Background

First identified in 1981, HIV impairs the immune system and leaves  affected individuals susceptible to certain cancers and infections. HIV, the  virus that causes AIDS, affects specific cells of the immune system. Over  time, HIV can destroy so many of these cells that the body cannot fight off  infections and disease, leading to AIDS. A person who has the HIV virus  can move in and out of AIDS status, which is the third stage of the  disease. Despite the number of deaths from AIDS and the steady  increase of HIV prevalence, there have been successes in the fight  against the disease. Developments in treatment have enhanced care  options and can extend the lives of those with HIV. The introduction of  highly active antiretroviral therapy in 1996 was followed by a decline in  the number of deaths and new AIDS cases in the United States for the  first time since the beginning of the disease. Since 1981, over 1.2 million  persons diagnosed with AIDS have been reported to the CDC and over  600,000 of them have died. The CDC estimates that of the more than 1.2  million persons living with HIV in December 2011, some 14 percent had  not been diagnosed and might not be unaware of their status.
In 2010, the White House’s Office of National AIDS Policy issued a  national strategy for addressing HIV and AIDS in the United States. The  strategy has three primary goals: (1) reduce the number of persons who  become infected with HIV, (2) increase access to care and improve health  outcomes for persons living with HIV, and (3) reduce HIV-related health  disparities. To accomplish these goals, the strategy calls for a  coordinated national response to the disease.

		HOPWA Program

Congress created the HOPWA program in 1990 under the National  Affordable Housing Act, authorizing grants for housing activities and  supportive services designed to prevent homelessness among persons  with HIV. Specifically, HOPWA grants are used to provide a wide range of  housing-related services, including rental assistance; operating costs for  housing facilities; short-term rent, mortgage, and utility payments;  permanent housing placement and housing information services;  resource identification (to establish, coordinate and develop housing  assistance); acquisition, rehabilitation, conversion, lease, and repair of  facilities; new construction (for single-room occupancy dwellings and  community residences only); and supportive services (case management  and mental health, alcohol and drug abuse, and nutritional services). To  be eligible for HOPWA, individuals must be HIV positive and low income  (below 80 percent of area median income). HOPWA assists persons who  are without stable housing arrangements, including those at severe risk of  homelessness (e.g., persons in emergency shelters; persons living in a  place not meant for human habitation, such as a vehicle or abandoned  building; or persons living on the streets).
HUD awards 90 percent of the annual HOPWA appropriation by formula  to eligible metropolitan statistical areas (MSA) and states. On the basis  of the statute, MSAs with populations greater than 500,000 and more  than 1,500 cumulative cases of AIDS are eligible for HOPWA formula  grants. The most populous city in an eligible MSA serves as that area’s  HOPWA grantee. In addition, states with more than 1,500 cumulative  cases of AIDS in areas outside of eligible MSAs qualify for formula  funds.aside for grants awarded on a competitive basis.

		Ryan White HIV/AIDS Program

Congress enacted the Ryan White Comprehensive AIDS Resources  Emergency Act of 1990 (CARE Act) to improve the availability and quality  of community-based health care and support services for individuals with  HIV and their families. The CARE Act was most recently reauthorized  through the Ryan White HIV/AIDS Treatment Extension Act of 2009.  HRSA administers the Ryan White HIV/AIDS program.program must be the payer of last resort, meaning that other sources of  funds for services, including housing services, must be exhausted before  using Ryan White HIV/AIDS program funds.
Ryan White Part A provides formula funds to Eligible Metropolitan Areas  and Transitional Grant Areas. To qualify for Eligible Metropolitan Area  status, an area must have reported at least a cumulative total of 2,000  AIDS cases in the most recent 5 years and have a population of at least  50,000. To be eligible for Transitional Grant Area status, an area must  have a cumulative total of 1,000, but fewer than 2,000 cases of AIDS in  the most recent 5 years and have a population of at least 50,000.absence of a waiver, Ryan White Part A grantees are required to spend  at least 75 percent of their grant on core medical services and no more  than 25 percent on supportive services, which include housing   In the  assistance. Ryan White HIV/AIDS program-funded housing assistance  provides short-term aid to support emergency, temporary, or transitional  housing so that an individual or family can gain or maintain health care.HRSA guidance encourages but does not require grantees to limit  housing assistance to 24 months. Additionally, housing assistance must  be accompanied by a strategy to transition the individual or family to  stable, permanent housing.
Ryan White Part A grantees are required by the Ryan White HIV/AIDS  Treatment Extension Act of 2009 to establish a Ryan White Part A  Planning Council, which is appointed by the chief elected official of the  city or county. The council is responsible for setting HIV-related service  priorities and allocating grant funds based on the needs of persons with  HIV. Planning councils are required to develop a comprehensive plan with  the Ryan White Part A grantee for the provision of services. The Ryan  White HIV/AIDS Treatment Extension Act of 2009 identifies 13 different  parties that must be involved in the council, including representatives  from community-based organizations serving affected populations,  persons with HIV, and grantees providing services in the area under other  federal HIV programs.

		Local Government Role in the HOPWA and Ryan White HIV/AIDS Programs

Both HOPWA and Ryan White Part A funds are awarded to government  agencies, which are referred to as “grantees” (see fig. 1). For the HOPWA  program, the formula grantee is generally either the city office dedicated  to housing and community development or the city health department.  HOPWA grantees may carry out eligible program activities themselves,  through any of their administrative agencies, or through a project sponsor.  A project sponsor can be any nonprofit organization or governmental  housing agency that receives funds from a grantee to carry out eligible  HOPWA activities. The grantees and project sponsors may also contract  with for-profit entities to provide services associated with their HOPWA  activities.
For the Ryan White Part A program, grants are awarded to the chief  elected official of the city or county that provides health-care services.  The chief elected official is legally the grantee but usually chooses a  department or other entity to manage the grant, and that entity is then  referred to as the grantee. Ryan White Part A grantees are generally  county or city health departments or public departments with  responsibility for health. Part A grants consist of formula and  supplemental components. Formula grants are based on reported living  cases of HIV and AIDS in eligible areas. Supplemental grants are  awarded competitively and are based on the ability of Eligible  Metropolitan or Transitional Grant Areas to document both a  demonstrated need for additional funds and the capacity to use them to  meet community needs. Ryan White Part A grantees can deliver services  to persons with HIV (clients) directly or through a subgrantee.  Subgrantees are generally community-based, nonprofit organizations. In  some cases, a city’s formula HOPWA grantee and Ryan White Part A  grantee are the same entity. Also, in some cases local community-based  organizations receive both HOPWA and Ryan White Part A funding.

	Estimates of Housing Need for Persons with HIV Are Not Reliable, and the HOPWA Formula Does Not Effectively Target Funds

As the number of persons with HIV in the United States continues to  increase, research finds that stable housing is critical for effective medical  care and is associated with improved health outcomes for persons with  HIV. The extent to which persons with HIV need housing assistance is not  known, in part because HUD’s estimates of the housing needs of persons  living with HIV are not reliable. In addition, the statutory HOPWA funding  formula may not be effectively distributing grant funds to communities  with the greatest need because the formula counts persons who are  deceased. As a result, HOPWA funds may not be targeted as effectively  as they could be.

		With the Number of HIV Cases Increasing, Stable Housing Is Critical

According to CDC estimates, there were about 50,000 HIV diagnoses  each year from 2008 to 2012. In 2012, the estimated rate of diagnosed  HIV infections in the United States was 15.3 per 100,000 population.  Rates of diagnosis of HIV infection have varied by region from 2008 to  2012. For example, the rate of diagnosis of HIV infection increased from  2008 through 2012 in the Midwest, and decreased during this period in  the Northeast, South, and West. In 2012, the rates of diagnosed HIV  infection were highest in the South, followed by the Northeast, West, and  Midwest, as shown in figure 2.
According to CDC data, from 2008 through 2011, the estimated number  of persons in the United States living with a diagnosed HIV infection, or  the prevalence of diagnosed HIV infection, increased. The prevalence  rate, or the number of persons living with diagnosed HIV infection per  100,000 population, was estimated to be nearly 283 at the end of 2011.
Prevalence rates vary by region, and regional differences have remained  relatively stable from 2008 through 2011. As shown in figure 3,  prevalence rates of diagnosed HIV infection are highest in the Northeast,  followed by the South, West, and Midwest.
The estimated rates of HIV diagnoses have varied over time across  different demographic groups. For example, from 2008 through 2012 the  rates of diagnosed HIV infection increased among persons aged 13 to 14  and 20 to 29 and either remained stable or decreased among other age  groups. Rates of diagnoses during this period also increased for  American Indian/Alaska natives and Asians, while decreasing for African- Americans, Hispanics/Latinos, and persons of multiple races. In 2012, the  estimated rate of HIV diagnoses for African-Americans was 58 per  100,000 population—the highest rate compared to other racial and ethnic  groups. From 2008 through 2012, rates of HIV diagnoses decreased  among females and remained stable for males. In 2012, males accounted  for 80 percent of all diagnoses newly reported among adults and  adolescents.
Stable housing is critical for persons with HIV. Staff from several  HIV/AIDS advocacy groups told us that stable housing was important  because many persons with HIV were required to adhere to strict  regimens for taking medicine. Some medicines require refrigeration, and  some cause debilitating side effects. Health care officials from CDC told  us that without stable housing, persons may not reach viral suppression   In addition, the National HIV/AIDS  or remain connected to medical care. Strategy states 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. A 2007 study  emphasized the relationship between housing assistance provided to  persons living with HIV and increased access to medical care and  appropriate treatment. The need for housing is prevalent among persons  living with HIV, and there is strong evidence that receipt of housing  assistance has a direct impact on improved medical care outcomes.Research has also indicated that persons with HIV who live in stable  housing have better health outcomes than those who are homeless or  unstably housed.
However, while stable housing is critical for effective medical care,  persons with HIV often have difficulty maintaining stable housing because  of the financial vulnerability that can be associated with the disease. 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. According to a recent study, housing challenges for a  person living with HIV may include the growing disparity between income  and the cost of rental housing, loss of income due to inability to maintain  employment, and loss of spouse or partner due to HIV-related death,  among other things. homelessness among persons with HIV. In addition, those who are  homeless may be more likely to engage in activities through which they  could transmit HIV.
Aidala and others, “Housing Need.” members from HOPWA and Ryan White Part A grantees we interviewed  told us that there was an increasing need for housing assistance for  persons with HIV. Some staff told us that infected persons were living  longer as a result of advances in medical care. Moreover, staff from  several grantees told us that these persons generally needed both  medical and nonmedical supportive services. Additionally, HUD officials  noted that as local housing costs increased, the need for programs that  provided affordable housing increased for all low-income people,  including those with HIV.

