Housing for Persons Living with HIV/AIDS

Contents

• Introduction
• Housing Status of Persons Living with HIV/AIDS
• Creation of the Housing Opportunities for Persons with AIDS (HOPWA) Program
• Distribution and Use of HOPWA Funds
• Formula Grants
• Competitive Grants
• HOPWA Funding in the Territories
• Eligibility for HOPWA-Funded Housing
• Eligible Uses of HOPWA Funds
• The HOPWA Program Formula
• Proposals to Change the HOPWA Formula
• Legislative Proposals
• Budget and Appropriations Proposals
• HOPWA Funding
• Housing Funded Through the Ryan White HIV/AIDS Program
• The Relationship Between Stable Housing and Health Outcomes

Summary

Since the beginning of the acquired immunodeficiency syndrome (AIDS) epidemic in the early 1980s, many individuals living with the disease have had difficulty finding affordable, stable housing. In the earlier years of the epidemic, as individuals became ill, they found themselves unable to work, while at the same time facing health care expenses that left few resources to pay for housing. In more recent years, HIV and AIDS have become more prevalent among low income populations who struggled to afford housing even before being diagnosed with the disease. The financial vulnerability associated with AIDS, as well as the human immunodeficiency virus (HIV) that causes AIDS, results in a greater likelihood of homelessness among persons living with the disease. At the same time, those who are homeless may be more likely to engage in activities through which they could acquire or transmit HIV. Further, recent research has indicated that individuals living with HIV who live in stable housing have better health outcomes than those who are homeless or unstably housed, and that they spend fewer days in hospitals and emergency rooms.

Congress recognized the housing needs of persons living with HIV/AIDS when it approved the Housing Opportunities for Persons with AIDS (HOPWA) program in 1990 as part of the Cranston-Gonzalez National Affordable Housing Act (P.L. 101-625). The HOPWA program, administered by the Department of Housing and Urban Development (HUD), funds short-term and permanent housing, together with supportive services, for individuals living with HIV/AIDS and their families. In addition, a small portion of funds appropriated through the Ryan White HIV/AIDS program, administered by the Department of Health and Human Services (HHS), may be used to fund short-term housing for those living with HIV/AIDS.

In FY2015, Congress appropriated $330 million for HOPWA as part of the Consolidated and Further Continuing Appropriations Act (P.L. 113-235). This was the same level that was appropriated in FY2014, and down slightly from the peak HOPWA funding level of $335 million in FY2010. Prior to FY2010, the most that had been appropriated for HOPWA was $310 million in FY2009. HOPWA funds are distributed to states and localities through both formula and competitive grants. HUD awards 90% of appropriated funds by formula to states and eligible metropolitan statistical areas (MSAs) based on population, reported cases of AIDS, and incidence of AIDS. The remaining 10% is distributed through a grant competition. Funds are used primarily for housing activities, although grant recipients must provide supportive services to those persons residing in HOPWA-funded housing. In FY2014, more than 55,000 households received housing assistance through HOPWA, a decrease compared to the previous years. See Table 1 for funding levels and households served since FY2001. The Appendix provides the formula grants distributed to eligible states and metropolitan statistical areas from FY2007 to FY2015.

For years the formula used to distribute the bulk of HOPWA funds has been an issue considered by both the Administration and Congress. The formula relies on cumulative cases of AIDS to distribute formula funds, a number that includes those who have died. In the 114^th Congress, both the House and the Senate appropriations committees noted the need to update the formula. The House Appropriations Committee Report to accompany the FY2017 HUD funding bill (H.R. 5394) encouraged HUD to work with the authorizing committees to modernize the HOPWA formula. The Senate-passed version of the FY2017 appropriations bill (H.R. 2577) would follow the Administration's FY2017 proposal and use new formula factors: persons living with HIV, fair market rents, and poverty, together with a hold harmless provision.

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Housing for Persons Living with HIV/AIDS

Introduction

Acquired immunodeficiency syndrome (AIDS), a disease caused by the human immunodeficiency virus (HIV), weakens the immune system, leaving individuals with the disease susceptible to infections. As of 2013, HIV, including AIDS, had been diagnosed and reported in an estimated 953,245 individuals living in the 50 states, the District of Columbia, and the territories.¹ These estimates do not include those who have not yet been diagnosed as HIV positive but are currently living with the disease. Currently there is no cure for HIV/AIDS, and in the early years of the AIDS epidemic, individuals infected with AIDS often died quickly. In recent years, however, medications have allowed persons living with HIV and AIDS to live longer and to remain in better health.

Despite improvements in health outcomes, affordable housing remains important to many who live with HIV/AIDS. This report describes research that shows how housing and health status are related and the effects of stable housing on patient health. It also describes the Housing Opportunities for Persons with AIDS (HOPWA) program, the only federal program that provides housing and services specifically for persons who are HIV positive or who have AIDS, together with their families. In addition, the report describes how a small portion of funds appropriated through the Ryan White HIV/AIDS program may be used by states and local jurisdictions to provide short-term housing assistance for persons living with HIV/AIDS.

Housing Status of Persons Living with HIV/AIDS

The availability of adequate, affordable housing for persons living with HIV and AIDS has been an issue since AIDS was first identified in U.S. patients in the early 1980s. The inability to afford housing and the threat of homelessness confront many individuals living with HIV/AIDS. From the early years of the epidemic, individuals who are infected with HIV/AIDS have faced impoverishment as they become unable to work, experience high medical costs, or lose private health insurance coverage. The incidence of HIV/AIDS has also grown among low-income individuals who were economically vulnerable even before onset of the disease.²

Not surprisingly, researchers have found a co-occurrence between HIV/AIDS and homelessness. Homeless persons have a higher incidence of HIV/AIDS infection than the general population, while many individuals with HIV/AIDS are at risk of becoming homeless.³ Studies of the relationship between HIV and homelessness have found prevalence among homeless populations that range from 2% to 22%.⁴ Further, homelessness has been found to be associated with greater likelihood of participation in the risk factors that might lead to HIV/AIDS (multiple sexual partners, sex exchange, drug use, and diagnosis of a sexually transmitted infection),⁵ as well as lowered adherence to anti-retroviral therapy.⁶

