to enforce compliance
on these matters, such as suspending grant awards. According to an Office of
HIV/AIDS Housing official, HUD has not taken any enforcement actions against
HOPWA-funded housing grantees.

Methodology and Information on Administrators' Compensation

To compare the compensation of top administrators of organizations receiving
CARE Act and Centers for Disease Control and Prevention (CDC) HIV prevention
funds with those of other nonprofit organizations, we first randomly
selected five eligible metropolitan areas (EMA)--Dallas, Kansas City,
Philadelphia, St. Louis, and San Francisco--that received title I CARE Act
funds for fiscal year 1999.20 We identified grantees that received at least
$250,000 in title I fiscal year 1998 funds from a list of grant recipients
in each of the five EMAs that the Health Resources and Services
Administration (HRSA) provided. We excluded hospitals, state and county
health departments, and universities from our sample because their size,
types of services, and range of clients would not have been comparable to
those of most of the organizations that receive CARE Act funds or CDC HIV
prevention funds. Through an EMA representative, we requested copies of the
latest tax filing, Internal Revenue Service (IRS) Form 990, for the 49
organizations that met our selection criteria. We could not obtain the form
for seven. In addition, because of incomplete or insufficient information,
we excluded eight more organizations from our analysis. As a result, our
analysis includes 34 organizations that received title I CARE Act funds in
fiscal year 1998.

We identified seven additional organizations that received $250,000 or more
in CDC HIV prevention grants for fiscal year 1998.21 We were able to obtain
a Form 990 for six of these grantees, but we eliminated one because of
incomplete information. In total, we identified 39 organizations that
received more than $250,000 in CARE Act or CDC prevention funds in fiscal
year 1998. Of the 39 organizations, 15 served only HIV/AIDS clients, and 24
served both HIV/AIDS and other clients.

To select nonprofit organizations for comparison, we contracted with the
Urban Institute's National Center for Charitable Statistics (NCCS). NCCS
identified and provided data for 273 nonprofit organizations whose annual
revenue was at least $300,000, located in the same five cities, that
provided health care, family planning services, and drug abuse prevention
and treatment services.22 We eliminated 24 organizations that serve HIV/AIDS
clients. We also eliminated 121 because of incomplete or questionable
information. Therefore, we used 128 organizations in our analysis.

The nonprofit organizations were limited to the following IRS National
Taxonomy for Exempt Organization classifications:

ï¿½ health treatment facilities, primarily outpatient;

ï¿½ ambulatory health centers and community clinics;

ï¿½ family planning centers;

ï¿½ public health programs (includes general health and wellness promotion
services);

ï¿½ alcohol, drug, substance abuse, and dependency prevention and treatment;

ï¿½ alcohol and drug abuse prevention only; and

ï¿½ alcohol and drug abuse treatment only.

Our analysis contains a number of qualifiers that limit drawing any
conclusions about the appropriateness of compensation among HIV/AIDS service
providers and other nonprofit organizations. First, although IRS Form 990 is
the most commonly used data source of such financial information about
nonprofit organizations, it can contain numerous errors. Several studies
have shown that a sizable number of these forms contain errors and
omissions. Also, we limited our selection of the organizations that were
funded by the CARE Act to five locations, which resulted in a sample of 34
organizations that received $250,000 or more in CARE Act funds. We obtained
data for only five of the seven organizations that received $250,000 or more
in CDC HIV prevention funds. We compared the organizations that received
CARE Act or CDC funds with 128 nonprofit organizations with total revenues
of at least $300,000 in the same locations. Further, our analysis is based
only on salary and other compensation and does not consider other factors
such as differences in job responsibilities, working conditions, and job
satisfaction that would be needed for a more complete analysis.
Additionally, because of the small number of organizations in each location,
we did not perform separate analyses by location. Therefore, we did not take
into account geographical differences in cost of living.