		HUD Does Not Reliably Estimate the Extent of Housing Needs among Persons with HIV

HUD’s estimate of the number of persons with HIV who have a housing  need is not reliable. HUD requires each formula and competitive HOPWA  grantee to report annually the number of HOPWA-eligible persons who  have an unmet housing need within the grantee’s jurisdiction. HUD then  develops an estimate of the number of persons nationwide with HIV who  have an unmet housing need by totaling the numbers reported by each  grantee. For 2013, HUD reported that approximately 131,000 HIV-positive  persons had unmet housing needs. HUD uses this information to justify  its HOPWA budget requests and to report on the program’s performance.  HIV advocacy groups use HUD’s estimates in their publications and  outreach efforts to Congress.
We found that HOPWA grantees used different methodologies to report  unmet housing needs, limiting the reliability of the reported information.  Grantees we met with used varying methods to produce the local unmet  need estimates that they reported to HUD annually. For example, officials  from one HOPWA grantee told us that they summed the unmet housing  need data provided by their project sponsors. In contrast, officials from  another HOPWA grantee use various data sources to produce both a low  and high estimate of unmet housing need and have historically reported  both numbers to HUD. In its 2010 and 2011 Consolidated Annual  Performance and Evaluation Reports (CAPER) Reports, this grantee  reported to HUD that the unmet need in its community could range from a  low of approximately 7,500 persons to a high of 15,000.
HUD officials told us that, at the time of our review, they did not require  HOPWA grantees to use a consistent methodology to calculate unmet  housing need for each jurisdiction. They told us that this policy was  intended to allow for local flexibility, so that the data were collected using  the most appropriate method for each jurisdiction. According to HUD’s  CAPER guidance, grantees can use one or more of seven data sources  to calculate unmet need, including data from prisons or jails on persons  being discharged with HIV and housing providers’ waiting lists.Grantees are required to indicate on their CAPERs all of the data sources  they use to estimate unmet need. However, HUD does not provide  additional guidance on how grantees should use the data sources in a  comparable manner. In June 2014 HUD granted a HOPWA technical  assistance contractor a 1-year contract extension to help the agency  address its unmet needs methodology, to include soliciting community  feedback at the U.S. Conference on HIV/AIDS. HUD convened  stakeholders and HOPWA grantees at this conference to discuss how  unmet needs were estimated, and participants discussed establishing a  working group to develop a consistent methodology. According to HUD,  as of February 2015, the agency was working with its technical  assistance contractor to develop a methodology and provide communities  CDC data related to persons with HIV. However, according to HUD, the  agency does not have specific goals or time frames for finalizing a  standard methodology.
GAO’s work on assessing data reliability indicates that data should be  consistent—that is, data should be clear and well defined enough to yield  similar results in similar analyses. Further, when data are entered at  multiple sites or reported using multiple sources (as in the case of  HOPWA program), there is a risk that data entry rules may be interpreted  inconsistently, resulting in data that, taken as a whole, are unreliable.  In  addition, federal internal control standards state that program managers  need operational data to determine whether they are meeting their goals  for effective and efficient use of resources. In our 1997 report on  HOPWA and the Ryan White HIV/AIDS program, we concluded that  equitable distribution of resources should be consistent with the current  need for such resources. Because HUD does not require grantees to  use selected data sources in a consistent manner, the resulting  information is not comparable. Further, the usefulness and reliability of  these data as an indicator of the unmet housing needs of persons with  HIV are unclear. Although data on unmet housing needs are not used to  determine HOPWA formula funding amounts, such information would be  helpful in determining the extent of the need for HOPWA funds in specific  areas, as well as the extent to which HOPWA is meeting its goals of  addressing the housing needs of persons with HIV.

		The HOPWA Formula Does Not Target Funds Based on Persons Living with HIV

As previously discussed, 90 percent of HOPWA funds are awarded  through formula grants to eligible states and MSAs. Seventy-five  percent of these formula-based funds are awarded to cities and states  that meet certain threshold criteria. These criteria are based on each  jurisdiction’s share of the number of cumulative AIDS cases in all eligible  jurisdictions. Cumulative AIDS case counts include both living and  deceased AIDS cases reported in the grantees’ jurisdiction since the  beginning of the AIDS epidemic in 1981.
Use of cumulative AIDS cases rather than living HIV cases has led to  MSAs with similar numbers of persons living with HIV receiving markedly  different amounts of HOPWA funding. For example, in fiscal year 2012 a  grantee in the South and a grantee in the Northeast both had about 2,300  persons living with HIV, according to CDC data. However, the grantee in  the Northeast received about $154,000 more in HOPWA formula funding  than the grantee in the South because it had approximately 776 more  reported cumulative AIDS cases. Similarly, in the same fiscal year, both a HOPWA formula grantee in the West and one in the South had about  3,500 persons living with HIV. However, the grantee in the West received  nearly $319,000 more in formula funding than the grantee in the South  because it had about 1,600 more reported cumulative AIDS cases.
The difference between cumulative AIDS cases and living HIV cases is  more pronounced in some MSAs than others. As shown in figure 4, the  relative difference ranged from less than 15 percent to more than 43  percent in the MSAs that received HOPWA formula funds in 2012. In  most of these MSAs (62 of 78), the number of cumulative AIDS cases  was greater than the number of persons living with HIV. For example, the  New York City MSA had 35 percent more cumulative AIDS cases than  cases of persons living with HIV. In contrast, about one-fifth of the  MSAs that received HOPWA funds in fiscal year 2012 had more persons  living with HIV than cumulative AIDS cases. For example, the Charlotte,  North Carolina MSA had 43 percent more cases of persons living with  HIV than cumulative AIDS cases. According to CDC officials, there can  be more living HIV cases than cumulative AIDS cases because not all  persons with HIV progress to the third stage of the disease (AIDS).  Appendix II provides additional information on the numbers of cumulative  AIDS cases and living HIV cases for all MSAs that received HOPWA  grants in fiscal year 2012.
We have assessed HOPWA’s funding formula in previous work. In 1997,  we recommended that HUD consider the legislative changes that would  be needed to make the HOPWA formula more reflective of current AIDS   We also noted that the general principle of allocating grants on  cases.the basis of the estimated number of persons living with HIV, excluding  those who are deceased, would ensure a more equitable allocation of the  available funds. In response, HUD reviewed potential changes to the  formula. It compiled an analysis to show the effects of various alternatives  on grantees’ funding levels, including use of 10-year weighted numbers to  reflect living cases of persons with AIDS. However, at that time, HUD was  reluctant to recommend any change that might disrupt funding for those  who depended on HOPWA support.
In 2006, we recommended that if Congress wanted HOPWA funding to  more closely reflect the distribution of persons living with AIDS, it should  consider changing the program so that HOPWA formula grant eligibility  would be based on a measure of living AIDS cases.the funding formula for the Ryan White HIV/AIDS programs in 2006 but  did not make the same change for HOPWA. Since our 2006 report,  medical treatment for HIV/AIDS and the make-up of the national  population with HIV or AIDS have continued to evolve. Additionally, CDC  officials now consider HIV case counts to be more accurate and reliable  than counts of AIDS cases alone because persons with HIV may live  many years before progressing to AIDS and may move between stages  as their health changes.
HUD officials and the four HOPWA grantees we met with stated that the  HOPWA funding formula was out of date. In its last three congressional  budget justifications, HUD has proposed updating the formula. According  to HUD’s 2015 budget justification, the HOPWA formula should be  updated to better reflect the nature of the HIV epidemic that has evolved  over the years through advances in HIV care and the increasingly  disproportionate impact on impoverished persons with HIV. HUD has  proposed basing the funding formula on living HIV rather than cumulative  AIDS cases and on consideration of local housing costs and poverty  rates. HUD recognized that some communities could lose funds as a  result of a redistribution of grant funds. To mitigate any potential negative  impacts of large funding reductions on some communities, HUD has also  proposed incrementally reducing funding over time.
HUD’s projections based on its proposed formula change—using living  HIV cases instead of cumulative AIDS cases and data on housing costs  and poverty—show a redistribution of funds that results in funding  increases for some communities and decreases for others. For example,  based on HUD’s 2015 projections of HOPWA award amounts, the New  York City MSA’s award would decrease by about $5 million from HUD’s  2014 estimated award amount. In contrast, smaller MSAs, such as  Charlotte North, Carolina, and Cleveland, Ohio would receive increases  of more than $200,000 from HUD’s 2014 estimated award amounts.  Although our analysis of CDC data suggests that the proportions of living  HIV cases among the cities that received HOPWA funds in 2012 are  similar to the proportions of cumulative AIDS cases, these changes could  result in meaningful differences in the amounts of funding that some  grantees receive.
The Office of Management and Budget has also noted that the current  formula for distributing HOPWA funds does not reflect the current nature  of the disease. As discussed in GAO’s prior work, a cumulative count of  AIDS cases that includes deceased persons does not necessarily reflect  the number of living HIV cases in a particular year. In contrast, data on  the number of persons living with HIV exclude the deceased and include  persons in all stages of HIV infection. In addition, regional changes in the  number of HIV cases may not be fully accounted for in the current  HOPWA formula due to the continued inclusion of deceased persons.  Reauthorizations of the Ryan White HIV/AIDS program in 2000, 2006 and  2009 required the use of living cases of both HIV and AIDS in the  distribution of formula grants for Ryan White Parts A and B. Because  HOPWA funds continue to be awarded based on cumulative AIDS cases,  HOPWA funds are not being targeted as effectively or equitably as they  could be.