Creation of the Housing Opportunities for Persons with AIDS (HOPWA) Program

In 1988, Congress established the National Commission on AIDS as part of the Health Omnibus Extension Act (P.L. 100-607) to "promote the development of a national consensus on policy concerning acquired immune deficiency syndrome (AIDS); and to study and make recommendations for a consistent national policy concerning AIDS." In April 1990, in its second interim report to the President, the commission recommended that Congress and the President provide "[f]ederal housing aid to address the multiple problems posed by HIV infection and AIDS."⁷ About the same time that the commission released its report, in March of 1990, the House Committee on Banking, Finance, and Urban Affairs held a hearing about the need for housing among persons living with HIV/AIDS. Witnesses as well as committee members discussed various barriers to housing for persons living with HIV/AIDS. Among the issues confronting persons living with HIV/AIDS discussed at the hearing were poverty, homelessness, and discrimination in attempting to secure housing.⁸ Another issue discussed was the eligibility for subsidized housing for persons living with the disease. A question raised during the hearing, but left unresolved, was whether persons living with HIV or AIDS met the definition of "handicap" in order to be eligible for the Section 202 Supportive Housing for the Elderly program (which also provided housing for persons with disabilities).⁹ Another concern was that persons living with HIV/AIDS often had difficulty obtaining subsidized housing through mainstream HUD programs such as Public Housing and Section 8 due to the length of waiting lists; individuals often died while waiting for available units.¹⁰

In the 101^st Congress, at least two bills were introduced that contained provisions to create a housing program specifically for persons living with AIDS. These proposed programs were called the AIDS Housing Opportunity Act (which was part of the Housing and Community Development Act of 1990, H.R. 1180) and the AIDS Opportunity Housing Act (H.R. 3423). The bills were similar, and both proposed to fund short-term and permanent housing, together with supportive services, for individuals living with AIDS and related diseases. The text from one of the bills, H.R. 1180, which included the AIDS Housing Opportunity Act, was incorporated into the Cranston-Gonzalez National Affordable Housing Act (S. 566) when it was debated and passed by the House on August 1, 1990. In conference with the Senate, the name of the housing program was changed to Housing Opportunities for Persons with AIDS (HOPWA). In addition, the several separate housing assistance programs that had been proposed in H.R. 1180—one for short-term housing, one for permanent housing supported through Section 8, and one for community residences—were consolidated into one formula grant program in which recipient communities could choose which activities to fund. The amended version of S. 566 was signed into law on November 28, 1990, and became P.L. 101-625, the Cranston-Gonzalez National Affordable Housing Act.

The HOPWA program is administered by the Department of Housing and Urban Development (HUD) and remains the only federal program solely dedicated to providing housing assistance to persons living with HIV/AIDS and their families.¹¹ The program addresses the need for reasonably priced housing for thousands of low-income individuals (those with incomes at or below 80% of the area median income). HOPWA was last reauthorized by the Housing and Community Development Act of 1992 (P.L. 102-550). Although authorization of appropriations for HOPWA expired after FY1994, Congress continues to fund the program through annual appropriations.

Distribution and Use of HOPWA Funds

Formula Grants

HOPWA program funding is distributed both by formula allocations and competitive grants. HUD awards 90% of appropriated funds by formula to states and eligible metropolitan statistical areas (MSAs) that meet the minimum AIDS case requirements according to data reported to the Centers for Disease Control and Prevention (CDC) in the previous year. (For the amounts distributed to eligible states and MSAs in recent years, see Appendix.) HOPWA formula funds are available through HUD's Consolidated Plan process. Jurisdictions applying for funds from four HUD formula grant programs, including HOPWA,¹² submit a single consolidated plan to HUD. The plan includes an assessment of community housing and development needs and a proposal that addresses those needs, using both federal funds and community resources. Communities that participate in the Consolidated Plan may receive HOPWA funds if they meet formula requirements. Formula funds are allocated in two ways:

• First, 75% of the total available formula funds, sometimes referred to by HUD as "base funding," is distributed to
  
  —the largest cities within metropolitan statistical areas (MSAs) with populations of at least 500,000 and with 1,500 or more cumulative reported cases of AIDS (which includes those who have died);¹³ and
  
  —to states with at least 1,500 cases of AIDS in the areas outside of that state's eligible MSAs.¹⁴
• Second, 25% of total available formula funds—sometimes referred to by HUD as "bonus funding"—is distributed on the basis of AIDS incidence: newly diagnosed AIDS cases. The statute provides that newly diagnosed AIDS cases be those reported by the CDC as of March 31 of the fiscal year preceding the appropriations law.¹⁵ However, since FY2012, the appropriations laws have provided that incidence be measured over a three-year period.¹⁶ Only the largest cities within MSAs that have populations of at least 500,000, with at least 1,500 reported cases of AIDS and that have a higher than average per capita incidence of AIDS are eligible.¹⁷ States are not eligible for bonus funding.

Although HOPWA funds are allocated to the largest city within an MSA, the recipient cities are required to allocate funds "in a manner that addresses the needs within the metropolitan statistical area in which the city is located."¹⁸ While the distribution of the balance of state funds is based on AIDS cases outside of eligible MSAs, states may use funds for projects in any area of the state, including those that receive their own funds.¹⁹ According to HUD guidance, states should serve clients in areas outside of eligible MSAs, but the state may operate anywhere in the state because it "may be coordinating the use of all resources in a way that addresses needs more appropriately throughout the state."²⁰ In FY2015, 97 MSAs (including the District of Columbia) received funds, while 40 states and Puerto Rico received funds based on the number of AIDS cases outside of recipient MSAs.²¹ HUD jurisdictions that receive HOPWA funds may administer housing and services programs themselves or may allocate all or a portion of the funds to subgrantee private nonprofit organizations. HOPWA formula funds remain available for obligation for two years.