The 15 organizations that provided services exclusively to HIV/AIDS clients
gave their top administrators compensation ranging from $37,450 to $197,014.
However, only one organization in this group paid its administrator more
than $100,000. While the median compensation was $64,878, the average
compensation was $72,871. Revenue at these organizations ranged from
$415,312 to $17.6 million, and about 73 percent of them reported revenues
between $1 million and $4 million. The organization with the lowest revenue
($415,312) paid its top administrator the fourth lowest compensation
($54,600), while the organization with the highest revenue paid its top
administrator the highest salary ($197,014). As a portion of total revenue,
their compensation accounted for 13 and 1 percent, respectively.

In the HIV/AIDS dedicated organizations, we also found that the portion of
CARE Act or CDC funds as a percentage of total revenue ranged from 12
percent to 77 percent. At the organization with the highest revenue ($17.6
million), CARE Act or CDC funds accounted for 18 percent of total revenue,
while at the organization with the lowest revenue ($415,312), CARE Act or
CDC funds accounted for 77 percent of total revenue.

The 24 organizations that served HIV/AIDS and other clients gave their top
administrators compensation ranging from $56,663 to $223,804. Further, nine
top administrators earned $100,000 or more in compensation. The median was
$89,783, and the average compensation among these organizations was
$104,751. Revenue at these organizations ranged from $1.4 million to $27.7
million. As a percentage of total revenue, top administrator compensation
ranged from 0.4 percent to 5 percent of total revenue. The organization with
the lowest revenue ($1.4 million) paid its top administrator the lowest
compensation ($56,663), but this was not true of the organization with the
highest revenue, which paid its top administrator the fifth highest
compensation ($129,927) in the group.

At these 24 organizations, CARE Act or CDC funds accounted for from 1
percent to 51 percent of total revenue. At the organization with the highest
revenue, CARE Act or CDC funds accounted for 2 percent of total revenue,
while at the organization with the lowest total revenue, CARE Act or CDC
funds accounted for 20 percent of total revenue. Table 8 provides
information on the organizations in the five locations that received at
least $250,000 in CARE Act title I funds in fiscal year 1998.

Table 8: Organizations in Five Locations Funded by CARE Act Title I, Fiscal
Year 1998

Continued from Previous Page

                                          Benefits                   Total     Title I
  Location      Total    Title I  Salary     and       Total      compensation funds as
              revenue     funds                    compensation    as a % of    a % of
                                          expenses
                                                                    revenue    revenue
 Dallas
 1           $514,196   $253,433  $40,000 0        $40,000       8%            49%
 2           415,312    318,723   54,600  0        54,600        13            77
 3           1,691,200  282,500   54,041  $1,923   55,964        3             17
 4           2,007,229  642,600   50,000  7,190    57,190        3             32
 5           1,137,791  496,822   60,000  2,397    62,397        6             44
 6           3,773,898  1,526,053 64,878  0        64,878        2             40
 7           2,610,912  349,900   70,258  0        70,258        3             13
 8           4,112,524  500,984   85,326  0        85,326        2             12
 Kansas City
 1           2,254,491  304,493   63,656  340      63,996        3             14
 Philadelphia
 1           2,331,515  433,233   52,982  0        52,982        2             19
 2           1,433,529  566,863   51,896  4,767    56,663        4             20
 3           1,611,038  269,863   58,266  0        58,266        4             35
 4           18,509,917 363,999   74,770  0        74,770        0.4           2
 5           3,400,227  1,524,141 73,798  3,567    77,356        2             45
 6           4,718,978  384,607   85,750  2,315    88,065        2             8
 7           4,307,284  778,872   87,063  10,560   97,623        2             18
 8           22,106,787 528,252   110,250 6,951    117,201       1             3
 9           27,742,432 440,993   119,657 10,270   129,927       0.5           2
 10          25,480,535 287,975   169,825 31,672   201,497       1             1
 San
 Francisco
 1           1,107,951  373,912   65,000  0        65,000        6             34
 2           1,971,651  334,395   68,275  3,343    71,618        4             17
 3           4,483,191  430,000   71,769  2,153    73,922        2             10
 4           1,558,470  278,051   78,000  0        78,000        5             18
 5           2,353,199  276,827   75,000  3,000    78,000        3             12
 6           4,104,965  2,108,102 65,747  13,903   79,650        2             51
 7           1,505,562  595,113   86,798  300      87,098        6             40
 8           13,375,684 252,033   86,700  4,800    91,500        1             2
 9           4,603,175  517,398   92,292  0        92,292        2             11
 10          10,487,800 979,699   108,925 0        108,925       1             9
 11          16,669,156 1,660,850 120,450 0        120,450       1             10
 12          16,311,005 1,122,477 141,428 11,999   153,427       1             7
 13          17,589,710 3,078,915 183,892 13,122   197,014       1             18
 14          19,497,658 1,699,928 130,384 93,420   223,804       1             9
 St. Louis
 1           2,471,436  321,894   75,210  4,528    79,738        3             13