	HOPWA and Ryan White Part A Provide Stable Housing for Persons with HIV, but Some Housing Data May Have Limitations

HOPWA grantees have used the majority of their grant funds to provide  housing assistance to extremely low-income persons with HIV, primarily  in the form rental assistance. In general, the majority of individuals who  receive housing assistance through HOPWA are male, African-American,  and extremely low income. Overall, a small share (about 2 percent) of  total Ryan White Part A expenditures is used for housing. Individuals who  receive temporary housing assistance through Ryan White Part A  generally have the same demographic characteristics as HOPWA  housing assistance recipients. Both HOPWA and Ryan White Part A  information indicate that the majority of individuals provided with housing  assistance became stably housed. However, the reliability of Ryan White  Part A housing data is not clear because grantees do not update  information on housing status consistently. Stakeholders such as  HOPWA and Ryan White Part A grantees, as well as advocacy groups,  note both strengths and challenges related to these programs.

		HOPWA Grantees Have Primarily Funded Housing Assistance

HOPWA grantees have primarily used their funds to provide housing  assistance. As previously noted, grantees can use HOPWA funds for  housing and supportive services and for administrative expenses. In  2012, the most recent program year for which data were available,  HOPWA grantees spent nearly $314 million to assist persons with HIV. Of  these expenditures, about $211 million (67 percent) was spent on  housing assistance and $64 million (20 percent) were spent on supportive  services, as shown in figure 5.receiving housing assistance decreased from around 60,000 in 2010 to  about 56,000 in 2012. According to HUD officials, this decrease is likely  due to improved grantee reporting as well as increases in the cost of  housing—that is, as housing costs have increased, the program has been  able to provide housing assistance to fewer persons.

		Ryan White Part A Grantees Spent a Small Share of Supportive Services Funds on Housing in 2011

Housing assistance represented about 2 percent ($14 million) of the total  expenditures of $592 million in fiscal year 2011 for all Ryan White Part A  funding categories—including medical and supportive services. The  largest category of program expenditures, $426 million, was for core  medical services, followed by about $93 million for supportive services  and about $73 million for clinical quality management and grantee  administration. Under the Ryan White HIV/AIDS Treatment Extension Act  of 2009, Ryan White Part A grantees are generally required to expend the  majority of their funds on core medical services but can also fund   Expenditures for the  supportive services (including housing assistance).Ryan White Part A program also reflect the priorities established by Ryan  White Part A Planning Councils.
Of the $93 million grantees spent on supportive services, housing  assistance made up about 15 percent (see fig. 7). Ryan White Part A  grantees also spent supportive services funds on nonmedical case  management, emergency financial assistance, food bank/home-delivered  meals, and health education.
Ryan White Part A data for calendar year 2012 indicate that the majority  of the 13,556 clients who received housing assistance were African- American. The data also indicate that the majority of clients who received  housing assistance had incomes at or below the federal poverty level.Table 2 summarizes selected demographic characteristics of persons  who received housing assistance through Ryan White Part A in calendar  year 2012.

		HOPWA and Ryan White Information Suggest Positive Outcomes in Housing Stability, but Ryan White Data May Have Limitations

HUD’s 2012 HOPWA performance data show a variety of positive  outcomes related to housing stability, access to care, and homelessness.  For the HOPWA program, permanent, stable housing includes private  housing without a subsidy, subsidized housing, and HOPWA-funded  rental assistance or facility-based housing. According to HUD’s 2012  data,
96 percent of the households that received tenant-based rental  assistance or lived in a HOPWA-funded permanent housing facility  had stable housing;
92 percent of households had contact with primary care;
90 percent of clients accessed medical insurance; and
5,736 formerly homeless individuals were placed in housingAdditionally, HUD’s 2013 Performance Report indicates that the HOPWA  program has contributed to the agency’s goal of preserving affordable  rental housing. The report states that HOPWA had funded 25,706 rental  units as of the end of fiscal year 2012, helping HUD exceed its fiscal year  2012-2013 agency priority goal of continuing to serve 5.4 million families  and serving an additional 61,000 families. According to the performance  report, HUD exceeded this goal by nearly 82,000 families. HOPWA  officials also told us that the program’s contributions to providing  permanent supportive housing supported HUD’s strategic objective for  ending homelessness. HOPWA officials noted that the HOPWA  program helped to keep persons with HIV from becoming homeless.
HUD uses the data that grantees report on outcomes to summarize the  achievements of individual grantees and the program as a whole. More  specifically, HUD contractors review the information grantees submit and  produce grantee-level and national summaries of performance for the  formula HOPWA program, the competitive HOPWA program, and both  programs combined. HUD posts these summaries, or performance  profiles, on a HUD website.
HRSA officials told us that the majority of clients provided with housing  assistance through the Ryan White HIV/AIDS program obtained  permanent, stable housing. According to a December 2013 White House  report addressing the outcomes associated with the National HIV/AIDS  Strategy, increasing the percentage of Ryan White HIV/AIDS program  clients with permanent housing to 86 percent is one of nine indicators in  the National HIV/AIDS Strategy. For the Ryan White HIV/AIDS program,  stable, permanent housing includes unsubsidized rooms, houses, or  apartments; subsidized housing; and permanent housing for formerly  homeless persons.
According to HRSA officials, the National HIV/AIDS Strategy indicator of  Ryan White HIVAIDS program clients with permanent housing is  measured using the data on the housing status that HRSA collects  annually. HRSA gathers this information from Ryan White HIV/AIDS  program grantees through the Ryan White HIV/AIDS Program Services  (RSR) report. However, it is not clear that HRSA’s housing status data  are current because HRSA does not require or encourage grantees to  maintain current data on clients’ housing status. RSR instructions state  that the housing status data element is the client’s housing status at the  end of the reporting period. HRSA officials told us that the instructions  were not intended to be used as guidance for local jurisdictions in  determining how often each client’s housing status should be collected.  The officials added that the frequency with which a client’s housing status  should be updated was decided at the local level and that currently HRSA  does not require grantees to assess a client’s housing status beyond the  initial intake period. Staff from one Ryan White Part A grantee told us that  information on housing status in the RSR report was not very reliable  because each client’s housing status was recorded at the point of intake  but might or might not be updated subsequently. Another Ryan White  Part A grantee told us that some of its subgrantees only reported on  clients’ housing status at the point of intake, even though they recertified  clients’ eligibility for the program every 6 months.
Internal control standards for the federal government state that events  should be promptly recorded to maintain their relevance and value to  management in controlling operations and making decisions. Because HRSA does not require grantees to ensure that their subgrantees  regularly update data on each client’s housing status, the usefulness of  these data to support housing-related outcomes is unclear. Among these  outcomes, for example, the extent to which the Ryan White HIV/AIDS  program is contributing to the National HIV/AIDS Strategy goal of  improving access to permanent housing. Further, because the Ryan  White HIV/AIDS program provides temporary housing assistance and  clients’ housing status is likely to change frequently, housing data may  not be as accurate and current as possible if they are not updated  regularly.

		Stakeholders Cite Strengths and Weaknesses of Programs That Provide Housing Assistance for Persons with HIV

HOPWA grantees, project sponsors, and HIV advocacy groups noted  several strengths of the design of the HOPWA program. For example,  three of the eight HOPWA project sponsors that GAO interviewed and an  HIV advocacy group stated that one strength of the program was that  clients must be provided with supportive services. These stakeholders  noted that HOPWA clients or other persons with HIV often had substance  abuse issues and a mental illness and that supportive services that  helped address these issues were critical to helping some clients become  stable. Three HOPWA grantees noted that another strength of the  program was the flexibility it offered to grantees, allowing them to fund the  type of housing assistance that was most needed in their communities.  Grantees that we visited funded a wide range of housing types, including  a facility for persons with HIV who had mental, physical, or drug abuse  issues; a facility for single adults who had progressed to AIDS and had a  history of homelessness; and a hospice for HIV-positive persons. Finally,  officials from four organizations that received both HOPWA and Ryan  White Part A funding explained that HOPWA worked well with the Ryan  White HIV/AIDS program. These officials explained that they took steps to  transition Ryan White Part A clients who received temporary housing  assistance into the HOPWA program, which offered permanent housing  assistance. Also, in one of the cities we visited local program  administrators emphasized that the programs were complementary and  said that they used Ryan White Part A funds only for core medical  services and nonmedical case management and HOPWA funds only for  housing assistance.
HOPWA grantees and project sponsors also identified weaknesses in the  HOPWA program, including certain requirements, administrative fees,  and the funding formula. Specifically, two of the four HOPWA grantees  we met with noted that rental assistance generally could not exceed Fair  Market Rent amounts, which HUD determined annually. Limiting rental  assistance to Fair Market Rents is challenging, particularly in high-cost  cities like New York City and San Francisco, where officials noted that the  average price of an apartment was double the amount of the Fair Market  Rent. Also, two of the four HOPWA grantees that we interviewed and  HUD administrators of the HOPWA program stated that the administrative  fee of 3 percent that grantees could retain from their HOPWA grant was  low. HUD officials stated that other HUD programs had higher fees,  including Community Development Block Grants (20 percent) and the  Home Investment Partnerships Program (10 percent). Finally, staff from  three HOPWA grantees, five organizations that receive HOPWA or Ryan  White Part A funding, and HUD officials with responsibility for  administering the HOPWA program told us that the funding formula  needed to be updated so that it was based on the number of persons  living with HIV. Officials from one HOPWA grantee stated that they  understood the need to update the HOPWA funding formula but had  concerns about potentially losing funding if cumulative HIV cases were  excluded from the formula. As previously discussed, in congressional  budget justifications for fiscal years 2013 through 2015, HUD proposed  updating the funding formula to incorporate local housing costs and  poverty rates. HUD has also proposed increasing the percentage of  HOPWA grant amounts that may be used for administrative expenses  from 3 percent to 6 percent of the grantee’s awarded amount.
Ryan White Part A grantees, subgrantees, and HIV advocacy groups that  we met with noted several strengths and weaknesses of the Ryan White  HIV/AIDS program. For example, three of the four Ryan White Part A  grantees we met with, as well as two HIV advocacy organizations, stated  that the Ryan White HIV/AIDS program complemented the HOPWA  program. Grantee staff told us that persons with HIV could receive  temporary housing assistance through Ryan White Part A and then  transition to permanent assistance through HOPWA. Also, members of  two HIV advocacy groups with whom we met stated that local Ryan White  Part A Planning Councils were beneficial because they identified the  unique, local needs of persons with HIV. Some Ryan White Part A  subgrantees and staff from an HIV advocacy group stated that the  inability to use Ryan White Part A funds for permanent housing  assistance created challenges. For example, the subgrantees told us that  it was generally difficult to address all of the issues that their clients face,  including substance abuse and mental illness, within the 2-year time  frame. As previously noted, HRSA guidance encourages but does not  require grantees to limit housing assistance to 24 months. Additionally,  staff from an advocacy group told us that because the Ryan White Part A  program could fund only temporary housing, recipients of this assistance  were still faced with a lack of stable, permanent housing.

