Ryan White Care Act: Access to Services by Minorities, Women, and
Substance Abusers (Letter Report, 01/13/95, GAO/HEHS-95-49).

AIDS is affecting minorities, women, and injection drug users at an
increasing rate. GAO reviewed the extent to which HIV-infected groups,
such as African-Americans, Hispanics, women, and injection drug users
received medical and support services funded by the Ryan White
Comprehensive AIDS Resources Emergency Act of 1990. GAO visited five
locations--Baltimore, Denver, Los Angeles, Sacramento, and the Maryland
suburbs of Washington, D.C.--and found that all three groups generally
used services at a rate that reflect their representation in the
HIV-inflected population in those areas. Medical and support services
providers said that this corresponds to their experience of the usage of
Ryan White Care Act-funded services. These providers and advocates
added, however, that barriers may limit some groups' access to services.

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

 REPORTNUM:  HEHS-95-49
     TITLE:  Ryan White Care Act: Access to Services by Minorities, 
             Women, and Substance Abusers
      DATE:  01/13/95
   SUBJECT:  Acquired immunodeficiency syndrome
             Federal funds
             State-administered programs
             Health care services
             Health resources utilization
             Drug abuse
             Infectious diseases
             Women
             Health care programs
             Minorities
IDENTIFIER:  Baltimore (MD)
             Denver (CO)
             Los Angeles (CA)
             Sacramento (CA)
             Maryland
             AIDS
             
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Cover
================================================================ COVER


Report to the Chairman, Committee on Labor and Human Resources, and
the Honorable Hank Brown, U.S.  Senate

January 1995

RYAN WHITE CARE ACT - ACCESS TO
SERVICES BY MINORITIES, WOMEN, AND
SUBSTANCE ABUSERS

GAO/HEHS-95-49

Access to Ryan White CARE Act Services


Abbreviations
=============================================================== ABBREV

  AIDS - acquired immunodeficiency syndrome
  CARE - Comprehensive AIDS Resources Emergency
  EMA - eligible metropolitan area
  HIV - human immunodeficiency virus
  HRSA - Health Resources and Services Administration
  IDU - injection drug user

Letter
=============================================================== LETTER


B-255864

January 13, 1995

The Honorable Nancy Kassebaum
Chairman
Committee on Labor and Human Resources
United States Senate

The Honorable Hank Brown
United States Senate

The acquired immunodeficiency syndrome (AIDS) epidemic, in its second
decade, continues to escalate at an alarming rate.  AIDS is the
second leading cause of death for men between ages 25 and 44 and the
fourth leading cause of death for women in that age group.  Since the
first cases were identified in 1981, more than 400,000 people in the
United States have been diagnosed with AIDS.  Furthermore, as many as
1 million people in the nation may be infected with the human
immunodeficiency virus (HIV), which causes AIDS. 

AIDS is affecting minorities, women, and injection drug users (IDU)
at an increasing rate.  As of September 1989, African-Americans and
Hispanics accounted for 43 percent of cumulative AIDS cases, women
for 10 percent, and IDUs for 21 percent.  From July 1993 through June
1994, the distribution of newly reported AIDS cases was 56 percent
African-American and Hispanic, 17 percent women, and 28 percent IDUs. 

The African-American and Hispanic communities have been particularly
hard hit.  These communities are disproportionately affected by the
AIDS epidemic.  African-Americans represent 12 percent of the
nation's population but account for 32 percent of the cumulative AIDS
cases as of June 1994.  Similarly, while Hispanics account for 9
percent of the population, 17 percent of the cumulative AIDS cases
affect Hispanics.  Concerns have been raised whether all these
affected populations have been receiving needed HIV services. 

This report responds to your request that we determine the extent to
which HIV-infected populations, such as African- Americans,
Hispanics, women, and IDUs, receive medical and support services
funded by the Ryan White Comprehensive AIDS Resources Emergency
(CARE) Act of 1990.\1 Because there are no national data to address
this issue, we visited five locations--Baltimore, Denver, Los
Angeles, Sacramento, and the Maryland suburbs of Washington, D.C.  We
chose sites on the basis of varying size and demographics of their
HIV-infected populations, how long they have been receiving Ryan
White CARE Act funding, and the amount of funding.  At these
locations, we interviewed program administrators and reviewed
incidence and utilization data provided by them.  We also interviewed
Ryan White CARE Act-funded service providers and advocates for
HIV-infected people.  Additionally, we discussed this issue with
national HIV/AIDS organizations and officials of the Department of
Health and Human Services' Health Resources and Services
Administration (HRSA).  (See app.  I for our objective, scope, and
methodology.)