As a result of language included in every HUD appropriations law since FY1999 (P.L. 105-276), states do not lose formula funds if their reported AIDS cases drop below 1,500, as long as they received funding in the previous fiscal year. States generally drop below 1,500 AIDS cases when a large metropolitan area becomes separately eligible for formula funds. These states are allocated a grant on the basis of the cumulative number of AIDS cases outside of their MSAs.²²

Competitive Grants

The remaining 10% of HOPWA funding is available through competitive grants. Funds are distributed through a national competition to two groups of grantees: (1) states and local governments that propose to provide short-term, transitional, or permanent supportive housing in areas that are not eligible for formula allocations, and (2) states and units of general local government or nonprofit entities that propose "special projects of national significance."²³ A project of national significance is one that uses an innovative service delivery model. In determining proposals that qualify, HUD must consider the innovativeness of the proposal and its potential replicability in other communities.²⁴

The competitive grants are awarded through HUD's annual SuperNOFA (Notice of Funding Availability), which is generally published in the Federal Register in the early spring. Beginning in FY2006, competitive funds have remained available for obligation for three years (from FY2002 through FY2005, competitive funds had been available only for two years). The extension made the rules for HOPWA's competitive program consistent with those of other competitive programs advertised in HUD's SuperNOFA.

Since FY2000 (P.L. 106-377), Congress has required HUD to renew expiring contracts for permanent supportive housing prior to awarding funds to new projects.²⁵ The most recent year in which HUD had sufficient funds to award new competitive grants was FY2011, awarding approximately $9 million in new competitive grants to seven projects.²⁶ However, in August 2015, HUD announced the availability of HOPWA competitive funds for a demonstration in conjunction with the Violence Against Women Act Transitional Housing Program.²⁷ The following year, in June 2016, HUD announced that $9 million had been awarded to eight projects to provide housing and supportive services to people living with HIV/AIDS who experience sexual assault, domestic violence, dating violence, or stalking.²⁸

HOPWA Funding in the Territories

Puerto Rico is the only territory that receives HOPWA formula grants. The formula grants are distributed to states and the most populous cities within metropolitan statistical areas of at least 500,000 that meet certain minimum AIDS case requirements.²⁹ The statute defines a "state" to include Puerto Rico, but no other territories.³⁰ Similarly "metropolitan statistical areas" (MSAs), which are established by the Office of Management and Budget, may include areas in Puerto Rico, but do not include areas in the other territories.³¹

HOPWA competitive grants may be awarded to Puerto Rico, Guam, The Commonwealth of the Northern Mariana Islands (CNMI), the U.S. Virgin Islands, and American Samoa. As with formula grants, Puerto Rico is defined as a state. The other territories are eligible as units of general local government. While the statutory definition of "unit of general local government" only lists the Federated States of Micronesia, Palau, and the Marshall Islands,³² the regulations governing HOPWA have further expanded the definition of "unit of general local government" to include Guam, CNMI, the U.S. Virgin Islands, and American Samoa.³³

Eligibility for HOPWA-Funded Housing

In the HOPWA program, individuals are eligible for housing if they are either HIV positive or if they are diagnosed with AIDS.³⁴ In general, clients must also be low income, meaning that their income does not exceed 80% of the area median income.³⁵ HUD reports area median incomes for metropolitan areas and non-metropolitan counties on an annual basis.³⁶ Housing and some supportive services are available for family members of persons living with AIDS. A family member is defined broadly in regulation to include someone who lives with an eligible individual, regardless of "actual or perceived sexual orientation, gender identity, or marital status," and who is important to the eligible individual or their care or well-being.³⁷ When a person living in HOPWA-supported housing dies, his or her family members are given a grace period during which they may remain in the housing.³⁸ This period may not exceed one year, however.

Individuals who are HIV positive or living with AIDS may also be eligible for other HUD-assisted housing for persons with disabilities. However, infection itself may not be sufficient to meet the definition of disability in these other programs. For example, in the case of housing developed prior to the mid-1990s under the Section 202 Supportive Housing for the Elderly program (which also funded units for persons with disabilities) and units developed under the Section 811 Supportive Housing for Persons with Disabilities program, an individual who is HIV positive or has AIDS must also meet the statutory definition of disability (in which HIV/AIDS status alone is not sufficient) to be eligible for housing.³⁹ The project-based Section 8 and Public Housing programs may also set aside units or entire developments for persons with disabilities. The definition of disability for these programs does "not exclude persons who have the disease of acquired immunodeficiency syndrome or any conditions arising from the etiologic agent" for AIDS.⁴⁰ However, the definition does not indicate whether the status of being HIV positive or having AIDS is alone sufficient to be considered disabled.

Eligible Uses of HOPWA Funds

HOPWA grantees may use funds for a wide range of housing, social services, program planning, and development costs. Supportive services must be provided together with housing. Formula grantees may also choose to provide supportive services not in conjunction with housing, although the focus of the HOPWA program is housing activities. Allowable activities include the following:

• The Development and Operation of Multi-Unit Community Residences, Including the Provision of Supportive Services for Persons Who Live in the Residences.⁴¹ Funds may be used for the construction, rehabilitation, and acquisition of facilities, for payment of operating costs, and for technical assistance in developing the community residence.
• Short-Term Rental, Mortgage, and Utility Assistance to Persons Living with AIDS Who Are Homeless or at Risk of Homelessness.⁴² Funds may be used to acquire and/or rehabilitate facilities that will be used to provide short-term housing, as well as to make payments on behalf of tenants or homeowners, and to provide supportive services. Funds may not be used to construct short-term housing facilities.⁴³ Residents may not stay in short-term housing facilities more than 60 days in any 6-month period, and may not receive short-term rental, mortgage, and utility assistance for more than 21 weeks in any 52-week period. These limits are subject to waiver by HUD, however, if a project sponsor is making an attempt to provide permanent supportive housing for residents and has been unable to do so. Funds may also be used to pay operating and administrative expenses.
• Project-Based or Tenant-Based Rental Assistance for Permanent Supportive Housing, Including Shared Housing Arrangements.⁴⁴ In general, tenants must pay approximately 30% of their income toward rent.⁴⁵ Grant recipients must ensure that residents receive supportive services, and funds may also be used for administrative costs in providing rental assistance.
• The New Construction or Acquisition and Rehabilitation of Property for Single-Room Occupancy Dwellings.⁴⁶
• Supportive Services, Which Include Health Assessments, Counseling for Those with Addictions to Drugs and Alcohol, Nutritional Assistance, Assistance with Daily Living, Day Care, and Assistance in Applying for Other Government Benefits.⁴⁷
• Housing Information Such as Counseling and Referral Services.⁴⁸ Assistance may include fair housing counseling for those experiencing discrimination.⁴⁹