	Federal and Local Agencies Generally Coordinate Their Efforts to Deliver Housing Assistance to Persons with HIV

Responding to the administration’s 2010 National HIV/AIDS Strategy,  HUD and HRSA have made formal and informal efforts to collaborate by  sharing information related to housing for persons with HIV. Coordination  in the delivery of housing assistance to persons with HIV also occurs  extensively at the local level, helping to ensure that the assistance  provided by both programs is complementary and mitigates the potential  for programs to provide duplicative services. Persons with HIV may be  eligible to receive housing assistance from other federal programs, such  as public housing. However, other programs may not be available and  may not provide supportive services.

		HUD and HRSA Have Coordinated to Address the National HIV/AIDS Strategy, Share Information, and Develop Guidance

The White House’s 2010 National HIV/AIDS Strategy and its  Implementation Plan encourage coordination among federal agencies  and between federal agencies and state, territorial, tribal, and local  governments, to achieve a more coordinated response to HIV. To  address the National HIV/AIDS Strategy, HUD, HRSA, and other federal  agencies have taken several steps. First, they have participated in a  federal interagency working group led by the White House Office of  National AIDS Policy. According to the July 2010 National HIV/AIDS  Strategy Federal Implementation Plan, the working group convened to  review public recommendations, assess scientific evidence, and make  recommendations related to the National HIV/AIDS Strategy. Additionally,  in July 2013, an Executive Order established an HIV Care Continuum  Working Group to coordinate federal efforts to improve outcomes  nationally across the HIV care continuum. This group is co-chaired by  the White House Office of National AIDS Policy and HHS. According to  HRSA officials, in September 2014 an HIV Care Continuum Initiative  meeting was held to examine best practices in implementing care  continuum recommendations and to provide agencies with the opportunity  to learn from each other. Staff from HRSA, HUD, and other agencies  attended the meeting. We have found that collaboration is enhanced  when common outcomes are defined, mutually reinforcing strategies are  established, and roles and responsibilities are agreed upon, among other  things. The efforts of HUD and HRSA to work together to help address  the National HIV/AIDS Strategy suggest that they have taken steps to  enhance collaboration.
Second, HUD and HRSA have taken steps to share information. HRSA  officials told us that, as required by statute, HHS issued a report to  Congress in 2012 describing the coordinated efforts at the federal, state,  and local levels to address HIV, including a description of barriers to HIV   According to this report, between 2005 and 2008:  program integration.
HRSA worked with several federal agencies including HUD to  examine case management models and examples of coordinated and  collaborative case management guidelines;
HRSA and HUD participated in the Interagency HIV/AIDS Case  Management Workgroup to develop a set of guidelines around  collaborative or coordinated case management services; and
HUD and CDC collaborated in a study to examine housing assistance  for homeless people with HIV to determine the impact of such  assistance on the progression of their disease and the risk of  transmitting HIV.
HUD and HRSA officials with responsibility for the HOPWA and Ryan  White HIV/AIDS programs told us that they had also met informally to  share information and data on their grantees. For example, in June 2014  staff from both agencies met to discuss data collection that could be  helpful to HUD in assessing the impact of the HOPWA program. During  this meeting, HRSA also discussed the results of efforts that began in  2014 to identify HOPWA and Ryan White HIV/AIDS program grantees  that collected both health and housing indicators. Additionally, HUD and  HRSA are collaborating to provide both remote and onsite technical  assistance to HOPWA grantees and project sponsors on improving  program participants’ access to health care. We have found that  collaboration is enhanced when two or more organizations engage in a  joint activity that is intended to produce more public value than could be  produced when the organizations act alone.
HUD and HRSA also worked together to refine HRSA’s policy related to  the length of time individuals can receive housing assistance through the  Ryan White HIV/AIDS program. In 2008, HRSA issued a policy that  imposed a 24-month cumulative cap on short-term and emergency  housing assistance for recipients of Ryan White HIV/AIDS program  housing assistance, to be effective beginning in March 2010. In  consultation with HUD, HRSA rescinded this policy in February 2010 in  response to feedback from Ryan White HIV/AIDS program grantees and  others that the time limits could negatively impact recipients of the  assistance. Ryan White Part A grantees with whom we met told us that  their clients generally had both substance abuse and mental health  issues that took time to address. They noted that 2 years was not always  sufficient for someone to be able to move out of temporary housing. In  May 2011 HRSA released a final notice that encourages, but does not  require, grantees to limit assistance to 24 months. HUD’s efforts to work  with HRSA on this housing policy are consistent with practices that we  have found can enhance collaboration among federal agencies.

		Different Emphases and Local Coordination Help Ensure That the HOPWA and Ryan White Part A Programs Complement Each Other

Although some overlap exists between the HOPWA and Ryan White  HIV/AIDS programs, different emphases and local coordination help to  ensure that the programs complement rather than duplicate each other.  HOPWA and the Ryan White HIV/AIDS program overlap in the areas of  temporary housing and supportive services for persons with HIV, which  both programs can fund. However, housing assistance for persons with  HIV involves both housing- and health-related issues, and HUD and  HRSA bring different types of expertise to these areas. HUD programs  focus on the provision of housing assistance and HUD awards the bulk of  federal housing-related resources. In contrast, HRSA’s primary focus is to  provide health care for medically vulnerable people, among others.  HRSA’s policy indicates that Ryan White HIV/AIDS program funds can be  used for short-term or emergency housing only to the extent that such  support is necessary for clients to gain or maintain access to medical  care. Additionally, the Ryan White HIV/AIDS Treatment Extension Act of  2009 requires Ryan White HIV/AIDS program grantees to be the payer of  last resort. In order to receive housing assistance through the Ryan White  HIV/AIDS program, individuals must not have HOPWA or other forms of  subsidized housing assistance available to them, even if they are eligible  for the programs. However, they may receive Ryan White HIV/AIDS  program assistance for other needs, such as medical care. The different  program emphases and requirements helps prevent duplication between  these programs.
Coordination among local entities helps ensure that assistance provided  by HOPWA and the Ryan White HIV/AIDS program complement each  other and mitigates the potential for the programs to provide duplicative  services. Coordination in the delivery of housing assistance to persons  with HIV occurs at the local level through formal planning processes. As a  condition of receiving a HOPWA grant, grantees must consult with other  public and private entities, as well as local citizens, in implementing the  HOPWA program and any other HUD Community Planning and  Development grant funds that the community receives. Community  Planning and Development grantees, including HOPWA grantees,  contribute to the development of a consolidated plan and annual action  plans. Through these plans, the grantees must describe the agencies,  groups, and others who participated in the planning process; their  consultations with social service agencies and other entities; and their  activities to enhance coordination between public and assisted housing  providers and private and governmental health, mental health, and  service agencies.
The Ryan White Part A program requires local planning councils to help  facilitate coordination between Ryan White Part A and HOPWA grantees.  As we have seen, the Ryan White HIV/AIDS Treatment Extension Act of  2009 requires planning councils to have members from various groups  and organizations. For instance, at least one-third of the planning council  members must be persons with HIV who receive Ryan White Part A  services and are consumers who do not have a conflict of interest,  meaning that they are not staff, consultants, or board members of Ryan  White Part A ‐funded agencies. The planning council and the grantee  work together to identify the needs of people with HIV and to prepare a  comprehensive plan on how to meet those needs. Both the planning  council and the grantee work together to make sure that other sources of  funding work well with Ryan White HIV/AIDS program funds and that the  Ryan White HIV/AIDS program is the payer of last resort. While the Ryan  White HIV/AIDS Treatment Extension Act of 2009 does not require that  the HOPWA program be represented on planning councils, there is a  requirement that other federal HIV programs be represented on the  council (which could include HOPWA). In addition, the 2015 Part A  funding announcement and 2013 program manual both indicate that the  planning council could include a HOPWA or housing service  representative.
Informal efforts to coordinate the delivery of housing assistance also help  to reduce the potential for duplication. Staff from four Ryan White Part A  subgrantees, which can provide clients with housing assistance for only a  limited period of time, told us that they consistently reached out to local  providers of subsidized housing. These providers may include other city  agencies, nonprofit organizations, and owners of single-room occupancy  hotels. Such coordination efforts could help to minimize the potential for  program duplication.
Coordination between the HOPWA and Ryan White Part A programs  does not appear to require formal agreements and processes when the  same local agency is the grant recipient of both programs. In two of the  four cities we visited, the same city agency was both the formula HOPWA  project sponsor and the Ryan White Part A grantee. As a result,  coordination between the activities funded and efforts to move clients  from temporary to permanent housing occurred through the agencies’  regular business practices. Officials from one of these city agencies  stated that different staff members were dedicated to each program, but  that they worked together and shared information related to clients’ needs  and the services provided. Officials from another city agency said that the  same city staff focused on both HOPWA and Ryan White Part A funds. In  this case, the same staff member reviewed performance information and  invoices from the local HOPWA sponsors and Ryan White Part A  subgrantees.