Compensation for top administrators in the 128 other nonprofit organizations
ranged from $23,434 to $527,807. Further, 33 organizations paid the top
administrator $100,000 or more. Total revenues of the organizations ranged
from $206,142 to $30.9 million.23 The median compensation was $74,203 and
the average was $89,996. As a percentage of total revenue, total
compensation ranged from 0.3 percent to 20 percent. The organization with
the highest revenue ($30.9 million) did not pay its administrator the
highest compensation. Nor did the organization with the lowest revenue pay
its administrator the lowest compensation. Table 9 provides information on
compensation at nonprofit organizations by type.

Table 9: Compensation by Type of Nonprofit Organization

             Category                    Range              Number of
                                                         organizations
 Alcohol and drug abuse prevention
 only                               $54,266-$125,916 7
 Alcohol and drug abuse treatment
 only                               $33,390-$135,844 30
 Alcohol, drug, and substance abuse
 dependency prevention and          $29,500-$131,994 23
 treatment
 Family planning center             $63,568-$267,867 8
 Public health programs (includes
 general health and wellness        $28,577-$318,625 16
 promotion services)
 Ambulatory health center,
 community clinic                   $23,434-$346,339 33
 Health treatment facility,
 primarily outpatient               $36,000-$527,807 11

To further compare the compensation of top administrators for organizations
receiving CARE Act or CDC funds, we considered two surveys of nonprofit
organizations that show salaries. One survey by the Congressional Budget
Office includes salary and benefits. This study, which considered large
nonprofit organizations with annual revenue of $50 million or more, found
that chief executive officer salary and benefits averaged about $212,000 per
year.24 Another survey by The NonProfit Times, a publication by the NPT
Publishing Group, which conducts annual salary surveys, found that chief
executive salaries averaged $73,687.25 In comparing different types of
nonprofit organizations, The NonProfit Times reported that foundation
executives averaged $103,976, followed by chief executives at health
organizations at $89,044.

Dates When States and Territories Began Reporting HIV Infection

 State and territory      Date
 Alaska              Jan.-June 1999
 Arizona             Jan. 1987
 Arkansas            July 1989
 Colorado            Nov. 1985
 Connecticut         July 1992a
 Florida             July 1997
 Idaho               June 1986
 Indiana             July 1988
 Iowa                July 1998
 Louisiana           Feb. 1993
 Michigan            April 1992
 Minnesota           Oct. 1985
 Mississippi         Aug. 1988
 Missouri            Oct. 1987
 Nebraska            Sept. 1995
 Nevada              Feb. 1992
 New Jersey          Jan. 1992
 New Mexico          Jan. 1998
 North Carolina      Feb. 1990
 North Dakota        Jan. 1988
 Ohio                June 1990
 Oklahoma            June 1988
 Oregon              Sept. 1988b
 South Carolina      Feb. 1986
 South Dakota        Jan. 1988
 Tennessee           Jan. 1992
 Texas               Jan. 1999
 Utah                April 1989
 Virginia            July 1989
 Virgin Islands      Dec. 1998
 West Virginia       Jan. 1989
 Wisconsin           Nov. 1985
 Wyoming             June 1989

a Confidential HIV infection reporting for pediatric cases only.

bConfidential infection reporting for children younger than 6 years old.

