Detailed Information on the
Minority HIV/AIDS Initiative Assessment

Establishing baselines and ambitious targets for long-term performance goals.

Developing an evaluation planning process in order to conduct an independent evaluation of comprehensive scope. This proposed evaluation will cover two years of MAI Fund activities

Developing a formal process to document how performance information is used by decision-makers in managing and making funding allocation decisions.

Establishing procedures for grantees to commit to measures and report on performance related to the program's goals.

Conducting an inventory of programs with related missions or activities to document their complementary relationship to the activities of the MAI Fund, and to identify gaps in prevention and treatment to be targeted with future MAI Fund awards.

Measure: By 2010 increase the percentage of ethnic and racial minority individuals surviving 3 years after a diagnosis of AIDS.

Explanation:The keystone to the HHS HIV/AIDS prevention strategy is HIV testing. This is followed by developing strategies to expand access and reduce barriers to keep HIV positive people in care and treatment, staving off the progression of the disease. This measure will indicate the impact that HIV/AIDS programs have on AIDS care and treatment within minority communities. The data will be collected from the CDC: Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report, Cases of HIV Infection and AIDS in the United States and Dependent Areas, "Proportion of persons surviving for more than 12, 24, and 36 months after an AIDS diagnosis in (2001, 2000, 1999 & 1998,)" Table 13 (2005, 2004, 2003, and 2002)

Measure: Reduce percentage of individuals from racial and ethnic minorities who are diagnosed with AIDS within 12 months of HIV diagnosis.

Explanation:The keystone to the HHS HIV/AIDS prevention strategy is HIV testing. This is followed by developing strategies to expand access and reduce barriers to keep HIV positive people in care and treatment, staving off the progression of the disease. This measure will indicate the impact that HIV/AIDS programs have on AIDS prevention and HIV care and treatment within minority communities. The data will be collected from the CDC: Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report, Cases of HIV Infection and AIDS in the United States and Dependent Areas, "Time to an AIDS diagnosis of HIV infection, by selected characteristics, (2004, 2003, 2002, 2001,)"

Measure: Reduce the rate of new HIV infections among individuals from racial and ethnic minorities in the United States.

Explanation:This measure mirrors the CDC measure except for the fact that it is manipulated to reflect the incidence rate among racial and ethnic minorities rather than the entire U.S. population.

Measure: By 2010 increase the percentage of black individuals surviving 3 years after a diagnosis of AIDS.

Explanation:This measure provides an annual indicator on progress made among black individuals for the corresponding long-term goal. The data will be collected from the CDC: Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report, Cases of HIV Infection and AIDS in the United States and Dependent Areas, "Proportion of persons surviving for more than 12, 24, and 36 months after an AIDS diagnosis in (2001, 2000, 1999 & 1998,)" Table 13 (2005, 2004, 2003, and 2002)

Measure: By 2010 increase the percentage of Hispanic individuals surviving 3 years after a diagnosis of AIDS.

Explanation:This measure provides an annual indicator on progress made among Hispanic individuals for the corresponding long-term goal. The data will be collected from the CDC: Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report, Cases of HIV Infection and AIDS in the United States and Dependent Areas, "Proportion of persons surviving for more than 12, 24, and 36 months after an AIDS diagnosis in (2001, 2000, 1999 & 1998,)" Table 13 (2005, 2004, 2003, and 2002)

Measure: By 2010 increase the percentage of Asian/Pacific Islander individuals surviving 3 years after a diagnosis of AIDS.

Explanation:This measure provides an annual indicator on progress made among Asian/Pacific Islander individuals for the corresponding long-term goal. The data will be collected from the CDC: Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report, Cases of HIV Infection and AIDS in the United States and Dependent Areas, "Proportion of persons surviving for more than 12, 24, and 36 months after an AIDS diagnosis in (2001, 2000, 1999 & 1998,)" Table 13 (2005, 2004, 2003, and 2002)

Measure: By 2010 increase the percentage of American Indian/Alaskan Native individuals surviving 3 years after a diagnosis of AIDS.

Explanation:This measure provides an annual indicator on progress made among American Indian/Alaskan Native individuals for the corresponding long-term goal. The data will be collected from the CDC: Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report, Cases of HIV Infection and AIDS in the United States and Dependent Areas, "Proportion of persons surviving for more than 12, 24, and 36 months after an AIDS diagnosis in (2001, 2000, 1999 & 1998,)" Table 13 (2005, 2004, 2003, and 2002)

Measure: Reduce the percentage of black individuals diagnosed with AIDS within 12 months of HIV diagnosis.

Explanation:This measure provides an annual indicator on progress made among black individuals for the corresponding long-term goal. The data will be collected from the CDC: Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report, Cases of HIV Infection and AIDS in the United States and Dependent Areas, "Time to an AIDS diagnosis of HIV infection, by selected characteristics, (2004, 2003, 2002, 2001,)"

Measure: Reduce the percentage of Hispanic individuals diagnosed with AIDS within 12 months of HIV diagnosis.

Explanation:This measure provides an annual indicator on progress made among Hispanic individuals for the corresponding long-term goal. The data will be collected from the CDC: Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report, Cases of HIV Infection and AIDS in the United States and Dependent Areas, "Time to an AIDS diagnosis of HIV infection, by selected characteristics, (2004, 2003, 2002, 2001)."

