CDC considers redesigning minority HIV programs

Criticism of program 704 spurs talk of reforms

Eight years ago, responding to the challenges of preventing HIV in minority communities, the Centers for Disease Control and Prevention established a competitive grants program to directly funnel HIV prevention dollars to minority community-based organizations (CBOs). The program became a mainstay for hundreds of CBOs and was seen as an effective way to assure that CDC dollars were targeted to the most needy places.

Until last year, that is, when many CBOs lost out in the competition and had to cut back staff or shut down completely. What happened last year caused such a backlash of criticism that the CDC is questioning whether a major overhaul is needed — not just of this program, known as 704, but of its entire portfolio of HIV prevention grants.

The CDC began the program in 1989 because of the disproportionate need for HIV prevention services in minority communities, coupled with the fact that state and local health departments were slow to award funding and technical assistance to these areas. Program 704 also was designed to improve community and organizational development of HIV prevention programs. Toward that end, the CDC provided up to $18 million in grants that came up for competitive renewal every three years.

In past funding cycles, many previously funded CBOs were awarded grants, but in 1997 the competition become unusually fierce, for several reasons, says Gary West, MPA, the CDC’s deputy director of the division of HIV/AIDS Prevention — Intervention, Research, and Support. More than 500 groups applied for the $18 million windfall, with requests totaling more than $90 million, West says. Unprepared for the large turnout, the CDC used 240 staff members to assess the applications using criteria that included the applicant’s degree of collaboration with the community planning process, which has become responsible in most locales for deciding how public HIV prevention dollars should be disbursed.

In the end, only 94 programs were selected for funding. What was more disturbing, however, was the fact that two-thirds of the applicants who had previously been funded did not make the cut. It was the highest turnover in any program administered by the CDC.

"They were very many disappointed applicants," says West. "Everyone was convinced they should have been funded. There were many good programs that were not funded, and it had a substantial effect among them. Some closed. Many had to lay off staff. And in all cases there were significant reductions in services."

More than one agency director complained to congressional representatives, who in turn called the CDC.

West attributes the heavy competition for direct grants to a dwindling supply of funding from non-governmental sources. "In recent years we have seen community-based organizations, especially minority ones, become more dependent on funding streams of the CDC," he notes. "There is actually less opportunity now for funding outside our programs than there was five or 10 years ago."

Asked why so many experienced CBOs lost out to start-up organizations, West responded: "I think organizations that were previously funded didn’t take the competition as seriously as they probably should have. And second, the bar was raised. There are many more minority organizations out there that have gained experience in other venues, and there is more interest now."

The uproar over program 704 has lead the CDC to review its short- and long-term strategies for developing and maintaining HIV prevention program infrastructures in racial and ethnic minority communities. As part of a program reassessment initiative, it plans to review and possibly redesign all CDC-supported HIV prevention programs in racial and ethnic minority areas, consult with minority community leaders, and set up conferences and workshops to share program experiences and ideas.

One consideration is how to provide more continuity of funding. As non-governmental organizations, CBOs cannot expect that guaranteed funding. "What we must determine is, are there better ways of using these resources that would service these communities in a less disruptive fashion?" asks Ron Valdisseri, MD, MPH, deputy director of the CDC’s Center for HIV, STD, and TB Prevention.

CBOs need financial management systems

Even CBOs that receive CDC funding often have trouble meeting the government’s stringent guidelines. As many as one-quarter of qualifying organizations must drop out because they don’t have systems in place to assess and manage funds, West says.

"Financial management systems and skills problems have been the Achilles’ heel of these programs," he notes. "You take an entrepreneur ial organization with two or three people and suddenly they get $300,000, and they are now facing rules and regulations and auditors who will look closely at what they are doing."

One area of confusion is the CDC’s criteria for qualifying as a minority organization, says Cynthia Gomez, PhD, a CDC consultant and research specialist at the Center for AIDS Prevention Studies in San Francisco. "Are they AIDS-specific, health-specific, or any organization that may be a conduit for prevention services?" she asks. "Also, why should the CDC target minority organizations when other non-minority organizations might be serving minority communities, and they may need technical assistance because they don’t understand minority communities?"

While some health officials have questioned the need for direct funding to minority CBOs, West points out that the vast majority of CDC funds for HIV prevention programs — $248 million — go to community planning and HIV prevention cooperative agreements with state and local health departments. Their treatment of minority CBOs is not consistent across the board, he argues.

"There are many strong programs at the state and local level, but we still hear about some areas of the country that have trouble giving money to CBOs — some give very small awards," he says.

High levels of suspicion’ remain

TheRev. Edwin Sanders, a CDC consultant and pastor of the Metropolitan Interdenomina tional Church in Nashville, TN, agrees that discrimination still exists and that the CDC is perceived as creating a more fair review of applications than state and local health departments. "Because of the struggle over limited funds, relationships between CBOs and health departments often translate to high levels of suspicion as to whether the process is a fair one," he notes. "I, too, have had some bad experiences with this."

Sanders suggests that the CDC might include in its criteria that a CBO should not qualify unless it shows it can sustain its programs without external funding. "That may mean they have to operate at a lower level, but at least the program won’t go away when the dollars do," he adds.

Beyond the issue of direct funding, the CDC is trying to evaluate how effective grant programs have been in building capacity for HIV prevention services in minority communities. As part of a viability study, the agency is using scientific methods to evaluate the factors that help CBOs sustain themselves, he adds.