CARE Act Title I Awards, Fiscal Year 1999

Continued from Previous Page

  Eligible metropolitan area  Title I award     CBCa
 Arizona
 Phoenix                      $3,865,319     $19,445
 California
 Los Angeles                  33,540,737     261,519
 Oakland                      6,218,532      55,004
 Orange County                4,300,690      23,586
 Riverside-San Bernardino     6,463,388      36,460
 Sacramento                   2,578,873      12,423
 San Diego                    8,872,685      52,934
 San Francisco                36,218,513     67,788
 San Jose                     2,486,136      15,214
 Santa Rosa                   1,127,018      0
 Colorado
 Denver                       4,150,341      19,265
 Connecticut
 Hartford                     4,019,409      48,703
 New Haven                    6,100,471      62,746
 District of Columbiab        18,322,558     259,988
 Florida
 Fort Lauderdale              10,810,324     118,291
 Jacksonville                 3,683,146      41,591
 Miami                        21,248,387     279,163
 Orlando                      4,907,180      54,824
 Tampa-St. Petersburg         7,236,728      48,163
 West Palm Beach              6,711,944      87,953
 Georgia
 Atlanta                      13,147,268     157,991
 Illinois
 Chicago                      18,227,884     191,570
 Louisiana
 New Orleans                  5,695,360      68,148
 Maryland
 Baltimore                    13,478,549     202,463
 Massachusetts
 Bostonb                      10,647,381     68,508
 Michigan
 Detroit                      6,585,744      73,909
 Minnesota
 Minneapolis-St. Paulb        2,548,603      12,783
 Missouri
 Kansas Cityb                 2,952,910      16,204
 St. Louisb                   3,664,771      33,669
 Nevada
 Las Vegas                    3,402,697      25,747
 New Jersey
 Bergen-Passaic               4,320,176      48,163
 Jersey City                  5,015,785      63,737
 Middlesex-Somerset-Hunterdon 2,555,029      26,467
 Newark                       14,390,269     192,110
 Vineland-Millville-Bridgeton 688,648        8,732
 New York
 Dutchess County              1,220,662      12,153
 Nassau-Suffolk               5,632,012      49,963
 New York                     96,961,856     1,260,780
 Ohio
 Cleveland                    2,933,058      31,148
 Oregon
 Portlandb                    3,115,251      0
 Pennsylvania
 Philadelphiab                16,011,451     205,884
 Puerto Rico
 Caguas                       1,610,314      29,348
 Ponce                        2,487,768      33,849
 San Juan                     11,912,865     217,047
 Texas
 Austin                       3,175,509      27,997
 Dallas                       10,164,078     82,552
 Fort Worth                   2,935,543      21,606
 Houston                      15,489,996     177,707
 San Antonio                  3,014,654      44,742
 Virginia
 Norfolkb                     3,665,087      49,963
 Washington
 Seattle                      5,303,343      0
 Total                        $485,846,900   $5,000,000

aIncluded in title I award. A Department of Health and Human Services (HHS)
and Congressional Black Caucus (CBC) initiative to further address HIV/AIDS
in racial and ethnic communities.

bEMA boundaries include jurisdictions in more than one state.