Measure: Reduce the percentage of Asian/Pacific Islander individuals diagnosed with AIDS within 12 months of HIV diagnosis.

Explanation:This measure provides an annual indicator on progress made among Asian/Pacific Islander individuals for the corresponding long-term goal. The data will be collected from the CDC: Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report, Cases of HIV Infection and AIDS in the United States and Dependent Areas, "Time to an AIDS diagnosis of HIV infection, by selected characteristics, (2004, 2003, 2002, 2001,)"

Measure: Reduce the percentage of American Indian/Alaskan Native individuals diagnosed with AIDS within 12 months of HIV diagnosis.

Explanation:This measure provides an annual indicator on progress made among American Indian/Alaskan Native individuals for the corresponding long-term goal. The data will be collected from the CDC: Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report, Cases of HIV Infection and AIDS in the United States and Dependent Areas, "Time to an AIDS diagnosis of HIV infection, by selected characteristics, (2004, 2003, 2002, 2001,)"

Measure: Increase the number of individuals who learn their HIV status for the first time through MAI Fund programs.

Explanation:HIV testing coupled with enrolling positive individuals into care and treatment services significantly reduces new infections when the tested individuals stop infecting others unknowingly. By measuring those who learn their status for "the first time" a more accurate count of the tested population will result The aim of this measure is to determine the number of clients the MAI Fund serves per year through HIV testing rather than the number of tests administered.

Measure: Maintain the actual cost per MAI Fund HIV testing client below the medical care inflation rate.

Explanation:By maintaining the actual cost per MAI Fund testing client below the medical care inflation rate, program efficiency is demonstrated when compared to the industry norm. The medical care inflation rate is an inclusive measure that takes into consideration not only the cost of the testing unit but also the services and administrative costs that are necessary to facilitate an HIV test, including but not limited to other equipment costs, storage costs, and staff labor costs.

Measure: Maintain the actual cost per MAI Fund physician and other clinical staff trained below the medical care inflation rate.

Explanation:By maintaining the actual training cost for MAI Fund physicians and clinical staff below the medical care inflation rate, program efficiency is demonstrated when compared to the industry norm. The medical care inflation rate is an inclusive measure that takes into consideration not only the cost of the training exercises but also the services and administrative costs that are necessary to facilitate training, including but not limited to equipment costs, building operating costs and staff labor costs.

Is the program purpose clear?

Explanation: The Minority AIDS Initiative (MAI) was created in FY 1999 when the congressional Black Caucus initiated a partnership with HHS to significantly increase the national response to the HIV/AIDS epidemic in racial and ethnic minority communities. In addition to money that is appropriated directly to HHS Operating Divisions, there is another appropriation of roughly $50M each year called the Minority AIDS Initiative (MAI) Fund. The purpose and mission of the MAI Fund is to increase the access of racial and ethnic minority communities to HIV prevention, care, and treatment services. The focus of the MAI Fund is to address the HIV/AIDS crisis facing racial and ethnic minorities by identifying strategies that specifically target the highest-risk and hardest-to-serve populations, which for the past two decades have eluded more traditional HIV/AIDS prevention, treatment, and education efforts.

Evidence: The Public Health and Social Services Emergency Fund Conference Agreement creates the MAI Fund. It identifies that the purpose of the fund is to address the prevention and treatment needs of ethnic and racial minorities. House Report 107-229 (Departments of Labor, Health and Human Services, and Education and related Agencies Appropriation Bill, 2002) states the reason for establishing the MAI Fund was to encourage innovative and successful strategies for HIV/AIDS prevention, treatment, and education while building up the capacity of minority community based organizations.

Does the program address a specific and existing problem, interest, or need?

Explanation: The MAI Fund focuses on racial and ethnic minority communities because HIV/AIDS has a markedly disproportionate impact on these populations. According to the Centers for Diseases Control and Prevention (CDC) there are approximately 1.2 million Americans infected with HIV, with racial and ethnic minority communities among the most vulnerable. African Americans make up only 13 percent of the U.S. population, but comprised approximately 49 percent of all new HIV/AIDS diagnoses reported in the United States for 2005. In 2004 Hispanics made up approximately 14 percent of the U.S. population, but represent approximately 20 percent of new HIV/AIDS diagnoses. The AIDS rate in adolescents and adults is much higher in minority communities. In 2004 the AIDS rate among non-minority communities was 7.1 cases/100,000, significantly lower than that of African Americans (72.1 cases/100,000), Hispanics (25.01/100,000), American Indians and Alaska Natives (9.9/100,000), and Asians and Pacific Islanders (4.4/100,000).

Evidence: The Centers for Disease Control and Prevention (CDC) Fact sheets: A Glance at the HIV/AIDS Epidemic, HIV/AIDS among African Americans (January 2007), HIV/AIDS among Hispanics (June 2006), HIV/AIDS among Asians and Pacific Islanders (April 2006), HIV/AIDS among American Indians and Alaska Natives (March 2007).

Is the program designed so that it is not redundant or duplicative of any other Federal, state, local or private effort?

Explanation: The program does not demonstrate how it is unique from other HIV/AIDS programs, such as Ryan White CARE Act programs, CDC activities or the funds directly appropriated to HHS Operating Divisions as part of the Minority AIDS Initiative. While the MAI Fund specifically targets minority communities, theses communities also receive preventative care and treatment services from other programs. It is unclear how the MAI Fund complements these other programs.