The majority of HOPWA funds are used to provide housing. According to HUD, for the 2014-2015 program year, nearly 69% of HOPWA funding was used for housing assistance. Housing assistance includes tenant-based rental assistance; permanent and transitional housing facilities that receive funds for operating costs; capital funds for permanent and transitional housing; short-term rent, mortgage, or utility assistance; and placement services for permanent housing.⁵⁰ An additional 2% was used to provide housing information, 1% for housing development (where units were not yet occupied), and 20% was used for supportive services. Of the amounts used for housing activities, 76% was used to support tenants in permanent housing, of whom 96% remained stably housed during the year.⁵¹ Grantee performance reports indicate that clients who receive housing assistance through HOPWA are often at the lowest income levels; in its FY2017 Congressional Budget Justifications, HUD reported that 78% of households served had extremely low incomes (at or below 30% of area median income) and 17% had very low incomes (at or below 50% of area median income).⁵²

The HOPWA Program Formula

The HOPWA method for allocating formula funds has been an ongoing issue due to the data that are used to distribute the majority of funds. Since the inception of HOPWA, 75% of funds have been distributed using the cumulative number of AIDS cases as reported by the CDC, including those who have died. An alternative way of distributing funds would be to use the current number of people living with AIDS and, potentially, HIV. HOPWA was enacted within four months of another federal program targeted to assist those living with HIV and AIDS, the Ryan White CARE Act program (now called the Ryan White HIV/AIDS program). Both programs relied to some degree on the cumulative number of AIDS cases in distributing funding to eligible jurisdictions;⁵³ the data reported by the CDC at the time were cumulative cases.⁵⁴ Since then, however, the Ryan White program stopped using cumulative AIDS cases and now uses the number of people living with AIDS and HIV. The HOPWA formula has remained the same.

The Ryan White program formula change came about shortly after the program's enactment. In 1995, at the request of two Senators from the Labor and Human Resources Committee, the General Accounting Office (GAO, now the Government Accountability Office) examined funding disparities per person living with AIDS that resulted from using cumulative AIDS cases to distribute Ryan White funds.⁵⁵ It proposed several data changes that would result in more equitable per-case funding, including a way to weight CDC data to arrive at an estimate of persons living with AIDS.⁵⁶ The next year, in 1996, Congress reauthorized the Ryan White program and changed the way in which grants to metropolitan areas were distributed to use CDC estimates of persons living with AIDS (P.L. 104-146). The data change included hold-harmless provisions to ensure that the shift in funding would not be too dramatic. Since then, in 2006, the Ryan White program formula has been further modified to incorporate living HIV cases in addition to living AIDS cases.⁵⁷

Proposals to Change the HOPWA Formula

Both Congress and recent presidential administrations have acknowledged that the HOPWA formula could be modified, but the formula has not been changed. Shortly after the first change to the Ryan White program formula, in 1997, GAO released a report regarding the performance of the HOPWA program in which it recommended that HUD look at recent changes to the formula used by the Ryan White program to "determine what legislative revisions are needed to make the HOPWA formula more reflective of current AIDS cases."⁵⁸ In response to the GAO report, the House Appropriations Committee included the GAO language in its report accompanying the FY1998 HUD Appropriations Act (P.L. 105-65) and directed HUD to make recommendations to Congress about its findings regarding an update to the formula.⁵⁹

In response to the FY1998 Appropriations Act, HUD issued a report to Congress in 1999 that proposed changes that could be made to the HOPWA formula.⁶⁰ The proposed formula in HUD's 1999 report would have used an estimate of persons living with AIDS (instead of all cumulative AIDS cases), together with housing costs, to distribute formula funds. It also would have included a protection for existing grantees. The recommendations were not adopted by Congress. A 2006 Government Accountability Office (GAO) report again looked at the way in which the HOPWA formula allocates funds.⁶¹ The report found that use of the cumulative number of AIDS cases resulted in disproportionate funding per living AIDS case depending on the jurisdiction.⁶² Most recently, GAO released a report in April 2015 discussing, in part, the failure of the HOPWA formula to target funds to areas of need.⁶³

Legislative Proposals

Two bills were introduced in the 109^th Congress (S. 2339 and H.R. 5009) that would have changed the way that HOPWA formula funds are allocated by counting the number of "reported living cases of HIV disease" instead of cumulative AIDS cases. Neither bill was enacted. Legislation was not introduced again until the 113^th Congress, the Housing for Persons With AIDS Modernization Act (H.R. 5640). It was not enacted either.

Budget and Appropriations Proposals

Nearly every Administration budget since FY2007 has discussed the need to change the formula. In each of President Bush's budgets from FY2007 through FY2009, the Administration proposed to change the way in which HOPWA funds are distributed. The FY2009 budget stated that "[w]hereas the current formula distributes formula grant resources by the cumulative number of AIDS cases, the revised formula will account for the present number of people living with AIDS, as well as differences in housing costs in the qualifying areas." The President's FY2007 and FY2008 budgets contained nearly identical language. HUD's budget justifications for FY2009 elaborated somewhat on the Administration's proposal to change the HOPWA distribution formula. HUD's explanation indicated that a new formula would use the number of persons living with AIDS, and that eventually, when consistent data on the number of persons living with HIV become available, that measure might also be used in determining the distribution of HOPWA funding.⁶⁴

As part of President Obama's FY2010 budget, the HUD budget justifications stated that HUD would review the formula and "make related recommendations at a future time."⁶⁵ The Administration's National HIV/AIDS Strategy, released in July 2010, stated that HUD would work with Congress to "develop a plan (including seeking statutory changes if necessary) to shift to HIV/AIDS case reporting as a basis for formula grants for HOPWA funding."⁶⁶ The FY2012 through FY2014 HUD budget justifications for HOPWA echoed this goal.

In its FY2015 through FY2017 budget justifications, HUD provided a bit more detail about its proposal to change the formula. Its proposal includes the following:

• using the number of persons living with HIV and AIDS to determine formula shares, and maintaining eligibility for all current grantees;
• ensuring that allocations not drop more than 10% per year nor increase more than 20% per year, with this phase-in to take place over three years; and
• replacing the incidence or "bonus" funding with a factor based on fair market rent and poverty.