CARE Act Title II HIV Grants, Fiscal Year 1999

Continued from Previous Page

 State and territory     Formula        ADAPa        Total
 Alabama              $3,314,520    $3,980,313    $7,294,833
 Alaska               269,662       323,829       593,491
 Arizona              2,224,423     4,057,517     6,281,940
 Arkansas             1,505,463     1,807,868     3,313,331
 California           30,669,853    65,267,693    95,937,546
 Colorado             1,968,440     3,787,302     5,755,742
 Connecticut          3,629,583     7,793,350     11,422,933
 Delaware             1,392,956     1,672,761     3,065,717
 District of Columbia 3,319,351     7,690,410     11,009,761
 Florida              24,976,515    48,505,772    73,482,287
 Georgia              7,658,435     13,815,288    21,473,723
 Guam                 8,929         10,723        19,652/
 Hawaii               1,101,864     1,323,197     2,425,061
 Idaho                264,304       317,396       581,700
 Illinois             6,967,711     14,548,730    21,516,441
 Indiana              3,253,801     3,907,398     7,161,199
 Iowa                 658,975       791,345       1,450,320
 Kansas               981,136       1,426,136     2,407,272
 Kentucky             1,851,917     2,223,914     4,075,831
 Louisiana            5,010,641     8,061,420     13,072,061
 Maine                441,103       529,708       970,811
 Maryland             6,496,978     14,175,575    20,672,553
 Massachusetts        4,213,646     8,413,129     12,626,775
 Michigan             3,740,253     6,712,489     10,452,742
 Minnesota            971,008       2,024,469     2,995,477
 Mississippi          2,269,803     2,725,742     4,995,545
 Missouri             2,683,738     5,127,655     7,811,393
 Montana              250,000       227,324       477,324
 Nebraska             548,253       658,381       1,206,634
 Nevada               1,568,357     3,079,595     4,647,952
 New Hampshire        308,492       553,298       861,790
 New Jersey           12,427,002    25,275,844    37,702,846
 New Mexico           1,125,079     1,351,076     2,476,155
 New York             41,145,958    85,949,879    127,095,837
 North Carolina       5,301,431     6,371,503     11,672,934
 North Dakota         100,000       75,060        175,060
 Ohio                 4,920,576     6,914,078     11,834,654
 Oklahoma             1,773,340     2,129,553     3,902,893
 Oregon               1,543,178     2,790,079     4,333,257
 Pennsylvania         8,590,475     15,041,980    23,632,455
 Puerto Rico          7,895,807     15,505,206    23,401,013
 Rhode Island         1,069,718     1,284,594     2,354,312
 South Carolina       4,968,208     5,966,180     10,934,388
 South Dakota         100,000       105,084       205,084
 Tennessee            4,461,029     5,357,124     9,818,153
 Texas                17,245,801    32,998,423    50,244,224
 Utah                 946,495       1,136,619     2,083,114
 Vermont              250,000       238,047       488,047
 Virginia             4,847,006     8,252,286     13,099,292
 Virgin Islands       283,949       340,986       624,935
 Washington           2,933,765     5,400,015     8,333,780
 West Virginia        624,763       797,778       1,422,541
 Wisconsin            1,730,610     2,082,373     3,812,983
 Wyoming              100,000       96,506        196,506
 Total                $248,904,300  $461,000,000  $709,904,300

aAIDS Drug Assistance Program.