Evidence: HHS targets almost $400M of its resources to address HIV/AIDS in minority communities, including the MAI Fund. HIV/AIDS treatment and prevention programs in minority communities including Ryan White (HRSA), HIV Viral Hepatitis STD and TB Prevention (CDC), and HIV/AIDS Programs of Regional and National Significance (SAMHSA). The Minority HIV/AIDS Initiative Crosscut Table provides a breakdown of the near $400M by agency.

Is the program design free of major flaws that would limit the program's effectiveness or efficiency?

Explanation: The construct of the program is designed to dispurse approximately $50 million annually through a competitive grant process to identify best practices in HIV/AIDS prevention, care and treatment among ethnic and racial minority communities. Funds appropriated to the Office of the Secretary for the MAI Fund are disbursed to the Public Health Service agencies in HHS, which then award funds through grants and/or contracts to support hundreds of organizations across the country. Oversight of the MAI Fund is provided by the Assistant Secretary for Health (ASH) with the assistance of the Office of HIV/AIDS Policy (OHAP). In order to facilitate the purpose, use, and distribution of these funds, the MAI Steering Committee on Implementation and Evaluation was established. Membership on this Steering Committee consists of representatives from each of the participating agencies and offices of the Fund and the Committee reports to the AHS/OHAP. The functions of this Committee are to participate in the development of: operating procedures; policy reviews; and data collection aggregation efforts. These efforts of the Steering Committee assist with the AHS/OHAP's role of monitoring and assisting with the Department's overarching efforts to respond to the HIV/AIDS epidemic in minority communities. There is no strong evidence that an alternative approach would yeild more efficient or effective results.

Evidence: The MAI Steering Committee uses various reporting mechanisms in order to assess and evaluate activities for funded programs. The Performance Assessment and Evaluation of Activities Report provides information on the status and outcomes of MAI funded projects, including: historical and current funding information; identification of qualitative and quantitative measures used to gauge performance and results, program impact, and identification of best practices; and application of lessons learned. The Biannual Progress Report for new activities provides information on a program's overall funding level, purpose, target populations, and performance assessment. These reports assist in the process and decision-making of the Fund through the decisions of the Steering Committee, and thus help and facilitate with the Department's monitoring and assisting of minority HIV/AIDS activities and programs.

Is the program design effectively targeted so that resources will address the program's purpose directly and will reach intended beneficiaries?

Explanation: The Minority AIDS Initiative Fund is designed to ensure that ethnic and racial minority communities receive HIV/AIDS prevention, care and treatment services. The ASH/OHAP provides: 1) informal guidance, 2) solicits proposals from the HHS Operating Divisions, than evaluates the proposals, and 3) based on criteria established by the MAI Steering Committee, determines which agency proposals will be funded. Once the Operating Division is notified of the funding level it will receive, a Request For Proposals is published in the Federal Register so that various groups may compete for the grants. The grants are then subject to specific criterion that determines how racial and ethnic minorities will benefit from the proposed activity or program and reviewed by the Grants Review Committee. In the end, awarded grants have been vetted through two rounds of evaluation, once at the ASH level and once at the agency/OPDIV level to ensure the resources will fulfill MAI's mission and reach minority communities with no unintended subsidies.

Evidence: Sample agendas from the MAI Steering Committee Meetings (June 20 & November 1, 2006) provide examples of what issues are discussed and the manner in which standard criteria for how agency proposals will be evaluated. Agency proposals from HRSA (Cross-Cultural Web-based Tool for Providers of Clinical Care to Adolescent HIV/AIDS Populations) and IHS (HIV/AIDS Tele-Medicine Support Network for Health Care Providers in Indian Health Service, Tribal and Urban Settings) are examples of the information provided to the ASH by agencies, and what is used to make the initial determination of agency awards. Finally, the Federal Register Notice (FR 68-231, December 2, 2003) provides an exhibit of how agencies inform the public of grant opportunities and the criterion they will used to make awards.

Does the program have a limited number of specific long-term performance measures that focus on outcomes and meaningfully reflect the purpose of the program?

Explanation: The Office of HIV/AIDS Policy's (OHAP) has developed three long-term performance measures that directly support the Minority AIDS Initiative (MAI) Fund 's purpose and reflect the intention of the program. The three long-term performance measures focus on increasing the survival rate of those diagnosed with AIDS; delaying the onset of an AIDS diagnosis among those testing for HIV for the first time; and reducing the incidence of HIV. Increasing access to prevention services, particularly prevention interventions and HIV testing opportunities in racial and ethnic minority communities, is crucial for a reduction in HIV incidence.

Evidence: The long-term measures seek to accomplish the following: (1) by 2010 increase the number of racial and ethnic minority individuals surviving 3 years after a diagnosis of AIDS; (2) reduce percentage of diagnosis with AIDS within 12 months of a HIV diagnosis among racial and ethnic minority communities; (3)**Reduce the rate of new infections among racial and ethnic minorities in the United States. [**Note- This incidence measure is a developmental measure for which actual data to establish baseline and targets will not be available from the CDC until 2007-2008.]

Does the program have ambitious targets and timeframes for its long-term measures?