		Persons with HIV May Be Eligible for Other Housing Programs but May Not Receive Timely or Appropriate Assistance from Them

Persons with HIV may be eligible to receive housing assistance from  other federal programs that are focused on assisting persons with low or  no income, including the following:
Public Housing provides housing aid for eligible low-income families,  the elderly, and persons with disabilities. HUD administers this federal  subsidy to participants of local public housing authorities that manage  the housing for low-income residents at rents they can afford.
The Housing Choice Vouchers program assists very low-income  families, the elderly, and persons with disabilities. Participants may  choose any housing that meets the requirements of the program and  is not limited to units located in subsidized public housing projects.  HUD administers the Housing Choice Voucher program, public  housing agencies manage it.
As we have seen, Continuum of Care is a HUD program that provides  funding to nonprofit providers and state and local governments to  quickly rehouse homeless individuals and families.
Emergency Solutions Grant is a HUD program that provides funding  to state and local governments for emergency shelters and services  for homeless individuals and families. It also provides services to  prevent families from becoming homeless.
The HUD Veterans Affairs Supportive Housing program combines  HUD’s Housing Choice Voucher rental assistance for homeless  veterans with case management and clinical services provided by the  Department of Veterans Affairs.
Home Investment Partnerships Program is a HUD program that  provides formula grants to states and localities to fund a wide range of  activities, including building, buying, or rehabilitating affordable  housing for rent or ownership or providing direct rental assistance to  low-income people.
While these programs have similar goals related to providing housing  assistance, they have varying eligibility requirements (see table 3). For  example, only homeless veterans are eligible for HUD-VASH, and an  individual must be homeless or at risk of homelessness to be eligible for  the Continuum of Care and Emergency Solutions Grant programs.
Housing assistance programs that are not targeted to persons with HIV,  such as Public Housing and the Housing Choice Voucher programs, may  not be able to provide timely assistance because they may not be readily  available. HOPWA and Ryan White Part A grantees from three of the  cities we visited, as well as staff from six organizations that received  funding from these grantees, told us that the local public housing  agencies had very long waiting lists and sometimes closed their Public  Housing and the Housing Choice Voucher programs to new applicants.  Staff from one non-profit agency that receives both HOPWA and Ryan  White Part A funding told us that they require recipients of HOPWA or  Ryan White Part A housing assistance to apply for public housing and the  Housing Choice Voucher programs. However, staff said the local public  housing agency has a long waiting list for both types of housing, and thus  the client would not likely be able to benefit from these programs. Also,  two of the HOPWA grantees with whom we met told us that even though  the local public housing agencies had set up a preference for homeless  persons with HIV, these agencies made few units available through this  preference system.
According to officials from organizations that receive HOPWA and Ryan  White Part A grant funds, housing assistance programs that are not  targeted to persons with HIV, such as public housing and the Housing  Choice Voucher programs, may not be appropriate because they are not  required to provide supportive services. Table 4 shows the kinds of  services these and other housing assistance programs provide, such as  substance abuse or mental health counseling. While not required to do  so, administrators of these programs may help individuals receive  supportive services through other funding sources.
HIV advocates and a researcher told us that providing housing assistance  without necessary medical care or other types of supportive services may  not effectively facilitate housing stability or improved health for persons  with HIV. Several of the organizations that received funding from HOPWA  or Ryan White Part A grantees told us that their clients generally had  mental health and substance abuse issues and would not thrive without  intensive counseling. While some public housing agencies may offer their  public housing residents access to a case manager or a staff member  who can help the resident obtain the services that they need, public  housing agencies are not required to offer this service. Additionally, HIV  positive persons with criminal records or who engage in criminal activity  may not be eligible for public housing and HCVs.HOPWA and Ryan White HIV/AIDS programs can provide housing  assistance to persons with HIV who have criminal records.

	HUD and HRSA Monitor Their Programs but May Be Missing Opportunities to Use Data to Improve Performance

HUD field office staff use a risk-based process to guide their monitoring of  grantees and provided evidence that they had implemented these  procedures. HRSA headquarters staff with primary responsibility for  monitoring Ryan White HIV/AIDS program grants have taken steps to  improve their efforts in recent years. Both HUD and HRSA collect data  from HOPWA and Ryan White HIV/AIDS program grantees, respectively,  including data on the activities funded and clients’ housing status (i.e.,  whether they have stable and permanent housing). HUD summarizes the  data it collects but does not evaluate year-to-year changes in unmet  housing need for individual grantees. HRSA staff with primary  responsibility for monitoring Ryan White Part A grantees assess whether  grantee data are submitted to HRSA on time but are not required to  review the housing-related data submitted. As a result, both programs  may be missing opportunities to use existing data to manage the  programs.

		HUD Field Office Staff Generally Follow Monitoring Policies for Selected Grantees

HUD’s field office staff have primary responsibility for monitoring HOPWA  grantees, and we found that they were generally following monitoring  policies for the four grantees that we visited. Field staff are responsible for  conducting annual risk assessments of all Community Planning and  Development grantees, which include recipients of HOPWA grants. To  conduct these assessments, field staff must adhere to Risk Analysis  Policy Notices and rate each grantee based on specific factors, including  financial factors, the physical condition of projects, and staff capacity,  among others. HUD field office staff use these factors to assess the risk  level for each grantee and assign a numeric score. Grantees with risk  assessments above a certain threshold are to receive onsite monitoring,  unless the local HUD field office determines that the grantee can be  excepted on the basis of additional HUD criteria and consideration of the  field office’s travel and staffing resources.meet with HOPWA sponsor staff and review documentation related to the  sponsor’s implementation of the program. HUD staff may identify findings  that the sponsor is required to address. In conducting site visits, HUD  staff are required to follow specific monitoring guidance related to the  HOPWA program.
During site visits, HUD staff  HUD has documented that it conducted risk assessments and onsite  monitoring visits for formula and competitive HOPWA grantees from fiscal  years 2008 through 2013. For the four formula HOPWA grantees we  visited, HUD’s field office staff conducted 24 risk assessments— one  assessment per year for each of the four HOPWA grants from 2008  through 2013. Nine of the 24 assessments indicated that the HOPWA  grant met HUD’s criteria for triggering onsite monitoring. HUD field office  staff subsequently conducted onsite monitoring for six of these nine  grantees. For the three HOPWA grantees that HUD did not visit for onsite  monitoring, the local HUD field office either did not have the resources to  conduct the review or the site visit was excepted because the grantee  had received a site visit within the previous 2 years, according to HUD.
HUD headquarters monitors HOPWA grantees’ compliance with the  requirement to submit annual performance reports—the CAPER for  formula grantees and the Annual Performance Report for competitive  grantees. These reports include information on the activities funded, client  characteristics, and outcomes related to housing stability, homelessness,  and access to care and support. According to HUD officials and  contractor staff, a contractor sends HOPWA grantees reminders prior to  report deadlines, tracks receipt of the reports, and reviews the reports for  completeness and internal consistency. HUD’s contractor also tracks the  timeliness of the initial submissions of performance reports. According to  the contractor’s data, 93 percent of the CAPERs and Annual Performance  Reports for program year 2013 were submitted within 30 days of their due  date. HUD’s contractor staff told us that they assisted grantees with any  technical difficulties or internal inconsistencies until the report was  submitted and met the contractor’s standards for reliability.

