Report: Oversight Lacking for HIV/AIDS Funding

The Department of Health and Human Services’ (DHHS) supervision of programs that receive funding under the Ryan White Care Act for HIV/AIDS has fallen short, according [pdf] to a recent Government Accountability Office report released on Wednesday.

The health department distributes grant money to state and local governments across the U.S. to fund the cost of medications, health insurance, case management and other health services for about a half million people with HIV/AIDS. Its agency, Health Resources and Services Administration, is charged with ensuring the grants are being used appropriately, through records and regular site visits.

The report found that HRSA failed to visit 44 percent of the grant recipients between 2008 and 2011, even in areas with high numbers of people living with HIV/AIDS.

• California, which received more than $148 million in 2011 and has an estimated 118,000 people living with the disease, was never visited.
• New York, which received more than $162 million in 2011 and has more than 130,000 people with the disease, was visited once in 2009.
• Texas received more than $85 million in 2011 and has about 66,000 people with HIV/AIDS, but was never visited.
• The District of Columbia, where HRSA is based, received $21 million in 2011 to serve 17,250 people, but had only one site visit from HRSA over the four-year period. HRSA, in a response, said that it had provided technical assistance to grant recipients in the district during that time.

Meanwhile, the agency made 12 separate trips to Puerto Rico, which received $31 million in 2011 for 18,172 patients, during that time, and six trips to the Virgin Islands, which received a little more than $1 million in 2011 to serve 568 patients.

Responding to the report, the department argued that it has a limited travel budget, and that both territories have challenges that “far exceed” most other grant recipients and therefore needed the visits. In Puerto Rico, DHHS said the recipients had problems getting access to HIV medications and care, high staff turnover and difficulties establishing contracts for HIV services. The Virgin Islands’ health department also had “significant fiscal, administrative, infrastructure and operational deficiencies,” DHHS said.

Marcia Crosse, GAO’s Health Care director, said that she didn’t dispute serious problems at the island sites. “I don’t have any evidence that this was a boondoggle for them to go to the Virgin Islands or Puerto Rico,” she told FRONTLINE. “But at the same time, it’s not clear to me that those places needed so many visits at the cost of going to other places that also had problems” and more people being served by the grants.

The report also said that the department’s monitoring branch, HRSA, lacked sufficient records and had frequent staff changes that made it difficult to monitor a particular program over time. The agency also destroyed records after two years’ time, making it difficult to establish a pattern of delinquent grant recipients.

In one instance, the report said, HRSA wasn’t able to sanction a poor-performing recipient because HRSA had thrown away the proper documentation.

Crosse said the GAO didn’t determine whether the shortcomings in oversight led to inadequate care for patients, because that wasn’t its mandate. But, she said, “HRSA was not doing a good job in fulfilling its responsibilities to maintain information to oversee these grants. It’s a lot of money.”

The GAO recommended, among other changes, that the agency improve its program to manage records, and set up a “strategic, risk-based approach” to determining which sites to visit.

HRSA said it agreed with the recommendations and “would work to fully implement those recommendations to improve Ryan White Program oversight.” It added that it places “great importance” on the oversight of grant recipients and that since 2010, it had been working on improving its review process, training employees on grant fraud and spending more money on monitoring and support for grant recipients.

The report comes as advocates and officials have said that despite increases in federal funding for HIV/AIDS, there still isn’t enough money to ensure everyone in the U.S. gets care. Federal and state budgets, already hammered by the recession, have been stretched as more people are living longer with the disease and more become infected.