Explanation: OHAP has not developed baselines and targets for all long-term measures. For the first long-term measure "Increase the number of HIV infected racial and ethnic minority individuals surviving 3 years after a diagnosis of AIDS by 2010," the baseline reflects the aggregate average for racial and ethnic minorities for FY 2005. FY 2005 data reflects those surviving for 36 months or 3 years after an AIDS diagnosis in 2001. The targets were developed on historical data dating three years prior to the baseline (2000, 1999 & 1998). For the second long-term measure, "Reduce percentage of diagnosis with AIDS within 12 months of a HIV diagnosis among racial and ethnic minority communities," the baseline reflects the aggregate average for racial and ethnic minorities for FY 2005. The targets were developed from historical data dating four years prior to the baseline (2004, 2003, 2002, & 2001). The third long-term measure, "Reduce the rate of new infections among racial and ethnic minorities in the United States," is a developmental measure for which data is not available at this time to establish a baseline or target. The CDC anticipates having usable incidence data within a two year timeframe, at which point baselines and targets will be developed.

Evidence: The baseline and out-year targets were established using data collected from the CDC: (1) Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report, Cases of HIV Infection and AIDS in the United States and Dependent Areas, "Proportion of persons surviving for more than 12, 24, and 36 months after an AIDS diagnosis in (2001, 2000, 1999 & 1998,)" Table 13 (2005, 2004, 2003, and 2002); (2) Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report, Cases of HIV Infection and AIDS in the United States and Dependent Areas, "Time to an AIDS diagnosis of HIV infection, by selected characteristics, (2004, 2003, 2002, 2001,)" Table 2 (2005, 2004, 2003, 2002); (3) Information was also collected from the CDC website: http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2005report/default.htm.

Does the program have a limited number of specific annual performance measures that can demonstrate progress toward achieving the program's long-term goals?

Explanation: The ASH/OHAP have adopted a limited number of annual goals to measure the performance of the MAI Fund. The measures gauge its annual progress in HIV/AIDS prevention and treatment. The long-term goals of "increasing the number of HIV infected ethnic and racial minority individuals surviving 3 years after a diagnosis of AIDS," and "reducing the percentage of diagnosis with AIDS within 12 months of a HIV diagnosis among racial and ethnic minority communities," have eight supporting annual measures that break out the four major minority groups for each with specific targets and baselines. The outcome measures tie directly to the long-term goals. One of the largest efforts supported by the MAI Fund is HIV/AIDS testing of racial and ethnic minority communities which is why the annual output measure of " individuals who learn their HIV status for the first time through activities supported by the MAI Fund," is included.

Evidence: The annual measures are to achieve the following targets: (1) By 2010 increase the AIDS survival rate beyond 36 months for African American (88%), Hispanic (90%), Asian/Pacific Island (89%), and American Indian/Alaskan Native (80%) individuals; (2) By 2010 reduce the percentage of diagnosis with AIDS when first diagnosed with HIV among African American (34%), Hispanic (38%), Asian/Pacific Islander (37%), and American Indian/Alaskan Native (36%) communities; (3) By 2010, increase the number of individuals who learn their HIV status for the first time per the MAI Fund to 158,172.

Does the program have baselines and ambitious targets for its annual measures?

Explanation: For the first set of annual measures "Increase the number of HIV infected African American, Hispanic, Asian/Pacific Islander, and American Indian/Alaskan Native individuals surviving 3 years after a diagnosis of AIDS by 2010," the baselines are the FY 2005 data for each racial and ethnic minority group. FY 2005 data reflects those surviving for 36 months or 3 years after an AIDS diagnosis in 2001. The targets were developed on historical data dating three years prior to the baseline (2000, 1999 & 1998). For the second set of annual, "Reduce percentage of diagnosis with AIDS within 12 months of a HIV diagnosis among African American, Hispanic, Asian/Pacific Islander, and American Indian/Alaskan Native communities," the baselines are the FY 2005 data for each racial and ethnic minority group. The targets were developed from historical data dating four years prior to the baseline (2004, 2003, 2002, & 2001). For the annual output measure of individuals who learn their HIV status for the first time through activities supported by the MAI Fund, the baseline reflects the actual testing count for FY 2005 MAI Fund projects. The targets are set at a 6% increase per year and are based on the FY 2005 baseline number. The estimated annual incidence rate in the U.S. is less than 2%, so the 6% targeted rate increase is considered ambitious for the racial and ethnic minority populations. In FY 2006, data demonstrated a 9% increase in the number of individuals who learned their serostatusfrom the efforts of the MAI Fund and thereby exceeded the target rate of 6%. OHAP is unclear if the spike was due to an anomaly inherent in a start-up testing campaign or other factors. The annual rate of increase is not expected to continue at the 9% rate, but out-year targets will be adjusted if new data suggests they are no longer ambitious.

Evidence: The baseline and out-year targets were established using data collected from the CDC: (1) Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report, Cases of HIV Infection and AIDS in the United States and Dependent Areas, "Proportion of persons surviving for more than 12, 24, and 36 months after an AIDS diagnosis in (2001, 2000, 1999 & 1998,)" ; (2) Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report, Cases of HIV Infection and AIDS in the United States and Dependent Areas, "Time to an AIDS diagnosis of HIV infection, by selected characteristics, (2004, 2003, 2002, 2001,)" ; The HIV testing numbers are derived from the Performance Assessment and Evaluation of Activities Report submitted by the Office of Population Affairs (OPA), pp. 1, 5-11 & 13 and the Substance Abuse and Mental Health Services Administration (SAMHSA), pp 4-5, 51, 55 & 58. It is important to note that upon collection of HIV testing data from the Indian Health Service and other agencies or offices that receive MAI Fund resources, the baseline and targets will be reconfigured.