		HRSA Headquarters Staff Monitor Ryan White Part A Grantees and Reported Following Updated Monitoring Policies

HRSA headquarters staff have primary responsibility for routine and  onsite monitoring of Ryan White HIV/AIDS program grantees. Routine  monitoring includes regularly scheduled phone calls and reviews of  grantee reports. The purpose of routine monitoring is to assess grantees’  performance and compliance with statutory requirements, regulations,  and guidance. HRSA staff are also responsible for conducting site visits  with the grantees. Site visits are intended to provide an opportunity to  review the grantee’s program and may serve as a technical-assistance  session for the grantee. HRSA guidance states that site visits should be  viewed as an opportunity to expand on information grantees have  provided in their grant application, reports, and conference calls. During  site visits, HRSA staff meet with grantee staff and may meet with staff  from one or more of the subgrantees to obtain feedback on how the  program is functioning. HRSA staff may also visit various locations at  which subgrantees deliver services and review grantee and subgrantee  program documentation.
HRSA staff with responsibility for the four Ryan White Part A grantees we  visited reviewed risk-related information, conducted monthly monitoring  calls, and provided technical assistance. HRSA staff reviewed single audit  documentation, including risk-related information. Two of the four risk  assessments indicated that the grantees had no major issues, and the  other two showed deficiencies with internal controls. For the latter two,  HRSA determined that these issues did not warrant a restriction in HRSA  funding. HRSA staff also conducted monthly calls to grantees and  summarized the discussions in electronic files. Additionally, HRSA staff  provided technical assistance to Ryan White Part A grantees. For  example, in 2013 HRSA arranged for a consultant to provide on-site  technical assistance to one of the Part A grantees that we visited.
HRSA has increased onsite monitoring visits for Ryan White HIV/AIDS  program grantees in response to our past recommendations. Specifically,  our June 2012 report found that HRSA did not have written guidance  describing its policy for selecting grantees to visit and did not prioritize  site visits in the manner described to us. Moreover, 44 percent of all  grantees did not receive a site visit from 2008 through 2011. We  recommended, among other things, that HRSA develop a strategic, risk- based approach for selecting grantees for site visits to ensure that the  visits were made at regular and timely intervals. HRSA addressed this  recommendation by developing a risk-based approach for selecting  grantees for site visits. Additionally, beginning in 2012, HRSA  implemented a policy that all Part A and Part B grantees would receive  site visits at least once every 5 years and more often if needed. According  to our analysis of HRSA’s Part A site visits through 2013, HRSA staff  conducted site visits to 11 of the 13 Part A grantees that had not been  visited from 2008 through 2012. Additionally, 32 of 53 Eligible  Metropolitan Areas and Transitional Grant Areas received a  comprehensive site visit between July 2012 and July 2013.
HRSA has taken additional steps to address four other recommendations  we made in 2012 to improve oversight of Ryan White HIV/AIDS program  grantees. As of October 2014, all four of these recommendations had  been implemented. The steps taken include the following: improved the functionality of an information system, the Electronic  Handbook, to enable staff to better document their oversight and  monitoring activities, including monthly calls, emails, and technical  assistance; assessed, revised, and updated records management policies for  HRSA staff with primary responsibility for monitoring grantees; created updated program manuals and posted the manuals on  HRSA’s technical assistance website; and updated its monitoring standards and worked with grantees that faced  challenges with implementing the standards.
Additionally, HRSA grantees are responsible for monitoring subgrantees,  which are the organizations that grantees contract with to provide  services to persons with HIV. In 2011 HRSA developed National  Monitoring Standards for Parts A and B of the Ryan White HIV/AIDS  program. These standards are designed to help Ryan White Part A and  Part B grantees meet federal requirements for program and fiscal  management, monitoring, and reporting. The standards were developed  because of the need to establish specific standards governing the  frequency and nature of grantee monitoring of subgrantees and create a  clear role for HRSA staff in monitoring grantee oversight of subgrantees.  HRSA staff with whom we met told us that they used these standards and  expected grantees to use them to monitor subgrantees.

		HUD Collects Performance Data but Does Not Assess Trends in Unmet Housing Need

HUD headquarters staff collect annual performance data from HOPWA  grantees on activities funded; client characteristics; and outcomes related  to housing stability, access to health care, and unmet housing need. As  noted earlier, HUD uses this information to create “performance  profiles”—two-page summaries of this information—for each HOPWA  grantee for each program year. Additionally, HUD creates annual  performance profiles for the formula HOPWA program, the competitive  HOPWA program, and both programs combined. Profiles are not  cumulative—that is, they do not show the total number of clients served  up to a point in time. Rather, the profiles provide data on the clients  served during the previous program year. A HUD contractor posts all of  the performance profiles on a HUD website.
HUD contractors are responsible for collecting Annual Performance  Reports and CAPERs and using the data grantees report to create  performance profiles. The contractors review the data for completeness  and follow up with grantees regarding inconsistencies. According to HUD,  its contractors also identify and document inconsistencies in data using  current and previously submitted data for four areas: access to care, cost  per unit, stability, and administrative costs. The contractors also  document efforts to clarify and correct data related to these issues.  However, HUD’s contractors told us that they do not compare current- year data to prior-year data for unmet housing need. In addition, HUD  field office staff with whom we met stated that they did not compare  grantee data from year to year to identify any potential data reporting  errors.
Our analysis of the unmet housing need data collected through CAPERs  from 2010 through 2013 found that some formula grantees reported  significant changes in the number of HOPWA-eligible persons with an  unmet housing need. For example, HUD data for 2012 indicated that 47  percent of the grantees reported changes of 30 percent or more in the  number of persons with an unmet housing need compared with 2011  numbers. According to HUD’s data, in 2011 one grantee had 145  persons with HIV with unmet housing needs and 525,957 in 2012.  Although changes in these estimates could be the result of increases or  decreases in the need for housing assistance for persons living with HIV,  large annual changes could also signal reporting errors. This and other  examples are shown in table 5.
HUD headquarters officials told us that the dramatic differences could be  the result of a change in the methodology used to report the figure, staff  turnover among grantees, or changes in grantee capacity. Prior to our  review, HUD officials had not followed up with grantees that had reported  significant changes in unmet need between 2010 and 2013. In response  to our review, HUD officials determined that one of the significant  changes in unmet housing need from year to year was the result of a data  entry error made by HUD’s contractor. Although HUD staff have  requirements for reviewing the accuracy of CAPER and Annual  Performance Reports, the requirements do not contain specific  instructions for assessing performance data over time.
Federal internal control standards state that monitoring should assess the  quality of performance over time and that activities need to be established  to monitor performance measures and indicators. These controls could  call for comparisons and assessments so that relationships can be  analyzed and appropriate actions taken. has shown, leading organizations use performance information to identify  gaps in performance, improve organizational processes, and improve  their performance. By not analyzing trends in the unmet housing need  data grantees are required to report, HUD may be missing opportunities  to identify and address problems in grantee reporting. Moreover, by not  following up on significant changes in the unmet housing need data  submitted, HUD may be missing indications that these data for the  program as a whole may not be reliable.
GAO/AIMD-00-21.3.1.

		HRSA Collects Program Data but Does Not Monitor Housing Information

Although HRSA headquarters staff conduct routine monitoring of Ryan  White HIV/AIDS program grantees, they do not focus on housing  information. HRSA staff are responsible for overseeing Ryan White  HIV/AIDS program grantees by routinely monitoring grantees’  performance and compliance with statutory requirements, regulations,  and guidance. Routine monitoring includes regularly scheduled  monitoring calls, reviews of grantee reports, and the provision of technical  assistance to grantees. If during the course of routine monitoring HRSA  staff find that a grantee has not met its program or financial requirements,  the staff are responsible for determining whether the grantee requires  more intensive monitoring. According to HRSA officials, agency staff with  responsibility for monitoring can use resources like the National HIV/AIDS  Strategy indicators to help grantees assess clients’ ability to access HIV  care and treatment. HRSA staff are also responsible for monitoring any  special conditions that are put in place. HRSA staff with responsibilities  related to monitoring are the agency’s primary contact with grantees, and  they are to communicate with their assigned grantees at least monthly.
HRSA’s routine monitoring efforts for the Ryan White HIV/AIDS program  do not focus on housing assistance. For example, monthly monitoring  calls between HRSA staff and grantees generally follow a standard  agenda, and housing is not an agenda item. According to HRSA officials,  housing is included when matters pertaining to housing assistance need  to be discussed. Also, according to HRSA’s 2011 Housing Policy, Ryan  White HIV/AIDS program grantees must provide an individualized written  housing plan to HRSA staff if they request one. The plan must cover each  client who is receiving short-term, transitional, or emergency housing  services. However, the four HRSA staff members we visited who had  responsibility for monitoring the grantees told us that they had never  requested or reviewed individualized housing plans. According to HRSA  officials, documents related to housing are reviewed only if housing needs  are identified as a priority by the grantee and HRSA staff. In addition,  while HRSA staff are responsible for monitoring grantee reports, including  whether RSR reports are submitted to HRSA on time, they are not  required to review or monitor the housing-related data submitted in these  reports.
As noted earlier, federal internal control standards state that activities  need to be established to monitor performance measures and indicators.  These controls could call for comparisons and assessments so that  analysis of the relationships can be made and appropriate actions taken.  Controls should also be aimed at validating the integrity of performance  indicators. In addition, our previous body of work has demonstrated the  importance of using performance management indicators for various  management activities and decision making. We have previously found  that there are five leading practices that can enhance or facilitate the use  of performance information: (1) aligning agency-wide goals, objectives,  and measures; (2) improving the usefulness of performance information;  (3) developing agency capacity to use performance information; (4)  demonstrating management commitment; and (5) communicating  performance information frequently and effectively.
HRSA staff with responsibility for monitoring grantees stated that they did  not focus their monitoring efforts on housing because the primary focus of  the program was medical care and because grantees spend a small  portion of their grant funds on housing assistance. However, as  previously noted the National HIV/AIDS Strategy emphasizes the  importance of stable housing as a means of improving access to medical  care for persons with HIV. The strategy states that access to housing is  an important precursor to getting many people into a stable treatment  regimen and emphasizes the importance of policies that promote access  to housing. By not focusing attention on the housing data that grantees  are required to report, such as housing status, HRSA staff with  responsibility for program monitoring may be missing an opportunity to  improve their management of grantees’ performance. Among other  things, they may not be monitoring an important indicator in the National  HIV/AIDS Strategy—the extent to which grantees are contributing to  housing stability for persons with HIV.