HOPWA Formula Grantees, Fiscal Year 1999

Continued from Previous Page

 State and territory             Grantee               Amount
 Alabama              State of Alabama               $796,000
                      Birmingham                     365,000
 Arizona              State of Arizona               366,000
                      Phoenix                        923,000
 Arkansas             State of Arkansas              552,000
 California           State of California            2,427,000
                      Los Angeles                    8,769,000
                      Oakland                        1,670,000
                      Riverside                      1,372,000
                      Sacramento                     656,000
                      San Diego                      2,168,000
                      San Francisco                  8,510,000
                      San Jose                       649,000
                      Santa Ana (for Orange County)  1,143,000
 Colorado             Denver                         1,164,000
                      State of Connecticut           920,000
 Connecticut          Hartford                       1,413,000
                      New Haven                      1,214,000
                      State of Delaware              113,000
 Delaware
                      Wilmington                     485,000
 District of Columbia Washington, D.C.               6,475,000
                      State of Florida               3,164,000
                      Fort Lauderdale                4,186,000
                      Jacksonville                   983,000
 Florida              Miami                          8,418,000
                      Orlando                        1,753,000
                      Tampa                          1,661,000
                      West Palm Beach                2,635,000
                      State of Georgia               1,297,000
 Georgia
                      Atlanta                        3,407,000
                      State of Hawaii                132,000
 Hawaii
                      Honolulu                       364,000
                      State of Illinois              534,000
 Illinois
                      Chicago                        4,219,000
                      State of Indiana               636,000
 Indiana
                      Indianapolis                   579,000
 Kentucky             Commonwealth of Kentucky       561,000
                      State of Louisiana             1,063,000
 Louisiana
                      New Orleans                    2,031,000
 Maryland             Baltimore                      4,689,000
 Massachusetts        Boston                         1,890,000
                      State of Michigan              677,000
 Michigan
                      Detroit,                       1,526,000
                      State of Minnesota             92,000
 Minnesota
                      Minneapolis                    670,000
 Mississippi          State of Mississippi           769,000
                      State of Missouri              396,000
 Missouri             Kansas City                    813,000
                      St. Louis                      944,000
                      State of Nevada                190,000
 Nevada
                      Las Vegas                      1,308,000
                      State of New Jersey            1,430,000
                      Dover (for Monmouth)           595,000
                      Jersey City                    2,271,000
 New Jersey
                      Newark                         5,777,000
                      Paterson (for Bergen-Passaic)  1,160,000
                      Woodbridge (for Middlesex)     671,000
 New Mexico           State of New Mexico            391,000
                      State of New York              2,218,000
                      Buffalo                        352,000
 New York             Islip (for Nassau-Suffolk)     1,362,000
                      New York City                  48,668,000
                      Rochester                      542,000
                      State of North Carolina        1,212,000
 North Carolina       Charlotte                      397,000
                      Raleigh                        386,000
                      State of Ohio                  822,000
                      Cincinnati                     395,00
 Ohio
                      Cleveland                      670,000
                      Columbus                       458,000
 Oklahoma             State of Oklahoma              723,000
 Oregon               Portland                       803,000
                      Commonwealth of Pennsylvania   1,135,000
 Pennsylvania         Philadelphia                   3,428,000
                      Pittsburgh                     491,000
                      Commonwealth of Puerto Rico    1,841,000
 Puerto Rico
                      San Juan                       5,891,000
 Rhode Island         Providence                     424,000
 South Carolina       State of South Carolina        1,657,000
                      State of Tennessee             525,000
 Tennessee            Memphis                        538,000
                      Nashville                      479,000
                      State of Texas                 2,086,000
                      Austin                         767,000
                      Dallas                         2,505,000
 Texas
                      Fort Worth                     655,000
                      Houston                        6,466,000
                      San Antonio                    805,000
 Utah                 State of Utah                  368,000
                      Commonwealth of Virginia       463,000
 Virginia             Richmond                       492,000
                      Virginia Beach (for Norfolk)   702,000
                      State of Washington            487,000
 Washington
                      Seattle                        1,401,000
                      State of Wisconsin             325,000
 Wisconsin
                      Milwaukee                      393,000

Characteristics of CARE Act Clients and Persons Living With AIDS at Seven
Locations

                 Orange
                County,       Los        San      Middlesex,   Michigan    Virginia  Washington,
                Calif.     Angeles    Francisco      N.J.                               D.C.
                                                                          CARE
 CharacteristicCARE AIDS   CAREAIDS   CARE AIDS   CARE  AIDS   CARE AIDS       AIDS  CARE  AIDS
               Act         Act        Act         Act          Act                   Act
                                                                          Act
 Gender
 Male          85.0 89.6   84.990.5   88.5 93.8   59.6  67.7   74.3 82.0  64.9 80.8  67.4  77.9
 Female        15.0 10.4   15.19.5    11.5 6.2    40.4  32.3   25.7 18.0  35.1 19.2  32.6  22.1
 Race
 White         53.7 63.0   37.543.0   56.7 67.4   35.9  40.0   32.7 41.4  30.1 38.9  17.4  23.4
 African
 American      6.0  5.2    21.721.4   24.1 16.0   42.4  36.5   63.0 54.8  66.3 56.4  76.6  71.0
 Hispanic      37.0 29.0   38.132.7   14.0 12.7   20.5  22.5   3.6  3.3   3.0  3.9   5.3   4.9
 Asian Pacific
 or Native     3.3  2.7    2.7 2.5    5.1  3.9    1.2   0.8    0.8  0.4   0.6  0.8   0.7   0.6
 American
 Exposure
 category
 Men who have
 sex with men  56.2 71.1   66.173.6   59.7 71.8   23.3  25.3   44.7 53.2  37.3 48.9  31.5  44.8
 Persons who
 inject drugs  15.8 13.3   7.1 9.6    17.5 12.8   36.2  43.2   19.0 24.6  18.0 21.5  19.7  28.9
 Men who have
 sex with men
 and inject    4.4  5.6    5.3 6.1    12.4 11.9   4.7   4.4    5.0  6.7   7.2  6.2   5.4   4.6
 drugs
 Persons who
 have
 heterosexual  22.3 7.7    14.98.1    8.7  2.7    34.9  21.4   26.6 12.1  34.8 19.2  39.8  17.9
 contact
 Other         1.4  2.2    6.7 2.7    1.6  0.8    0.8   5.6    4.8  3.4   2.7  4.3   3.6   3.8
 Stage of
 illness
 HIV but not
 AIDS          50.6        59.3       52.0        58.1         57.9       57.3       58.7
 AIDS          49.4        40.7       48.0        41.9         42.1       42.7       41.3