During the FY2016 and FY2017 appropriations processes, both the House and Senate addressed formula modernization. In FY2016, the Senate Appropriations Committee-passed bill (H.R. 2577) would have followed the recommendations in the President's budget to change the formula. The House Appropriations Committee report accompanying H.R. 2577 encouraged the Administration to work with the authorizing committees to modernize the HOPWA formula (H.Rept. 114-129).

In F2017, the Senate, using the same vehicle for HUD appropriations (H.R. 2577), again proposed to modernize the formula in the same way as recommended in the President's budget, while the House Appropriations Committee report, as in FY2016, encouraged the Administration to work with the authorizing committees (see H.Rept. 114-606 accompanying H.R. 5394).

HOPWA Funding

As a result of advances in medical science and in the care and treatment of persons living with HIV and AIDS, individuals are living longer with the disease.⁶⁷ As the number of those with HIV and AIDS grows, so do the jurisdictions that qualify for formula-based HOPWA funds. Since 1999, there has been a steady increase in the number of jurisdictions that meet the eligibility test to receive formula-based HOPWA funds. Funding for the HOPWA program steadily increased from the time the program was created, and, since FY2010, funding has ranged between $330 million and $335 million. (See Table 1.)

The number of households receiving HOPWA housing assistance (including short-term housing assistance, housing provided through community residences, or rental assistance in permanent housing) has generally declined from FY2003 through FY2015. (See Table 1.) Between FY2003 and FY2009, the number of households served dropped from 78,467 to 58,367.⁶⁸ With increased funding, however, the total households served went up in FY2010 to 60,669 and by FY2012 was 61,614.⁶⁹ However, households assisted have declined since FY2012, reaching 54,647 in FY2015. These general reductions in households served could be due to such factors as increased housing costs and households remaining longer in housing units.

Housing Funded Through the Ryan White HIV/AIDS Program

In addition to funds for housing provided through HUD, funds appropriated to the Department of Health and Human Services (HHS) Ryan White HIV/AIDS program may be used to provide short-term housing assistance to persons living with HIV/AIDS. The Ryan White Comprehensive AIDS Resources Emergency Act (P.L. 101-381) established the Ryan White program in 1990. The program provides funds to states and metropolitan areas to help pay for health care and supportive services for persons living with HIV/AIDS (referred to as "support services" in the statute).⁷⁰

The statute governing the use of Ryan White funds does not specifically list housing as an eligible activity for which grantees may use funds. However, the statute defines support services as those "that are needed for individuals with HIV/AIDS to achieve their medical outcomes."⁷¹ In 1999, the HIV/AIDS Bureau of the Health Resources and Services Administration (HRSA) within HHS released policy guidance regarding the type of housing that Ryan White grantees could provide for their clients (Policy Notice 99-02).⁷² Grantees may use funds for housing referral services and for emergency or short-term housing. Ryan White funds must be the payer of last resort, meaning that other sources of funds for housing must be exhausted before using Ryan White funds.

Initially, the policy regarding use of Ryan White funds for housing did not impose time limits on short-term housing. However, when the Ryan White program was reauthorized in 2006, the law limited the amount of grants to states and urban areas that could be used for supportive services to no more than 25% by requiring that at least 75% of funds be used for "core medical services."⁷³ Due to these funding limits, HRSA released guidance on time limits for housing assistance. Its final notice, released on May 12, 2011 (Notice 11-01), defined "short-term or emergency housing" as:

transitional in nature and for the purposes of moving or maintaining an individual or family in a long-term, stable living situation. Thus, such assistance cannot be permanent and must be accompanied by a strategy to identify, relocate, and/or ensure the individual or family is moved to, or capable of maintaining, a long-term, stable living situation.⁷⁴

In addition, the Notice 11-01 strongly encouraged grantees or local planning bodies to define short-term housing themselves, recommending that they consider adopting the HUD definition of transitional housing: 24 months.⁷⁵

Under Notice 11-01, housing must either provide medical or supportive services, or, if it does not provide these services, the housing must be necessary for clients to gain access to or compliance with medical care. In 2013, out of 524,675 Ryan White clients served, 14,837 received housing services.⁷⁶

The Relationship Between Stable Housing and Health Outcomes

HIV/AIDS status is associated with homelessness: persons who are homeless are more likely to be HIV positive than those who are housed (see "Housing Status of Persons Living with HIV/AIDS"). In addition, during the last decade, research has found that the health outcomes of homeless individuals living with HIV/AIDS may be improved with stable housing. In response to evidence from some studies, the Administration's National HIV/AIDS Strategy, published in 2010, acknowledged that "access to housing is an important precursor to getting many people into a stable treatment regimen. Individuals living with HIV who lack stable housing are more likely to delay HIV care, have poorer access to regular care, are less likely to receive optimal antiretroviral therapy, and are less likely to adhere to therapy."⁷⁷ The National HIV/AIDS Strategy included pursuing the goal of housing as one of the ways to increase access to care and improve health outcomes for individuals living with HIV and AIDS.⁷⁸

This section of the report gives a short overview of several studies that have examined how access to stable housing influences health outcomes for those living with HIV and AIDS.

Community Health Advisory & Information Network (CHAIN) Project Data

The CHAIN Project is a longitudinal study, begun in 1994, of a sample of individuals living with HIV/AIDS in New York City and the northern suburbs. In 2007, researchers released a study that used the CHAIN data to examine the effects of stable housing on health care for individuals living with HIV and AIDS.⁷⁹

The study looked at those who were unstably housed—meaning that they were either living in some form of transitional housing; in a jail, drug treatment facility, or halfway house; in a hospice; or temporarily living in someone else's home—or who were homeless, meaning that they were living in a shelter or place not meant for human habitation. Researchers measured the likelihood of six scenarios involving the receipt or continuity of both medical care in general and appropriate HIV medical care. In general, individuals who were unstably housed were less likely to enter into and retain both medical care and appropriate HIV care.⁸⁰ However, the likelihood of obtaining and retaining medical care increased if individuals received some form of housing assistance.⁸¹ In addition, receipt of mental health services and social services case management had a statistically significant relationship to individuals entering into and retaining medical care.