	Conclusions

HIV continues to pose a serious health threat even with advances in  medicine. In order to manage programs that provide housing assistance  for persons with HIV, agencies need to have reliable data and effective  practices for using that data to manage program performance. First,  HUD’s estimate of HOPWA-eligible individuals with an unmet housing  need is based on data that HOPWA grantees develop using varying  methodologies. While HUD advises grantees to use one or more of seven  specific data sources, HUD does not require grantees to use these  sources in a consistent and therefore comparable manner, as suggested  by federal internal control standards and our work on data reliability. HUD  has taken steps toward developing a standard methodology but has not  established time frames for finalizing these efforts. As a result, the  usefulness of HUD’s overall estimate is not clear. Furthermore, Congress  may not have a complete understanding of the continuing need for  programs that provide housing assistance to persons with HIV.
Second, the funding provided under HOPWA has filled important gaps in  the availability of affordable housing in communities throughout the  country. However, the current statutory formula for HOPWA has not kept  pace with the changing nature of the disease. Congress recognized this  shift in the 2000, 2006, and 2009 reauthorizations of the Ryan White  HIV/AIDS program that required HIV case counts to be used in the  distribution of Ryan White HIV/AIDS program funds. While we recognize  that it may not be appropriate to use precisely the same formula for both  HOPWA and the Ryan White HIV/AIDS program, the rationale for  allocating funds on the basis of those currently living with HIV applies to  both grant programs. Because HOPWA funds are awarded based on  cumulative AIDS cases, these funds are not being targeted as effectively  or equitably as they could be.
Third, HRSA relies on housing data reported by Ryan White HIV/AIDS  program grantees to report on its progress in addressing one of the goals  of the National HIV/AIDS Strategy but does not require grantees to  ensure that these data are current. Internal control standards for the  federal government state that events should be promptly recorded to  maintain their relevance and value to management in controlling  operations and making decisions. Without taking steps to ensure that  grantee-reported housing status data are current, HRSA may not have  reliable information to use in reporting on the extent to which Ryan White  HIV/AIDS program clients are reaching the National HIV/AIDS Strategy  goals for attainment of permanent housing.
We also found that HUD had not optimized its use of the performance  information it required HOPWA grantees to collect. While HUD has  processes in place to review the completeness and internal consistency  of each grantee’s annual data submission, HUD has not established  specific procedures to compare the unmet housing need data individual  grantees submit from year to year. The extent to which persons with HIV  have an unmet housing need speaks to the continuing need for the  HOPWA program. Reported data on unmet housing need may vary  significantly, and HUD does not have steps in place to determine if the  local unmet housing need has changed or whether the grantee may need  technical assistance. Without a specific process to make comparisons  among the unmet housing need data individual grantees submit from year  to year, in accordance with federal internal control standards, HUD may  not be able to ensure that significant changes are identified and  addressed if necessary.
Finally, HRSA has missed opportunities to help ensure that HRSA staff  are using all available tools to effectively monitor grantee performance  related to housing. While housing is not the primary objective of the Ryan  White HIV/AIDS program, stable housing is critical to the health of  persons with HIV, as HHS has acknowledged. Internal controls for the  federal government note that activities need to be established to monitor  performance measures and indicators. Moreover, we have reported on  the importance of using performance management indicators for  management activities and decision making. Without requiring HRSA staff  with monitoring responsibility to review the housing data that individual  Ryan White Part A grantees submit, HRSA may not be able to proactively  identify performance issues, including the extent to which individual  grantees are contributing towards housing stability.

	Matter for Congressional Consideration

If Congress wishes HOPWA funding to more closely account for the  current impact of the HIV, it should consider revising the funding formula  used to determine grantee eligibility and grant amounts to reflect a  measure of persons living with HIV, including those with AIDS.

	Recommendations for Executive Action

We make the following four recommendations:
To improve information on the unmet housing needs of persons with  HIV and follow through on its efforts to develop a standard  methodology, we recommend that the Secretary of HUD direct the  Assistant Secretary for Community Planning and Development to  require grantees to use comparable methodologies to analyze HUD’s  recommended data sources on unmet housing need.
In order to improve the reliability of the housing data HRSA collects  from Ryan White HIV/AIDS program grantees, we recommend that  the Administrator of HRSA require program grantees that provide  housing assistance to reflect each client’s current (within the previous  12 months) housing status in the client-level housing status data that  they report to HRSA.
To help ensure that HUD is using grantee performance data to identify  and address any irregularities or issues in grantee reporting, we  recommend that the Secretary of HUD direct the Assistant Secretary  for Community Planning and Development to develop and implement  a specific process to make comparisons between the unmet housing  need data submitted by individual grantees from year to year,  including a process to follow up with grantees when significant  changes are identified.
In order to promote the use of housing assistance data to monitor  program performance, we recommend that the Administrator of HRSA  require the HRSA staff who have primary responsibility for monitoring  Ryan White HIV/AIDS program grants to monitor indicators of  grantees’ performance in contributing towards housing stability, an  HHS-identified indicator of HIV care.

	Agency Comments and Our Evaluation

We provided a copy of this report to HUD and HHS for their review. In its  written comments, which are reprinted in appendix III, HUD agreed with  one of the two recommendations directed toward it and expressed  concerns about the report’s description of the agency’s use of grantee  data. In its written comments, which are reprinted in appendix IV, HHS  agreed with both of our recommendations.
HUD agreed with our recommendation that it require HOPWA grantees to  use comparable methodologies to analyze HUD’s recommended data  sources on unmet housing need. However, the agency said that our  report did not acknowledge the agency’s efforts to provide further  guidance to communities beginning in the first quarter of fiscal year 2014.  We requested documentation of such efforts, but HUD was unable to  provide it. Our report notes that the Consolidated Annual Performance  and Evaluation Reports (CAPER reports) describe the data sources that  grantees can use to estimate unmet need. Our report also acknowledges  an October 2014 meeting between HUD, stakeholders, and HOPWA  grantees to discuss identifying and reporting on unmet housing need as  well as HUD’s efforts to work with a contractor to develop a standard  methodology. While these efforts are helpful steps toward developing a  standard methodology, HUD does not have specific goals or time frames  for finalizing this methodology.
HUD disagreed without our recommendation that it develop and  implement a specific process to make comparisons between the data  submitted by individual grantees from year to year, including a process to  follow up with grantees when significant changes are identified. In its  written response, HUD stated that the agency already conducts this type  of analysis with contractor support. More specifically, HUD stated that  data analysis is conducted using current and previously submitted data.  However, HUD’s documentation of the contractor’s grantee-level analysis  indicates that its trend analysis is focused on four areas: access to care,  cost per unit, stability, and administrative costs. HUD’s documentation of  its contractor’s analysis of data trends among formula grantees does not  include other data elements collected through CAPER reports, including  unmet housing need. Moreover, during the course of our review, HUD’s  contractors told us that they do not assess grantee-level, year-to-year  changes in unmet housing need. Based on our analysis of unmet housing  need data collected from CAPER reports from 2010 through 2013, we  found that some formula grantees reported significant changes in unmet  housing need from year to year. As noted in the report, in response to our  review HUD determined that its contractor had made data entry errors in  some cases. In other cases, HUD had not followed up with the grantee  and stated that dramatic differences could be attributed to a variety of  causes, including grantee staff turnover or changes in grantee capacity.   In addition, staff from the four HUD field offices we visited told us that  they review CAPER reports but do not compare the information grantees  report from year to year. We revised our recommendation to clarify that  we are recommending that HUD analyze year-to-year trends in the unmet  housing need data that individual grantees submit.
HUD also agreed with our matter for congressional consideration.  Specifically, HUD agreed that HOPWA funds are not being targeted as  effectively or equitably as they could be, based on the outdated HOPWA  statute. HUD noted that it has continued to seek congressional action on  a legislative proposal, which includes statutory changes that reflect  advances in both HIV health care and surveillance. Our report  acknowledges HUD’s efforts by discussing its proposal for updating the  formula in its last three budget justifications.
In its general comments, HUD stated that the introductory part of the draft  report (highlights page) would benefit from a more balanced approach to  the discussion of the HOPWA program’s strengths and weaknesses. The  report discusses the strengths of the HOPWA program as part of one of  our research objectives. Additionally, the section of the report that  focuses on coordination describes HUD’s and HRSA’s efforts to  collaborate with one another and provides examples of formal and  informal coordination at the local level to avoid providing duplicative  services. We also revised our highlights page to note that HUD has taken  steps toward developing a standard methodology for grantees to use to  assess unmet housing needs.
In its letter, HUD also provided technical comments, which we addressed  as appropriate. HUD disagreed that it uses unmet housing need data to  justify its HOPWA budget request and to assess the performance of the  program. Regarding the first part of this statement—that HUD uses unmet  housing need data to justify its HOPWA budget request—we did not  make a change to the characterization of HUD’s use of the data in its  budget requests, and our analysis of HUD’s budget requests supports our  characterization. While HUD’s technical comments characterized the  agency’s use of unmet need data in its budget requests as an anecdotal  data point, HUD uses this information to justify the continuing need for the  program.  As an example, HUD’s 2015 budget request notes that 131,164  HIV-positive households had unmet housing needs in the portion of the  budget request that describes why the program is necessary. Regarding  the second part of the statement with which HUD disagreed—that HUD  uses unmet housing need to assess the performance of the program—we  revised the report to state that HUD uses unmet housing need data for  reporting on the performance of the program, rather than assessing the  performance of the program. Specifically, the agency reports this  information to the public not only through budget justification documents,  but also through individual grantee and program-wide performance  reports.
HUD also disagreed with the statement that the agency does not require  HOPWA grantees to use a consistent methodology to calculate unmet  need, and noted that formula grantees are required to report this need  through CAPER reports. Our analysis of CAPER report guidance and  grantees’ implementation of this guidance supports our characterization.  As described in the report, according to CAPER guidance formula  HOPWA grantees can use one or more of seven data sources to  calculate unmet need, including housing providers’ waiting lists. However,  HUD does not provide additional guidance on how these sources should  be analyzed. As a result, grantees could use different methods for  analyzing the same data sources. The report provides examples of how  HOPWA grantees we interviewed use different methodologies to  calculate unmet housing needs.
HUD also disagreed with the statement that agency officials had not  followed up with grantees that had reported significant changes in unmet  housing needs between 2010 and 2013, and stated that contracted  support plays a role in the review and analysis of HOPWA data. Our  report acknowledges contractors’ efforts to review HOPWA data for  completeness and follow up with grantees regarding inconsistencies.  However, our work supports our description of HUD’s efforts to follow up  with grantees that reported significant changes in unmet needs between  2010 and 2013, and therefore we did not make changes. As an example,  our analysis of the unmet need data grantees reported to HUD found that  one grantee reported an unmet need of 145 persons in 2011 and 525,957  persons in 2012. HUD did not research this anomaly until presented with  our analysis. Furthermore, the documentation HUD provided of its follow- up efforts with grantees did not include information about unmet housing  need data.
HHS agreed with our recommendation that HRSA require program  grantees that provide housing assistance to reflect each client’s current  (within the previous 12 months) housing status in the client-level housing  data that they report to HRSA.  In its written comments, HHS also stated  that HRSA does require Ryan White HIV/AIDS program grantees to  maintain current clients’ housing status. As we discuss in the report,  HRSA requires grantees to report data on clients’ housing status to HRSA  every year. However, during the course of our review, HRSA officials told  us that the frequency with which this information is updated is determined  at the local level, and we found that this information may not be current.  In its written comments, HRSA stated that it will update data instructions  and provide a webinar for HRSA monitoring staff and Ryan White  HIV/AIDS program grantees to help ensure that grantees are collecting  data consistently and correctly. These actions, if implemented effectively,  would address the intent of our recommendation.
HHS also agreed with our recommendation that HRSA staff who have  primary responsibility for monitoring Ryan White HIV/AIDS program  grants monitor indicators of grantees’ performance in contributing towards  housing stability. HHS noted that HRSA had taken steps to provide  monitoring staff with reports that show grantee-level data and HHS  indicators. According to HHS, these reports support the monitoring of  performance indicators, including housing status. Additionally, HHS  stated that monitoring staff have begun to be trained on how to interpret  these data. These are positive steps that should help HHS to more  effectively monitor individual grantees’ contributions towards housing  stability. HHS also provided technical comments, which we incorporated  as appropriate.
We are sending copies of this report to the Secretary of Housing and  Urban Development, the Secretary of Health and Human Services, and  interested congressional committees. In addition, the report will be  available at no charge on the GAO website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-8678 or garciadiazd@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs are listed on the last  page of this report. GAO staff who made key contributions to this report  are listed in appendix V.