--------------------
\1 Support services include but are not limited to case management,
counseling, financial assistance, and transportation. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

We found that minorities, women, and IDUs generally use services at a
rate that reflect their representation in the HIV-infected population
in the five locations.  Medical and support services providers and
advocates of HIV-infected people told us that this corresponds to
their experience of the usage of Ryan White CARE Act-funded services. 
These providers and advocates also said, however, that barriers exist
that may limit access to services to certain groups. 


   BACKGROUND
------------------------------------------------------------ Letter :2

The Ryan White CARE Act of 1990 (P.L.  101-381) was enacted to
improve the quality and availability of medical and support services
for individuals and families with HIV disease.  For fiscal year 1994,
34 eligible metropolitan areas (EMA)\2 received $320 million under
title I of the act; the 54 states and territories received $162.7
million under title II of the act. 

EMAs award Ryan White CARE Act title I funds to providers of medical
and support services.  These providers include hospitals, ambulatory
care facilities, community health centers, community-based
organizations, and hospices, among others.  Ryan White CARE Act funds
cannot be used for in-patient care but can be used for in-patient
case management services that expedite hospital discharge. 

States and territories use title II funds to establish and operate
HIV care consortia that provide services to HIV-infected individuals
and their families.  A consortium is an association of one or more
public and nonprofit service providers operating in areas determined
by the state to be most affected by HIV disease.  The consortium uses
the funds to plan, develop, and deliver medical and support services. 
In addition to funding consortia, states use title II funds to
provide HIV-infected people with home and community-based care
services, continuity of health insurance coverage, and prescription
drugs such as antiviral medications. 

HRSA's Division of HIV Services is responsible for awarding and
monitoring title I and II grants.  One-half of title I funds and all
of title II funds are awarded on the basis of legislated formulas. 
EMAs apply to HRSA for additional or supplemental funding.  HRSA
requires that EMAs, in their applications, describe activities
directed toward community-based and minority service providers that
would improve access to care for low-income and underserved
populations.  Project officers monitor grantees' compliance with
requirements and progress in serving affected groups.  HRSA also
offers technical assistance, such as organizational development and
capacity building in underserved communities, to the grantees through
the project officers and a contractor. 


--------------------
\2 To be eligible for funding, metropolitan areas must have a total
of more than 2,000 AIDS cases or a per capita incidence of 25
cumulative AIDS cases for every 100,000 people in the population. 


   MINORITIES, WOMEN, AND IDUS ARE
   RECEIVING RYAN WHITE SERVICES
------------------------------------------------------------ Letter :3

At the five locations we visited, minorities, women, and IDUs appear
to access Ryan White CARE Act-funded medical and support services
generally in similar or somewhat greater proportion than their
representation in the HIV-infected population.\3 In a few instances,
some subpopulations used fewer services.  For example, in Los
Angeles, Hispanics accounted for 23 percent of the estimated
HIV-infected population but used 13 percent of drug abuse treatment
services during the 3-month period we analyzed.  To illustrate the
use of services, figure 1 shows that the use of primary care services
in Baltimore is generally in proportion to or slightly higher than
the estimated HIV-infected population.  (See app.  II for the
distribution of other services we analyzed in the five locations.)

   Figure 1:  Distribution of CARE
   Act-Funded Primary Care
   Services in the Baltimore EMA
   (January-March 1994)

   (See figure in printed
   edition.)

Notes:

1.  Of the $4.6 million title I and II funds awarded in 1994, primary
care services providers received 40.6 percent.

2.  The Baltimore EMA estimates its HIV-infected population to be
about 16,500 persons.

3.  During the 3-month period, 839 primary care visits were
conducted. 

We also sought views on access from advocates for HIV-infected people
and medical and support service providers located in the five areas
we studied.  We selected advocates and providers representing and
serving various populations, including minorities, women, and IDUs. 
The advocates and providers affirmed that affected groups generally
accessed services in proportion to their representation in the
HIV-infected population. 


--------------------
\3 At some locations, some service providers did not report one or
more client characteristic, such as gender or risk group.  In those
locations, we could not compare all population and client
characteristics. 