Housing and Health Study

In the Housing and Health Study, HUD, together with the CDC, provided HIV positive individuals who were homeless or at severe risk of homelessness with HOPWA-funded rental housing. (The study considered individuals to be at severe risk of homelessness if they frequently moved from one temporary housing situation to another.) Individuals in the comparison group received services, including assistance with finding housing, but did not receive HOPWA-funded housing.⁸² Despite the differences in rental assistance provided between the treatment and comparison groups, both groups had a statistically significant increase in stable housing.⁸³ After 18 months, 82% of HOPWA-assisted renters and 52% of individuals in the comparison group were living in their own housing. Perhaps due to the fact that the comparison group also had some success in achieving and maintaining housing, both groups saw statistically significant improvements in health outcomes. After 18 months, both groups had fewer emergency room visits, fewer hospitalizations, reduced opportunistic infections (those that occur due to weakened immune systems), and reduced use of medical care generally. Self-reported depression and perceived stress saw improvement as well.

Chicago Housing for Health Partnership Study

The Chicago Housing for Health Partnership study identified homeless individuals with chronic illnesses, including HIV, for participation. Among those who participated in the study, 36% were HIV positive. The treatment group received housing funded through either HOPWA or HUD's Supportive Housing Program for homeless individuals, while the comparison, or usual care group, received available supportive services but no separate assistance with rent. The study found that, after 12 months, the group receiving housing assistance had higher rates of intact immunity compared to the comparison group and were more likely to have undetectable viral loads.⁸⁴ There was no statistically significant difference between CD4 counts for the treatment and usual care group. (Very generally, CD4 counts are a measure of immune system strength.) At the conclusion of the study, the treatment group was found to have spent fewer days in emergency rooms and hospitals during the 18 month period in which the researchers followed participants. Specifically, compared to those in the usual care group, those in the treatment group showed 29% reduction in hospitalizations, a 29% reduction in the number of days spent in the hospital, and a 24% reduction in visits to the emergency room.⁸⁵