Do all partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) commit to and work toward the annual and/or long-term goals of the program?

Explanation: The Performance Assessment and Evaluation of Activities Reports and the Progress Reports that are submitted to the Office of HIV/AIDS Policy, which are the primary mechanisms for collecting information on grantee and HHS Operating Division activities, do not tie the performance of key partners to the established long-term goals. Currently OHAP does not require MAI Fund recipients to submit and monitor performance measures for grantees.

Evidence: Both the long-term and annual outcome measures were recently developed. The ASH/OHAP will establish mechanisms to ensure grantee contribution to the achievement of the long-term and annual goals.

Are independent evaluations of sufficient scope and quality conducted on a regular basis or as needed to support program improvements and evaluate effectiveness and relevance to the problem, interest, or need?

Explanation: HHS does not have a comprehensive methodology for conducting independent evaluations to occur on a predetermined basis and be of sufficient quality and rigor to provide information on the effectiveness of the MAI Fund, nor the Minority AIDS Initiative. A policy brief was issued in June 2004 by the Kaiser Foundation that provided an overview of the Initiative and identified challenges on the horizon. The brief did not assess the Initiative's progress toward performance targets, because at that time none existed.

Evidence: The Henry J. Kaiser Family Foundation: HIV/AIDS Policy Brief - The Minority AIDS Initiative, June 2004 [http://www.kff.org/hivaids/upload/Minority-AIDS-Initiative-Policy-Brief.pdf]

Are Budget requests explicitly tied to accomplishment of the annual and long-term performance goals, and are the resource needs presented in a complete and transparent manner in the program's budget?

Explanation: The measures discussed in 2.1 and 2.3 are new, and will be reflected in future budget requests. No marginal cost analyses have been prepared for the MAI Fund.

Evidence: FY 2008 General Departmental Management Performance Budget Submission

Has the program taken meaningful steps to correct its strategic planning deficiencies?

Explanation: The key strategic planning deficiencies involve a lack of structured processes of guidance during the solicitation process for new proposals and the lack of standardized progress and performance reporting mechanisms. Both of these deficiencies have been corrected with the development of more formal procedures, guidance, and mechanisms to account for and report on MAI Fund activities.

Evidence: The MAI Steering Committee developed a series of templates for the programs to use when reporting performance and management information back to the ASH/OHAP. The most comprehensive examples are the MAI Progress Report template and the MAI Performance Assessment and Evaluation of Activities Report template.

Does the agency regularly collect timely and credible performance information, including information from key program partners, and use it to manage the program and improve performance?

Explanation: While performance information is collected from HHS Operating Divisions and key partners, HHS has not demonstrated how the performance information collected is being used to manage the MAI Fund and improve performance. Agencies and key program partners are required to submit biannual progress reports, annual performance assessments and evaluation activity reports on MAI-funded programs and activities. These reports detail the status of programs and activities; record major developments toward the completion of goals and objectives; include an assessment of current performance; and evaluate progress toward the goal of improving health outcomes for racial and ethnic minority communities disproportionately affected by HIV/AIDS. No links are evident supporting the use of this data in managing the Fund.

Evidence: The Indian Health Service FY 2005 Minority AIDS Initiative Report of Performance Assessment and Evaluation of Activities and the HIV Prevention for Women Living in the U.S. Virgin Islands/HIV Prevention for Women Living with HIV/AIDS in Puerto Rico Progress Report are included as examples of performance reports submitted to the MAI Fund program managers by key partners. No examples were provided of how this information was used to evaluate and/or improve the performance of the MAI Fund.

Are Federal managers and program partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) held accountable for cost, schedule and performance results?

Explanation: The integration of program performance into HHS employee performance plans is a mechanism used by HHS to hold federal managers with in the Office for HIV/AIDS Policy accountable to the MAI Fund's performance. An example performance plan includes performance outcomes that holds the individual accountable for: 1) promotion, encouragement, and support of HIV/AIDS prevention, care and treatment services provided through the National HIV Testing Mobilization Campaign, 2) providing management and oversight as the Project Officer of the Regional Resource Network, and 3) providing management and oversight for the Data Retrieval system project which is designed to centralize the Department's ability to report on HIV/AIDS program activity and expenditures. Accountability of grantees is achieved through collaboration of the HHS Operating Divisions (OPDIV) and the ASH/OHAP. HHS OPDIVs ensure grantees adhere to schedule and cost agreements. Site visits are a way that program partners hold grantees accountable for the cost, schedule, and management of projects supported by the MAI Fund. Additionally, HHS OPDIVs are responsible for reporting their findings in regard to grantee performance as part of the Progress Reports and the Performance Assessment and Evaluation of Activities Reports submitted to the ASH/OHAP. The ASH/OHAP becomes involved with grantee performance when issues such as grant termination are recommended by the HHS OPDIV.

Evidence: (1) Program Manager Performance Plan (National HIV Testing Mobilization Campaign) (2) The site visit evaluation form from Office of Women's Health provides an illustrative example of how the visits inform managers of potential problems the programs are facing. The visit conducted on April 4, 2007 revealed that the San Antonio site was experiencing low attendance of both clients and volunteers. Additionally, it was suggested from the site that they believe attendance would increase if housing was available to clients.

