Audit of Outreach and Risk Reduction Programs Funded by the New York Eligible Metropolitan Area Under Title 1 of the Ryan White Comprehensive AIDS Resources Emergency Act of 1990

EXECUTIVE SUMMARY:

This report discusses our audit of outreach and harm reduction/recovery readiness and risk reduction programs provided by the New York Eligible Metropolitan Area (EMA), under Title I of the Ryan White Comprehensive AIDS Resources Emergency Act of 1990 (CARE Act). The objective of our audit was to determine whether Title I funds expended by EMA on these programs were for the purpose of delivering or enhancing services for individuals and families with HIV disease.

During 1995, EMA awarded 35 contracts totaling $4.7 million, or about 5 percent of the total $93.6 million, grant award received from the Health Resources and Services Administration (HRSA) for Outreach, and Harm Reduction/Recovery Readiness and Risk Reduction programs.

During our on-site review at seven contractors ($1.7 million in Title I contracts), we found that these services were provided predominantly to individuals whose HIV status was unknown at the time the services were provided. The providers classified the individuals to whom the services were provided as either "at risk, " "risk unknown, " or otherwise not HIV-infected. These programs were targeted to the "at risk" population of the respective provider catchment areas.

In light of the statutory language of Title I of the CARE Act, we believe it is not appropriate to spend Title I funds on programs designed for the "at risk" population instead of programs for individuals with HIV and their families. According to the CARE Act, the primary purpose of Title I grants from HRSA to EMAs is to provide direct financial assistance for the purpose of delivering services for individuals and families with HIV disease.

Three of the contractors ($447,000) provided outreach services such as distributing literature about HIV/AIDS and other sexually transmitted diseases. Two of the three contractors did not maintain documentation that would allow us to determine whether their clients had HIV disease or were family members of persons with HIV disease. The third contractor reported that, over a 2-month period, 66 clients out of over 3,200 outreach contacts availed themselves of referral services. We reviewed case records of 38 of these 66 clients. Of the 38 clients, 19 received an HIV test. Only one tested positive.

Four of the contractors ($1.3 million) provided harm reduction/recovery readiness and risk reduction services. The program eligibility documentation maintained by these providers varied from contractor to contractor depending on the nature of services provided. For example:

• a substance abuse program had no documentation regarding the individual's HIV status because the program requires anonymity, and

• a entry-level drug program was available to the "at risk" population. Therefore, the provider did not require documentation of HIV disease.

We also found that neither HRSA nor EMA had established clear guidelines which would have defined the parameters of eligibility or documentation required to ensure that only eligible individuals or their families received services.

In addition, the methodologies used by EMA and service providers to evaluate the success of outreach and risk reduction efforts were ineffective because they were based primarily on the total number of individuals served rather than the number of HIV-infected individuals served.

We are recommending that HRSA:

• immediately advise EMAs that funds awarded under Title I of the CARE Act may not include outreach programs related to prevention of HIV, rather than the provision of medical and other services to individuals infected with HIV; and that grantees must assure that any outreach programs supported with Title I funds must demonstrate that they have a high probability of identifying persons with HIV infection for purposes of enrolling them in care;

• coordinate with the Office of General Counsel, and others (the Centers for Disease Control and Prevention (CDC), Office of Science and Epidemiology), to establish eligibility and documentation requirements for outreach services that are reasonably calculated to reach HIV-infected individuals; and

• develop procedures for local grantees to use in evaluating the effectiveness of qualified outreach and harm reduction/recovery readiness and risk reduction programs.

In their response to our draft report, HRSA concurred with our recommendations.