   SEVERAL BARRIERS MAY LIMIT
   ACCESS TO SERVICES
------------------------------------------------------------ Letter :4

Use rates of CARE Act-funded services may not fully explain access to
services.  Providers and advocates told us about many barriers to
access that in their view are particularly difficult to overcome. 
HIV-infected people often have other priorities and pressing needs
that may affect the extent to which they seek HIV- related care. 
Substance abuse and homelessness, among other barriers, were
mentioned as affecting the extent to which HIV/AIDS- infected people
seek services. 

In some instances, lack of knowledge about and lack of motivation to
seek services affect the extent to which some people use services. 
Additionally, the advocates and providers told us of other barriers,
including a lack of trust of the medical community, denial of the
disease by some HIV-infected people, and a reluctance to obtain care
from a provider of a certain racial or ethnic group or who primarily
serves a different racial or ethnic group than that of the person
seeking services.  As agreed, we did not try to determine the extent
to which these barriers limit access to services. 


---------------------------------------------------------- Letter :4.1

We discussed our findings with officials of HRSA's AIDS Program
Office, the Division of HIV Services, and the Office of Science and
Epidemiology.  They generally agreed with our findings, and we
incorporated their suggestions where appropriate. 

We are sending copies of this report to the Secretary of Health and
Human Services; the Assistant Secretary for Health; the
Administrator, Health Resources and Services Administration; and
other interested parties.  We will make copies available to others on
request. 

If you or your staff have any questions about this report, please
call me at (202) 512-7119 or Bruce D.  Layton, Assistant Director, at
(202) 512-6837.  Other contributors to this report include Roy
Hogberg, Howard Cott, Marie DeCocker, and Mark Vinkenes. 

Mark V.  Nadel
Associate Director
National and Public Health Issues


OBJECTIVE, SCOPE, AND METHODOLOGY
=========================================================== Appendix I

Our objective was to determine the extent to which selected human
immunodeficiency virus- (HIV) infected subpopulations, that is,
African-Americans, Hispanics, women, and injection drug users (IDU)
were receiving services in proportion to their representation in
their areas' HIV-infected populations.  To conduct our study, we
visited five locations:  Baltimore, Denver, and Los Angeles eligible
metropolitan areas (EMA); the Sacramento, California, Consortium; and
the Suburban Maryland HIV Consortium (serving the Maryland suburbs of
Washington, D.C.).  We chose sites on the basis of varying size and
demographics of HIV-infected population, how long they have been
receiving Ryan White CARE Act funding, and the amount of funding.  We
cannot generalize the results of our work to all Ryan White CARE
Act-funded EMAs and consortia. 

To determine the extent to which HIV-infected populations were being
served, we compared the estimated HIV-infected population at each
site with service provider reports of clients served.  The estimates
and reports identified such characteristics as race/ethnicity,
gender, and mode of HIV transmission.  Each EMA estimated its own
HIV-infected population.  The consortia did not have the estimated
HIV-infected population for their areas so we used reported AIDS
cases for our analysis. 

At each location, we reviewed one or more medical or support service
funded by the Ryan White CARE Act.  For each EMA and consortium, we
selected the top priority services they identified.  We did this by
choosing those services that cumulatively accounted for about half of
the funds as estimated by the EMAs and consortia.  The percent of
funding accounted for ranged from 41.3 percent in Denver to 69.9
percent in Baltimore.  Using this method for selecting services, the
number of services we used for analysis varied from one service in
Sacramento to seven services in Baltimore.  For Denver and Los
Angeles, we identified three services and, for Suburban Maryland, we
identified two.\4

For the identified services, we obtained data on the characteristics
of clients served by Ryan White CARE Act-funded providers.  We
obtained the data from provider-generated reports to the EMA or
consortia.  The data were generally for a 3-month period but, since
reporting requirements varied at the EMAs and consortia, reporting
periods were not consistent across locations.  Table I.1 shows the
services and reporting periods for each location. 



               Table I.1

 Services and Reporting Period Used in
       Analysis of Clients Served


--------------------
\4 In Denver, we identified three services--primary care, case
management, and dental care--that comprised about 50 percent of
projected 1994 title I funds.  However, because Denver's dental care
program was in a developmental stage, the small number of clients did
not allow us to analyze client characteristics. 