Are funds (Federal and partners') obligated in a timely manner, spent for the intended purpose and accurately reported?

Explanation: Financial audits and program reviews indicate that the MAI Fund resources are obligated in a timely manner and are consistent with the overall program plan. In order to ensure that grant proposals from agencies are in line with the purpose of the MAI Fund, a pre-award screening is conducted. Agencies prepare and submit their proposals for review in November. OHAP and the ASH review MAI Fund proposals by the end of February. All projects approved by the ASH must document their intent and scope in one or more acquisition documents such as the P-Dash Review form or HHS - 393 form. Projects are then competed, and once awards are made, the financial accounting is reflected in the year end reports of the Office of the Secretary and several of the Operating Divisions.

Evidence: The scheduled process for which funds are allocated is as follows: first, the ASH approves all funding for the year in March (FY 2006 MAI Fund Allocations, March 30 2006), by April Intra-Department Delegation of Authority is signed to transfer funds from General Departmental Management to the Operating Divisions (FY 2006 IDDA Transfer, April 26, 2006), the partners are responsible for obligating funds by September 30th. In FY 2006, the Final Status Financial Report showed 99% of the awards were obligated by year end. For 2007, the ASH approved the allocation of MAI funding on March 23, 2007, and the IDDA Transfer was signed on April 5, 2007. Since projects are typically awarded in the fourth quarter, the obligations will not be reflected in UFMS until then. Detailed accounting reports from agencies have also been included to show how they track MAI expenditures (OMH, OWH, HRSA, and SAMHSA).

Does the program have procedures (e.g. competitive sourcing/cost comparisons, IT improvements, appropriate incentives) to measure and achieve efficiencies and cost effectiveness in program execution?

Explanation: MAI has established two efficiency measures: (1) to maintain the actual cost per MAI Fund HIV testing client below the medical care inflation rate, and (2) to maintain the actual cost per MAI Fund physician and other clinical staff trained below the medical care inflation rate. The baseline data value was established in 2005 and the first year of actual data will be available in July 2007. In addition, competitive grant actions and cost comparison are exercised when evaluating agency proposals and determining grant awardees.

Evidence: The medical care inflation numbers are found in the Bureau of Labor Statistics' Consumer Price Index - All Urban Consumers, Medical Care Table. The annual figures have been rounded from 1997 to 2006 and the yearly percentage increases in the CPI are calculated. That number is then used to compare to the yearly cost difference per MAI Fund HIV testing of a client and the yearly cost difference in training each MAI Fund physician and other clinical staff. Maintaining costs associated with the MAI Fund below the medical care inflation rate is evidence that the services are being delivered efficiently as compared to the industry norm. Each competitive grant action begins with a request for proposals, like the RRNP Request for Proposal (RFP); once proposals are received they are evaluated against a set criterion and the proposal that provides the government the greatest value is selected. When multiple proposals are deemed "acceptable" a cost comparison is conducted, in which prices are tried against an independent government cost estimate, which estimates the market value for a good or service. An Evaluation of Business Proposals Submitted in response to RFP 06T085151 is an example of a cost comparison from MAI. Standard information for the cost comparison is collected through the standardized Government Cost Estimate Worksheet.

Does the program collaborate and coordinate effectively with related programs?

Explanation: The MAI Fund, managed by OHAP and the ASH, coordinates financial and intellectual resources to better implement best practices and obtain lessons learned from Fund activities. The OHAP and the ASH are proactive in encouraging collaboration and coordination of HHS Operating Divisions, and in some cases make it a condition for funding. This was the case of Interagency Agreements (IAA) between Indian Health Service (IHS) and Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC). The MAI Steering Committee is another mechanism established and leveraged by the ASH to coordinate HHS Operating Divisions that receive MAI Fund resources. The committee is headed by the Office of HIV/AIDS Policy and is comprised of representatives from: CDC, HRSA, SAMHSA, IHS, & OPHS. Coordination with state and local entities occurs at the HHS Operating Division level.

Evidence: The Indian Health Service (IHS) has entered into IAAs with the CDC and HRSA for activities targeted at American Indian/Alaska Native (AI/AN) populations. IHS' objectives align with those of CDC and HRSA, and an IAA ensures that AI/AN communities have trained healthcare providers who are aware of the unique needs and vulnerabilities of the AI/AN community (IHS and HRSA Intra-Agency Agreement and Performance Assessment and Evaluation of Activities Report, Office of HIV/AIDS Policy and IHS Intra-Agency Agreement). The Steering Committee Operating Procedures outlines the guidelines for how agency proposals to receive MAI Fund resources will be reviewed, identifies the requirements once funding has been approved, and enumerates a plan for monitoring and evaluating MAI resources. The Steering Committee agendas (June 20, 2006 & November 1, 2006) show issues that are raised for discussion, including administration priorities, consensus on standardized templates for evaluating and reporting progress of MAI projects, whether or not appropriate data is being provided, and how to handle qualitative vs. quantitative data from grantees.

Does the program use strong financial management practices?