Note: Numbers are percentages.

(101838)

Table 1: The Ryan White CARE Act's Programs Described 9

Table 2: Selected CDC HIV Prevention Program Funding,
Fiscal Year 1998 10

Table 3: Characteristics of Individuals Who Receive Services From Providers
Funded and Not Funded by the CARE Act 13

Table 4: Average Percentage of CARE Act Title I and Title II Funds
Spent on Services, Fiscal Year 1998 18

Table 5: Available CARE Act Title I and Title II Funds per AIDS Case
in Six States, Fiscal Year 1997 23

Table 6: Distribution of HOPWA Funds in Six States and Their
EMSAs, Fiscal Year 1997 25

Table 7: Compensation Characteristics at Nonprofit Organizations 31

Table 8: Organizations in Five Locations Funded by CARE Act Title I,
Fiscal Year 1998 39

Table 9: Compensation by Type of Nonprofit Organization 41

Figure 1: Federal HIV/AIDS Funding, Fiscal Year 1999 6

Figure 2: Distribution of CARE Act Title I-III Funds, Fiscal Year 1998 16

Figure 3: Distribution of Selected CDC HIV Prevention Program
Funds, Fiscal Year 1998 20

Figure 4: Distribution of HOPWA Funds, 1994-98 22

Figure 5: ADAP Clients and AIDS Cases in Non-MSA Areas, 1998-99 28

Figure 6: Distribution of AIDS Cases and CARE Act Clients in
Michigan, 1998 29

Figure 7: Distribution of AIDS Cases and CARE Act Clients in
Virginia, 1998 30
  

1. Medicaid is a joint federal and state program that pays for health care
services for eligible low-income or disabled individuals.

2. A disabled adult is unable to engage in any substantial gainful activity
because of a medically determined physical or mental impairment that has
lasted (or can be expected to last) at least 12 months or that is expected
to result in death. An individual with AIDS or HIV infection could also
qualify for Medicaid on the basis of eligibility under another eligibility
category such as being a pregnant woman, a child under 21, or a member of a
family with a dependent child.

3. This is based on AIDS cases in adults and adolescents 13 years of age or
older reported to CDC in 1996 from the 50 states and the District of
Columbia.

4. Large MSAs are defined as having populations larger than 500,000,
medium-sized MSAs between 50,000 and 500,000, and non-MSAs smaller than
50,000.

5. Health care services are limited to persons with HIV/AIDS and not other
family members. Further, the cost of these services is limited when payments
are made by other sources.

6. HCSUS is being conducted under a cooperative agreement between RAND and
AHRQ. Additional funding has been provided by a number of agencies within
HHS, the Robert Wood Johnson Foundation, Merck & Co., and Glaxo-Wellcome
Inc. The study is based on a sample of 2,864 respondents representing the
231,400 persons who were at least 18 years old, known to have been infected
with HIV, and receiving medical care in the 48 contiguous United States in
early 1996.

7. M. Shapiro and others, "Variations in the Care of HIV-Infected Adults in
the United States," Journal of the American Medical Association , Vol. 281
(1999), pp. 2305-15.

8. HCSUS defines CARE Act clients as all patients receiving care from a site
that has received CARE Act funds. It is possible that some individuals
received services at a CARE Act-funded site that were not funded under the
CARE Act. AHRQ performed specific analyses of the HCSUS data at our request.

