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Housing for Persons Living with HIV/AIDS
Name: Housing for Persons Living with HIV/AIDS
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Year: 2013
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Housing for Persons Living with HIV/AIDS Congressional Research Service 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. As individuals become ill, they may find themselves unable to work, while at the same time facing health care expenses that leave few resources to pay for housing. In addition, many of those persons living with AIDS 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 those 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 FY2012, Congress appropriated $332 million for HOPWA as part of the Consolidated Appropriations Act (P.L. 112 55). This was a reduction of $3 million from the $335 million appropriated in FY2011 and FY2010, the most funding ever appropriated for the program. 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. The Appendix provides the formula grants distributed to eligible states and metropolitan statistical areas from FY2004 to FY2012.


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Housing for Persons Living with HIV/AIDS Congressional Research Service Contents Introduction ...................................................................................................................................... 1 Housing Status of Persons Living with HIV/AIDS ................................................................... 1 Creation of the Housing Opportunities for Persons with AIDS (HOPWA) Program ................ 2 Distribution and Use of HOPWA Funds .......................................................................................... 3 Formula Grants .......................................................................................................................... 3 Competitive Grants .................................................................................................................... 5 Eligibility for HOPWA Funded Housing .................................................................................. 6 Eligible Uses of HOPWA Funds ................................................................................................ 6 HOPWA Program Formula and Funding ......................................................................................... 8 The HOPWA Formula ............................................................................................................... 8 HOPWA Funding ..................................................................................................................... 10 Housing Funded Through the Ryan White HIV/AIDS Program ................................................... 12 The Relationship Between Stable Housing and Health Outcomes ................................................ 15 Tables Table 1. HOPWA Funding and Eligible Jurisdictions, FY2001 FY2012 and FY2013 Proposal ...................................................................................................................................... 11 Table A 1. HOPWA Formula Allocations, FY2004 FY2012 ........................................................ 17 Appendixes Appendix. Recent HOPWA Formula Allocations .......................................................................... 17 Contacts Author Contact Information........................................................................................................... 24


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Housing for Persons Living with HIV/AIDS Congressional Research Service 1 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 2009, AIDS had been diagnosed and reported in an estimated 490,696 individuals living in the 50 states, the District of Columbia, and the territories. 1 These estimates do not include those diagnosed with HIV where the disease has not yet progressed to AIDS or 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, those persons 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 recent 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, those individuals who have been infected with HIV/AIDS face 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 1 Note that this represents persons living with AIDS, not a cumulative total. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, HIV Surveillance Report 2010, vol. 22, Atlanta, GA, March 2012, pp. 56 57, table 16b, http://www.cdc.gov/hiv/surveillance/resources/reports/2010report/pdf/ 2010_HIV_Surveillance_Report_vol_22.pdf#Page=1. 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 (continued...)


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Housing for Persons Living with HIV/AIDS Congressional Research Service 2 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 "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 that were discussed at the hearing were poverty, homelessness, and discrimination in attempting to secure housing. 8 Another issue discussed at the hearing 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 (...continued) 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, 101 st Cong., 2 nd sess., June 21, 1990, H.Rept. 101 559.


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Housing for Persons Living with HIV/AIDS Congressional Research Service 3 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 these 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 initiative. 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 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.


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Housing for Persons Living with HIV/AIDS Congressional Research Service 4 the largest cities within metropolitan statistical areas (MSAs) 13 with populations of at least 500,000 and with 1,500 or more cumulative reported cases of AIDS (which includes those who have died); 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 as reported by the CDC for the time period April 1 through March 31 of the year preceding the appropriations law. 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. 15 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." 16 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. 17 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." 18 In FY2012, 94 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. 19 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. 20 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)(1)(B). 16 42 U.S.C. 12903(f). 17 24 C.F.R. 574.3. 18 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. 19 U.S. Department of Housing and Urban Development, Office of Community Planning and Development, Formula Allocations for FY2012, http://www.hud.gov/offices/cpd/about/budget/budget12/. 20 According to HUD, the states that have retained funding under this provision are 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.


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Housing for Persons Living with HIV/AIDS Congressional Research Service 5 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." 21 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. 22 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. 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. In FY2009 and FY2010, the amount of funds required for project renewals meant that there were no funds available for new competitive grants. 23 In FY2011, HUD awarded approximately $9 million in new competitive grants to seven projects. 24 HUD did not award new competitive grants in FY2012. 25 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. 21 42 U.S.C. 12903(c)(3). 22 Ibid. 23 See U.S. Department of Housing and Urban Development, Congressional Justifications for 2012 Estimates, p. Z 13, http://portal.hud.gov/hudportal/documents/huddoc?id=HOPWA_2012.pdf. 24 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. 25 FY2012 Budget Justifications, p. Z 13.


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Housing for Persons Living with HIV/AIDS Congressional Research Service 6 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. 26 In general, clients must also be low income, meaning that their income does not exceed 80% of the area median income. 27 HUD reports area median incomes for metropolitan areas and non metropolitan counties on an annual basis. 28 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. 29 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. 30 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. 31 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. 32 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, 26 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. 27 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. 28 U.S. Department of Housing and Urban Development, FY2013 HUD Income Limits Briefing Material, December 11, 2012, http://www.huduser.org/portal/datasets/il/il13/IncomeLimitsBriefingMaterial_FY13.pdf. Tables showing area median incomes in recent years are available at http://www.huduser.org/datasets/il.html. 29 24 C.F.R. 574.3. 30 24 C.F.R. 574.310(e). 31 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 Libby Perl. 32 42 U.S.C. 1437a(b)(3).


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Housing for Persons Living with HIV/AIDS Congressional Research Service 7 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. 33 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. 34 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. 35 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. 36 In general, tenants must pay approximately 30% of their income toward rent. 37 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. 38 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. 39 Housing Information Such as Counseling and Referral Services. 40 Assistance may include fair housing counseling for those experiencing discrimination. 41 33 42 U.S.C. 12910. 34 42 U.S.C. 12907. 35 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). 36 42 U.S.C. 12908. 37 See 24 C.F.R. 574.310(d). 38 42 U.S.C. 12909. 39 24 C.F.R. 574.300(b)(7). 40 42 U.S.C. 12906. 41 24 C.F.R. 574.300(b)(1).


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