Explanation: The Office of Inspector General's audit of the financial statement for DHHS in FY 2006 reflected an unqualified audit for the Department. Specifically, the audit reported "that the FY 2006 DHHS consolidated/combined financial statements were fairly presented in all material respects, in conformity with accounting principles generally accepted in the United States of America." The audit does not cite any material internal control weaknesses specific to OHAP or to the Office of Public Health and Science (OPHS). OHAP and OPHS administrative and budget staff routinely monitor overall expenditures through monthly and quarterly budget reviews and monthly commitment registers. MAI Fund-supported projects award their grants, cooperative agreements, and contracts through a competitive process. This includes soliciting cost proposals from competing vendors, when appropriate. When making financial decisions, OHAP considers cost and compares it with an Independent Government Cost Estimate. OHAP also monitors monthly tracking systems, record-keeping, and invoicing and payment processes for the MAI projects.

Evidence: (1) FY 2006 OPHS Final Status of Funds, (2) FY 2006 Detailed Year End Reports for the Office of the Secretary Accounts & Summary Year End Reports for the other Operating Divisions (3) The information supporting the unqualified (clean) audit opinions of the Office of Inspector General can be found in the Performance and Accountability Report (PAR); http://www.hhs.gov/of/library/par06/pdfmenu/.

Has the program taken meaningful steps to address its management deficiencies?

Explanation: One of the management challenges for MAI is ensuring transparency of the grant proposal process. Timelines for submission of proposals varied, the criteria for proposals assessment was not consistent, and notification of the ASH's allocation decisions was scattered. To address this issue, MAI has moved toward more formalized procedures, providing standard forms for data collection and report templates, establishing deadlines and timelines; clarifying the review process and providing guidance on the emerging HHS priorities that should be reflected in proposal submissions.

Evidence: Progress Report and Performance Assessment and Evaluation of Activities Templates have provided the MAI Fund with a regular assessment structure that makes the Fund more accountable and responsive to internal and external stakeholders. Agencies have clear expectations for reporting on their projects and activities provided through the MAI General Operating Procedures. Additionally, the Comprehensive HIV/AIDS Information Reporting System (CHAIRS) has been adopted for data collection (submission deadlines are semi-annual, set for June and December).

Are grants awarded based on a clear competitive process that includes a qualified assessment of merit?

Explanation: All MAI Fund grants are distributed through a two-tiered fair and open competitive grants process. In November of each fiscal year all HHS OPDIVs are invited to submitt proprosals for projects to be supported by the MAI Fund. Funds are distributed first to HHS Operating Divisions following review and approval by the ASH in March. Following notification of their proposal approval, HHS Operating Divisions publish announcements for funding in the Federal Register (or other public format). Proposals from partners are then submitted, reviewed, and scored by a Grants Review Committee. The Review Committee is a non-aligned group of health professionals conducting an objective review of the proposals. Funding decisions are then made based on the Committee's selection. Applications are reviewed based on established evaluation criteria which are published in the Federal Register announcement or other public format. The criteria may include Technical Approach; Understanding of the Project; Corporate Experience and Background; Staff Qualifications and Experience; and Management Plan. Agencies award the funds in the format of Grants, Cooperative Agreements, Task Order Contracts, and restricted pools. Some grants are advertised and awarded as multi-year funding opportunities. Additionally, some grants are advertised and awarded with the possibility of renewal for a limited and defined period of time. In both cases the awards are considered competitive in the inital year as well as subsequent years. Grants that exceed a one year performance period are contingent upon satisfactory performance as determined by the ASH.

Evidence: The HIV/AIDS Regional Resource Network Project Request for Proposal (RFP) provides an example of the type of announcement published by the HHS Operating Divisions (FR 68-231, December 2, 2003). This announcement included a funding opportunity description, award information, application and submission information, application review information, and award administration information. After the announcement is published in the Federal Register, it follows the process outlined above to evaluate submitted proposals and make grant awards. Other information, such as the number of copies to submit and where, is transmitted through Offeror Letters from the contract specialist.

Does the program have oversight practices that provide sufficient knowledge of grantee activities?

Explanation: All MAI Fund participants must submit biannual Progress Reports for new activities. All funded programs and projects, including those with one or more years of implementation, must submit an annual Performance Assessment and Evaluation of Activities Report, which documents and measures activities and outcomes. Contractors or grantees must also submit quarterly financial reports so that OHAP may track and verify the use of funds. The monthly reports and the quarterly financial reports allow OHAP to monitor expenditures. Over the course of an activity's implementation, scheduled update reports are required by the agency or office. Structured teleconference calls and face-to-face meetings throughout each year of funding provide for an ongoing exchange of information between the programs and the coordinating office. In addition, site visits with grantees are another form of project monitoring and oversight.

Evidence: (1) Minority AIDS Initiative Progress Report: U.S/Mexico HIV/AIDS Education and Training Center Border Initiative - (HRSA). (2) Minority AIDS Initiative Progress Report: HIV Prevention for Women Living in the U.S. Virgin Islands and HIV Prevention for Women Living with HIVIAIDS in Puerto Rico (Office on Women's Health). (3) FY05 Minority AIDS Initiative: Report of Performance Assessment and Evaluation Activities (Indian Health Service, Office of Urban Indian Health Programs). (4) Monthly Report from contractor - January - February 2007 - Regional Resource Network Project (MAI Fund project). (5) Monthly Report from contractor - February 2007- National HIV/AIDS Community Mobilization Campaign Evaluation and Assessment Project (MAI Fund project). (6) Quarterly Financial Activities Report, October 1, 2006 to December 31, 2006 National HIVIAIDS Community Mobilization Campaign Evaluation and Assessment Project (MAI Fund project). (8) Site Evaluation Visit Agenda and Report- Office on Women's Health.