Appendix. Recent HOPWA Formula Allocations

Author Contact Information

Footnotes

1.	U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, HIV Surveillance Report 2014, vol. 26, Atlanta, GA, February 2015, pp. 93-94, table 18b, http://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-us.pdf.
2.	John M. Karon, Patricia L. Fleming, Richard W. Steketee, and Kevin M. DeCock, "HIV in the United States at the Turn of the Century: An Epidemic in Transition," American Journal of Public Health 91, no. 7 (July 2001): 1064-1065. See also, Paul Denning and Elizabeth DiNenno, Communities in Crisis: Is There a Generalized HIV Epidemic in Impoverished Urban Areas of the United States?, Centers for Disease Control and Prevention, August 2010, http://www.cdc.gov/hiv/topics/surveillance/resources/other/pdf/poverty_poster.pdf.
3.	See, for example, M-J Milloy, B.D. Marshall, and J. Montaner, et al., "Housing Status and the Health of People Living with HIV/AIDS," Current HIV/AIDS Reports, vol. 9, no. 4 (December 2012), pp. 364-374.
4.	David Buchanan, Romina Kee, and Laura Sadowski, et al., "The Health Impact of Supportive Housing for HIV-PositiveHomeless Patients: A Randomized Controlled Trial," American Journal of Public Health, vol. 99, no. S3 (September 3, 2009), pp. S675-S680.
5.	See, for example, Danielle German and Carl A. Latkin, "Social Stability and HIV Risk Behavior: Evaluating the Role of Accumulated Vulnerability," AIDS and Behavior, vol. 16, no. 1 (January 2012), pp. 168-178.
6.	See, for example, Anita Palepu, M-J Milloy, and Thomas Kerr, et al., "Homelessness and Adherence to Antiretroviral Therapy among a Cohort of HIV-Infected Injection Drug Users," Journal of Urban Health, vol. 88, no. 3 (June 2011), pp. 545-555.
7.	The second interim report was released on April 24, 1990. Its recommendations were reprinted in National Commission on Acquired Immune Deficiency Syndrome, Annual Report to the President and Congress, August 1990, pp. 106-109.
8.	Hearing before the House Committee on Banking, Finance, and Urban Affairs, Subcommittee on Housing and Community Development, "Housing Needs of Persons with Acquired Immune Deficiency Syndrome," March 21, 1990. See also, Statement of Representative James A. McDermott, 135 Cong. Rec. 23641, October 5, 1989.
9.	Ibid., pp. 25-30.
10.	U.S. Congress, House Committee on Banking, Finance, and Urban Affairs, Housing and Community Development Act of 1990, report to accompany H.R. 1180, 101st Cong., 2nd sess., June 21, 1990, H.Rept. 101-559.
11.	The law is codified at 42 U.S.C. §§12901-12912, with regulations at 24 C.F.R. Parts 574.3-574.655.
12.	The others are the Community Development Block Grant, the Emergency Solutions Grants, and HOME.
13.	MSAs are defined as having at least one core "urbanized" area of 50,000 with the MSA comprised of "the central county or counties containing the core, plus adjacent outlying counties having a high degree of social and economic integration with the central county or counties as measured through commuting." See Office of Management and Budget, "2010 Standards for Delineating Metropolitan and Micropolitan Statistical Areas," 75 Federal Register 37246-37252, July 28, 2010.
14.	42 U.S.C. §12903(c)(1)(A).
15.	42 U.S.C. §12903(c).
16.	See Section 203(d) of the HUD General Provisions in P.L. 112-55. In subsequent appropriations laws, the general provisions refer back to P.L. 112-55. E.g., in FY2015, see Section 203 of the HUD General Provisions in P.L. 113-235.
17.	42 U.S.C. §12903(c)(1)(B).
18.	42 U.S.C. §12903(f).
19.	24 C.F.R. §574.3.
20.	U.S. Department of Housing and Urban Development, 2011 HOPWA Formula Operating Instructions, April 28, 2011, p. 3, http://www.hudhre.info/documents/2011Operating_Formula.pdf.
21.	U.S. Department of Housing and Urban Development, Office of Community Planning and Development, Formula Allocations for FY2015, http://portal.hud.gov/hudportal/HUD?src=/program_offices/comm_planning/about/budget/budget15.
22.	States that have retained funding under this provision include Arizona, Connecticut, Delaware, Hawaii, Massachusetts, Minnesota, Nevada, New Mexico, Oklahoma, and Utah. See U.S. Department of Housing and Urban Development, Congressional Justifications for FY2011, p. Z-12, http://hud.gov/offices/cfo/reports/2011/cjs/hofpwAIDS2011.pdf.
23.	42 U.S.C. §12903(c)(3).
24.	Ibid.
25.	The FY2014 Consolidated Appropriations Act (P.L. 113-76) provided that if there are insufficient funds to renew existing contracts, then funds should be taken from the formula grants for that purpose. The language has not appeared in subsequent appropriations acts.
26.	U.S. Department of Housing and Urban Development, "HUD Awards $8.8 Million to Improve Housing and Services for Families and Individuals Living with AIDS," press release, September 21, 2011, http://portal.hud.gov/hudportal/HUD?src=/press/press_releases_media_advisories/2011/HUDNo.11-225.
27.	U.S. Department of Housing and Urban Development, Violence Against Women Act (VAWA) and Housing Opportunities for Persons With AIDS (HOPWA) Project Demonstration, August 11, 2015, https://www.hudexchange.info/news/vawa-hopwa-project-demonstration-nofa-and-faqs/.
28.	U.S. Department of Housing and Urban Development, "HUD and Justice Department Award $9.2 Million to Provide Stable Housing to Victims of Domestic Violence Living with HIV/AIDS," press release, June 14, 2016, http://portal.hud.gov/hudportal/HUD?src=/press/press_releases_media_advisories/2016/HUDNo_16-088.
29.	42 U.S.C. §12903.
30.	42 U.S.C. §12902(9).
31.	Specifically, MSAs are county-based areas with at least one urbanized area of 50,000 or more in the United States and Puerto Rico. See, for example, Office of Management and Budget, "2010 Standards for Delineating Metropolitan and Micropolitan Statistical Areas," 75 Federal Register 37245-37252, June 10, 2010. The Census definition of "United States" includes only the 50 states plus the District of Columbia. U.S. Census, Geographic Terms and Concepts, 2010, p. A-25, http://www.census.gov/geo/www/2010census/GTC_10.pdf.
32.	The HOPWA statute, 42 U.S.C. §12902, refers to 42 U.S.C. §12704 to define "unit of general local government."
33.	24 C.F.R. §574.3.
34.	The HOPWA statute defines an eligible person as one "with acquired immunodeficiency syndrome or a related disease." 42 U.S.C. §12902(12). The regulations have further specified that "acquired immunodeficiency syndrome or related diseases means the disease of acquired immunodeficiency syndrome or any conditions arising from the etiologic agent for acquired immunodeficiency syndrome, including infection with the human immunodeficiency virus (HIV)." 24 C.F.R. §574.3.
35.	42 U.S.C. §12908 and §12909. The statutory provisions regarding short-term housing and community residences do not require individuals to be low income, although to be eligible for short-term housing a person must be homeless or at risk of homelessness. See 42 U.S.C. §12907 and §12910.
36.	Income limits are available on the HUD Policy Development and Research website at http://www.huduser.gov/portal/datasets/il.html.
37.	24 C.F.R. §574.3.
38.	24 C.F.R. §574.310(e).
39.	For more information about housing for persons with disabilities and the definitions of disability under these programs, see CRS Report RL34728, Section 811 and Other HUD Housing Programs for Persons with Disabilities, by [author name scrubbed].
40.	42 U.S.C. §1437a(b)(3).
41.	42 U.S.C. §12910.
42.	42 U.S.C. §12907.
43.	HOWPA funds may only be used for construction of community residences and single-room occupancy dwellings. See 24 C.F.R. §574.300(b)(4).
44.	42 U.S.C. §12908.
45.	See 24 C.F.R. §574.310(d).
46.	42 U.S.C. §12909.
47.	24 C.F.R. §574.300(b)(7).
48.	42 U.S.C. §12906.
49.	24 C.F.R. §574.300(b)(1).
50.	U.S. Department of Housing and Urban Development, HOPWA Performance Profile National Program 2014-2015 Program Year, https://www.hudexchange.info/resource/reportmanagement/published/HOPWA_Perf_NatlComb_2014.pdf.