9. HRSA obtains client data from service providers, and clients may seek
services from more than one provider. Therefore, an unduplicated count of
clients is typically not available. HRSA initiated "Client-Level Data
Demonstration Projects" at eight sites that can provide an unduplicated
count of clients. For California, however, limited data were available and
are therefore not included in our analysis.

10. While both HIV-infected and AIDS patients can receive services funded
under the CARE Act, we are limited to comparing CARE Act clients with
persons with AIDS because data on HIV-infected persons are not uniformly
reported. The percentage of CARE Act clients with AIDS ranged from about 41
percent at one location to about 49 percent at another. Our analysis of the
seven locations shows CARE Act client characteristics and HCSUS data to be
similar. Also, we noted that the characteristics of persons with AIDS and
CARE Act clients vary by location.

11. The proportion of AIDS cases that resulted from heterosexual contact is
increasing in the general population. Of the AIDS cases reported for the 12
months ending June 1993, exposure to HIV through heterosexual contact
accounted for 9 percent in which exposure category was known. This compares
with 15 percent of the AIDS cases reported for the 12 months ending June
1999 for the same exposure group.

12. HRSA was not able to provide data on the distribution of funds among
various services for title IV and demonstration and training programs.

13. States that receive a minimum allotment of title II funds (between
$100,000 and $250,000) may spend up to the amount required to support one
full-time equivalent employee for administration, planning, and evaluation.

14. CDC uses a grantee's federal negotiated indirect cost rate. Typical
examples of indirect costs are costs of general administrative services,
general research and technical support, security, rent, employee health and
recreation facilities, and operating and maintenance costs for buildings,
equipment, and utilities.

15. Grantees can carry out program activities themselves or by contract with
a program sponsor. Program sponsors are nonprofit organizations or
governmental housing agencies.

16. The analysis includes only title I and title II funds. We assigned all
ADAP funds, including any title I contributions, to statewide distribution.
Remaining title I funds and title II consortia funds for the EMA community
were assigned to the EMA. Other title II consortia funds were assigned to
the remainder of the state. We did not include title III grants in our
analysis because these are not distributed by formula. However, in fiscal
year 1999 half of the 26 title III grants in these six states were awarded
to organizations located within the EMAs.

17. Reporting periods for ADAP clients varied: Two states provided number of
clients receiving medications during June 1999, two states included clients
enrolled during June 1999, and two states provided the number of clients
enrolled as of June 30, 1999. The estimated number of people living with
AIDS is as of June 30, 1998. As with other comparisons in this report, we
are not including people with HIV infection who have not progressed to AIDS,
since not all states report HIV cases.

18. CARE Act client data are by zip codes; AIDS population data are by
county.

19. IRS Form 990 instructions state that compensation includes salary, fees,
bonuses, and severance payments. For this report, we included in the
computation of total compensation contributions to employee benefit plans,
deferred compensation, and expense account and other allowances.

20. The compensation line item from IRS Form 990 includes salary, fees,
bonuses, and severance pay. We also included as part of total compensation
contributions to employee benefit plans, deferred compensation, and expense
account and other allowances. These line items were also obtained from Form
990.

21. Because of the limited number of CDC prevention grantees, we included
these grantees; they are in San Antonio, Tex.; Jersey City, N.J.; New York,
N.Y.; Hartford, Conn.; and San Francisco, Calif.

22. Of the 273 organizations, 107 were in San Francisco, 31 in Dallas, 92 in
Philadelphia, 21 in Kansas City, and 22 in St. Louis.

23. We limited our analysis to organizations with revenues of $300,000 or
more. However, in some cases, the IRS file we used to identify the
orgnizations had revenue amounts different from those in the file used for
analysis.

24. Congressional Budget Office, Comparing the Pay and Benefits of Federal
and Nonfederal Executives (Washington, D.C.: CBO, Nov. 1999).

25. The NonProfit Times Online, The 1998 Salary Survey (Cedar Knolls, N.J.:
The NonProfit Times Online, Feb. 1999).
*** End of document ***