Does the program collect grantee performance data on an annual basis and make it available to the public in a transparent and meaningful manner?

Explanation: The MAI Fund requires all participates to collect grantee performance data on an annual basis. The annual Assessment and Evaluation Report collects this information and is submitted to the coordinating office. Agencies publish data on their public web sites at annual intervals and often publish them via print media.

Evidence: (1) 2004 Ryan White Care Act Annual Data Summary provides performance information on Ryan White CARE Act funded programs that provide HIV testing and counseling information, CARE Act funds used to support HIV counseling services, and CARE Act providers that offered partner notification; http://hab.hrsa.gov/reports/2004_Data_Summary/page1.htm (2) The AIDS Epidemic and the Ryan White Care Act: Past Successes & Future Challenges, 2004-2005 provides performance information on HIV status of CARE Act-funded provider clients, poverty level of HIV-positive clients served by CARE Act-funded providers, HIV-positive clients served by CARE Act-funded providers based on gender, race, ethnicity and age; http://hab.hrsa.gov/publications/progress05/index.html

Has the program demonstrated adequate progress in achieving its long-term performance goals?

Explanation: Data needed to gauge progress made toward long-term goals are not available at this time. The program has recently developed three long-term performance measures that directly support the program's purpose and reflect the intention of the program. The measures related to increasing the survival rate of those diagnosed with AIDS and delaying the onset of an AIDS diagnosis among those testing positive for HIV both have established baselines and targets, however the actual performance data for FY 2006 will not be available until late FY 2007. The HIV/AIDS Surveillance Report: HIV Infection and AIDS in the United States and Dependent Areas, from which the data is collected, is published annually. The third measure related to the incidence rate of HIV/AIDS is a measure currently under development, and data to establish baseline and targets will not be available from the CDC until 2007-2008.

Evidence: The HIV/AIDS Surveillance Report: HIV Infection and AIDS in the United States and Dependent Areas, from which the perforamnce data will be collected, is published annually: http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2005report/default.htm

Does the program (including program partners) achieve its annual performance goals?

Explanation: The preliminary data on the annual output measure shows a positive trend, acheiving 150% of the established target in the first year. This is evidence that the HIV/AIDS testing campaigns are exceeding the projections of ASH/OHAP. Actual performance data for the other annual measures is expected to be available in early fall 2007 and will reflect 2006 data.

Evidence: In FY 2005, "the number of people who learned their HIV/AIDS status for the first time per the MAI Fund," was baselined at 118,196. In FY 2006 there was an 9% increase to 128,975 individuals, exceeding the 6% increase targeted. Once data is available for the annual outcome and efficiency measures the rating may increase.

Does the program demonstrate improved efficiencies or cost effectiveness in achieving program goals each year?

Explanation: MAI has established two efficiency measures: (1) to maintain the actual cost per MAI Fund HIV testing client below the medical care inflation rate, (2) to maintain the actual cost per MAI Fund physician and other clinical staff trained below the medical care inflation rate. The baseline data value was established in 2005 and the first year of available actual data will be available in July 2007. A qualitative assessment of the efficiency measures cannot be conducted at this time.

Evidence: The medical care inflation numbers are found in the Bureau of Labor Statistics' Consumer Price Index - All Urban Consumers, Medical Care Table. The annual figures have been rounded from 1997 to 2006 and the yearly percentage increases in the CPI are calculated. That number is then used to compare to the yearly cost difference per MAI Fund HIV testing of a client and the yearly cost difference in training each MAI Fund physician and other clinical staff.

Does the performance of this program compare favorably to other programs, including government, private, etc., with similar purpose and goals?

Explanation: To date, there has been no formal or informal comparison made between the performance of the MAI Fund activities and similar programs. Additionally, without a clearly defined set of annual performance measures, it is difficult to compare the program's performance to other programs with similar purpose and goals.

Evidence: Annual outcome measures are in development. The OHAP is in the process of seeking approval to arrange for a comprehensive, independent evaluation of the MAI Fund. If approved, this process will likely begin in late 2007 or early 2008 and the results can then be compared to research institutions such as Johns Hopkins' Bloomberg School of Public Health and Jackson State University's, Mississippi Urban Research Center and other HIV/AIDS related programs with coordinating functions like The National Minority AIDS Council (NMAC) and The National Association of People with AIDS (NAPWA).

Do independent evaluations of sufficient scope and quality indicate that the program is effective and achieving results?

Explanation: HHS could not demonstrate an independent assessment has been done that focuses on effectiveness and the results demonstrated by the MAI Fund.

Evidence: It is noted in The Henry J. Kaiser Family Foundation HIV/AIDS Policy Brief that at least two federal agencies, CDC and HRSA have contracted for external evaluation of their MAI funded activities. These evaluations were not comprehensive of the MAI Fund and focused on process indicators rather than program performance. (1) The Henry J. Kaiser Family Foundation: HIV/AIDS Policy Brief - The Minority AIDS Initiative, June 2004 [http://www.kff.org/hivaids/upload/Minority-AIDS-Initiative-Policy-Brief.pdf]