51.	Ibid. The percent stably housed includes those living in permanent dedicated housing units as well as those receiving tenant-based rental assistance.
52.	U.S. Department of Housing and Urban Development, FY2017 Congressional Justifications, p.22-5, http://portal.hud.gov/hudportal/documents/huddoc?id=22-HSNG_Opp.Persons_wAIDS.pdf.
53.	Part A of the Ryan White CARE Act distributed funds to metropolitan statistical areas using "the cumulative number of cases of acquired immune deficiency syndrome in the eligible area involved.... " See P.L. 101-381. While the HOPWA statute did not use the word "cumulative" in describing the formula distribution, the program's regulations, issued in 1992, described the formula factor as cumulative cases. See U.S. Department of Housing and Urban Development, "Housing Opportunities for Persons with AIDS," 57 Federal Register 61735-61751, December 28, 1992.
54.	When HOPWA and Ryan White were enacted, in 1990, the CDC issued annual HIV/AIDS Surveillance Reports that contained the number of new AIDS cases, and the cumulative number of cases, but not the number of persons living with AIDS. These were the data relied on by both programs. In 1993, the CDC released estimates of persons living with AIDS by state, but the report did not contain estimates broken down by metropolitan statistical area.
55.	U.S. General Accounting Office, Ryan White CARE Act of 1990: Opportunities to Enhance Funding Equity, GAO/HEHS-96-26, November 1995, http://www.gao.gov/assets/230/221925.pdf.
56.	Ibid., pp. 21-27.
57.	Ryan White HIV/AIDS Treatment Modernization Act of 2006 (P.L. 109-415).
58.	U.S. General Accounting Office, HUD's Program for Persons with AIDS, GAO/RCED-97-62, March 1997, p. 27, http://www.gao.gov/archive/1997/rc97062.pdf.
59.	See U.S. Congress, House Committee on Appropriations, Subcommittee on VA, HUD, and Independent Agencies, Departments of Veterans Affairs and Housing and Urban Development and Independent Agencies Appropriations Bill, report to accompany H.R. 2158, 105th Cong., 1st sess., July 11, 1997, H.Rept. 105-175, pp. 33-34.
60.	U.S. Department of Housing and Urban Development, 1999 Report on the Performance of the Housing Opportunities for Persons with AIDS Program, October 6, 1999.
61.	U.S. Government Accountability Office, Changes Needed to Improve the Distribution of Ryan White CARE Act and Housing Funds, GAO-06-332, February 2006, p. 23, http://www.gao.gov/new.items/d06332.pdf.
62.	The GAO report looked at FY2004 HOPWA allocations and found that the amount of money grantees received per living AIDS case ranged from $387 per person to $1,290. According to the report, if only living AIDS cases had been counted in that year, 92 of 117 grantees would have received more formula funding, while 25 would have received less. Ibid., p. 24.
63.	U.S. Government Accountability Office, Persons with HIV: Funding Formula for Housing Assistance Could Be Better Targeted, and Performance Data Could Be Improved, GAO-15-298, April 2015, http://www.gao.gov/assets/670/669705.pdf.
64.	U.S. Department of Housing and Urban Development, Congressional Justifications for FY2009, p. Q-2, http://www.hud.gov/offices/cfo/reports/2009/cjs/cpd1.pdf.
65.	FY2010 Congressional Budget Justifications, p. X-13.
66.	National HIV/AIDS Strategy Federal Implementation Plan, July 2010, p. 28, http://aids.gov/federal-resources/policies/national-hiv-aids-strategy/nhas-implementation.pdf.
67.	For example, researchers who analyzed data from 25 states found that from 1996 to 2005, average life expectancy after HIV diagnosis increased from 10.5 to 22.5 years. See Kathleen McDavid Harrison, Ruiguang Song, and Xinjian Zhang, "Life Expectancy after HIV Diagnosis Based on National HIV Surveillance Data from 25 States, United States," Journal of Acquired Immune Deficiency Syndromes, vol. 53, no. 1 (January 2010), pp. 124-130.
68.	Through FY2009, HUD provided estimates of the numbers of households served in its annual Performance and Accountability Reports. The most recent is the FY2009 Performance and Accountability Report, November 16, 2009, p. 349, http://www.hud.gov/offices/cfo/reports/hudfy2009par.pdf.
69.	The FY2010 and FY2012 numbers of households served is reported in HUD's Annual HOPWA Performance Profiles, available at https://www.hudexchange.info/manage-a-program/hopwa-performance-profiles/.
70.	For more information about the Ryan White program, see CRS Report RL33279, The Ryan White HIV/AIDS Program, by [author name scrubbed].
71.	42 U.S.C. §300ff-14(d)(1) and §300ff-22(c)(1). At the time that HHS established its housing policy, the statute stated that funds could be used "for the purpose of delivering or enhancing HIV-related outpatient and ambulatory health and support services, including case management and comprehensive treatment services ... " The statute was amended to read as stated in the text of this report as part of the Ryan White HIV/AIDS Treatment Modernization Act of 2006, P.L. 109-415.
72.	Policy Notice 99-02 is reproduced in U.S. Department of Health and Human Services, Health Resources and Services Administration, Housing is Health Care: A Guide to Implementing the HIV/AIDS Bureau (HAB) Ryan White CARE Act Housing Policy, 2001, p. 3, ftp://ftp.hrsa.gov/hab/housingmanualjune.pdf (hereinafter, Housing is Health Care).
73.	The program was reauthorized in the Ryan White HIV/AIDS Treatment Modernization Act of 2006 (P.L. 109-415). See Section 105.
74.	U.S. Department of Health and Human Services, Health Resources and Services Administration, "HIV/AIDS Bureau Policy Notice 11–01 (Replaces Policy Notice 99–02)," 76 Federal Register 27649-27651, May 12, 2011.
75.	Transitional housing is defined in the law governing the HUD Homeless Assistance Grants as "housing the purpose of which is to facilitate the movement of individuals and families experiencing homelessness to permanent housing within 24 months or such longer period as the Secretary determines necessary." 42 U.S.C. §11360(29).
76.	The United States—Ryan White HIV/AIDS Program Services Received, HRSA website accessed June 2, 2016, http://hab.hrsa.gov/stateprofiles/Services-Received.aspx#chart2.
77.	National HIV/AIDS Strategy for the United States, July 13, 2010, p. 28, http://www.whitehouse.gov/sites/default/files/uploads/NHAS.pdf.
78.	Ibid., pp. 27-28.
79.	Angela A. Aidala, Gunjeong Lee, and David M. Abramson, et al., "Housing Need, Housing Assistance, and Connection to HIV Medical Care," Aids and Behavior, vol. 11, no. 6 (November 2007, supplement), pp. S101-S115.
80.	The statistical significance of the likelihood varied among the models used. See Table 3, pp. S110-S111 for significance.
81.	Findings were statistically significant in all but one of six models—continuity of appropriate HIV medical care.
82.	The methodology of the study is described in Daniel P. Kidder, Richard J. Wolitski, and Scott Royal, et al., "Access to Housing as a Structural Intervention for Homeless and Unstably Housing People Living with HIV: Rationale, Methods, and Implementation of the Housing and Health Study," AIDS and Behavior, vol. 11, no. 6 (November 2007, supplement), pp. 149-161.
83.	Richard J. Wolitski, Daniel P. Kidder, and Sherri L. Pals, et al., "Randomized Trial of the Effects of Housing Assistance on the Health and Risk Behaviors of Homeless and Unstably Housing People Living with HIV," AIDS & Behavior, vol. 14, no. 3 (2010), pp. 493-503.
84.	David Buchanan, Romina Kee, and Laura S. Sadowski, et al., "The Health Impact of Supportive Housing for HIV-Positive Homeless Patients: A Randomized Controlled Trial," American Journal of Public Health, vol. 99, no. S3 (November 2009), pp. S675-S680.
85.	Laura S. Sadowski, Romina A. Kee, and Tyler J. VanderWeele, et al., "Effects of a Housing and Case Management Program on Emergency Department Visits and Hospitalizations Among Chronically Ill Homeless Adults," Journal of the American Medical Association, vol. 301, no. 17 (May 6, 2009), pp. 1775-1776.