Appendix I: Scope and Methodology

Our objectives were to discuss (1) the need for housing assistance for  persons with the human immunodeficiency virus (HIV) and the extent to  which federal assistance reaches communities in need; (2) the results  that have been achieved through federal programs that provide housing  assistance for persons with HIV and what is known about the strengths  and weaknesses of these programs; (3) the extent to which federal  programs that provide housing assistance and supportive services for  persons with HIV coordinate with one another; and (4) the extent of  federal oversight of programs that provide housing assistance to persons  with HIV.
To identify information on the housing needs of persons living with HIV,  we obtained and reviewed available data from the Department of Housing  and Urban Development (HUD) on the unmet housing needs of HOPWA- eligible persons for program years 2010 (the earliest year for which HUD  considered the data to be reliable) through 2013 (program year refers to  grantees’ fiscal years, which may vary from the federal fiscal year). To  assess the reliability of this information, we interviewed HUD officials,  conducted electronic testing of the data to identify outliers as well as  missing or duplicated data, and interviewed grantees of HUD’s Housing  Opportunities for Persons with AIDS (HOPWA) program. We compared  HUD’s methodology for calculating unmet housing need to internal control  standards for the federal government, as well as GAO guidance on  preparing reliable data. We determined that HUD’s unmet housing need  data were not sufficiently reliable for the purposes of estimating the  number of HOPWA-eligible individuals with an unmet need because they  were based on data developed by HOPWA grantees using inconsistent  methodologies.
We also analyzed the Centers for Disease Control and Prevention’s  (CDC) fiscal year 2012 HIV surveillance data—the most recent data  available at the time of our review—to identify and describe geographic  trends in persons living with diagnised HIV infections as well as the  demographic characteristics of persons diagnosed with HIV.the reliability of this information, we interviewed CDC officials and  reviewed documentation of CDC’s methodology for collecting the data.  We determined that the data were sufficiently reliable for the purpose of  describing trends in HIV infection. To determine whether the Health  Resources and Services Administration (HRSA) assessed the number of  HIV-infected persons that might need emergency housing assistance, we  reviewed HRSA guidance and interviewed HRSA officials. In addition, we  reviewed requirements for Ryan White Planning Councils to assess local  needs for HIV-related services. To identify the federal programs that  provide housing assistance specifically for persons with HIV, we reviewed  Congressional Research Service, GAO, HUD, and HRSA reports issued  from 1997 through 2014 on housing for persons with HIV and interviewed  HUD and HRSA officials. For HRSA’s Ryan White HIV/AIDS program, we  focused on Part A because it can fund housing assistance; because Part  A grantees expended significantly more of their funding on housing  assistance than Part B grantees in 2011, and because, like HOPWA  grants, Part A grants are generally awarded to local governments.
The MSA delineations are based on the 2000 Office of Management and Budget  Standards for Delineating Metropolitan and Micropolitan Statistical Areas (implemented in  2003). of March 2011. This approach helped ensure that the two data sets were  comparable to one another and corresponded to the data that would have  been available in fiscal year 2012. These data were not adjusted for  reporting delays. According to the CDC, estimates of persons living with  HIV (i.e., HIV prevalence data) in a given year are generally more  accurate when at least 12 months have elapsed since the end of the  measurement period, as both diagnoses and deaths are often subject to  reporting delays. The specific direction of any bias is unclear and may  vary by jurisdiction. For each MSA, we calculated the absolute relative  difference between cumulative AIDS cases and the number of cases of  persons living with HIV (including AIDS). Additionally, we identified  examples of MSAs that had similar numbers of persons living with HIV  but received notably different amounts of HOPWA formula funds for fiscal  year 2012.
We also compared the current HOPWA funding formula to our previous  work that addressed funding grants based on cumulative AIDS cases,  including the deceased.  To describe HUD’s proposed changes to the  HOPWA funding formula, we reviewed HUD’s congressional budget  justifications for fiscal years 2013, 2014, and 2015.
GAO, Housing: HUD’s Program for Persons with AIDS, GAO/RCED-97-62 (Mar. 24,  1997) and HIV/AIDS: Changes Needed to Improve the Distribution of Ryan White CARE  Act and Housing Funds, GAO-06-332 (Feb. 28, 2006). received both HOPWA and Ryan White Part A grants. We used HRSA’s  2011 Ryan White HIV/AIDS program expenditure data to identify grantees  that had spent Ryan White Part A funds on housing assistance. We  compared the locations of the Ryan White Part A grantees that had  funded housing assistance to locations of the formula HOPWA grantees  and selected four cities that had both. We based our selection on grant  size (i.e., grant amounts at either the higher end or middle of the range in  fiscal year 2011), the presence of Ryan White Part A grantees that had  expended Ryan White Part A funds on housing assistance, and  geographic diversity. Based on this analysis, we selected New York City,  New York; New Orleans, Louisiana; San Francisco, California; and St.  Louis, Missouri. In each city, we interviewed officials from the formula  HOPWA grantees and Ryan White Part A grantees; one or more HOPWA  project sponsors; one or more Ryan White Part A subgrantees; the local  HUD field office; the local Continuum of Care grantee; and at least one  HIV advocacy organization. We selected HOPWA project sponsors and  Ryan White Part A grantees based on discussions with grantee staff and  selected advocacy organizations based on information from a national  HIV advocacy organization about active local HIV advocacy  organizations. We also toured housing that was funded through formula  HOPWA funds or Ryan White Part A in each city, including emergency  housing, a permanent housing facility, and a hospice, to see how the  funds had been used. To obtain views on the impact of the HOPWA and  Ryan White HIV/AIDS Programs in rural areas, we also interviewed the  State AIDS Directors for California, Louisiana, Missouri, and New York.
To determine the results that have been achieved through federal  programs that provide housing assistance to persons with HIV, we  obtained and analyzed HOPWA data on how funds were used and client  characteristics for program years 2009 through 2012. To assess the  reliability of the HOPWA data, we interviewed HUD officials and  contractors that had responsibility for processing information about their  data reliability procedures. We also conducted electronic testing for  missing data, outliers, or obvious errors. We found that most data were  reliable for the purposes of describing how funds were used and  identifying the characteristics of the persons who benefitted from housing  assistance. As previously noted, we found that HUD’s data on unmet  housing need were not sufficiently reliable for our purposes.
For the Ryan White HIV/AIDS program, we obtained and reviewed Ryan  White HIV/AIDS Program Services Report (RSR) data for Part A, and for  fiscal years 2010 through 2012. Agency officials told us that 2009 data  were only available in aggregate form and not by Part A grantee. To  assess the reliability of HRSA’s Ryan White Part A data related to  housing assistance, we reviewed HRSA guidance and policies,  interviewed HRSA officials with responsibility for processing the data,  interviewed four HRSA Program Officers, and conducted electronic  testing. We also compared HRSA’s methodology for calculating the  percentage of Ryan White HIV/AIDS program clients who had stable  housing to internal control standards for the federal government. Because  HRSA does not require grantees to regularly update each client’s housing  status, we determined that housing status data were not sufficiently  reliable for our purposes. Also, we obtained and analyzed expenditure  data for both programs. For HOPWA and Ryan White Part A, the most  recent years of expenditure data were 2012 and 2011, respectively. For  HOPWA, we analyzed program data on activities funded (e.g., housing  assistance, housing development, supportive services); types of housing  assistance funded (e.g., tenant-based rental assistance, permanent  facilities); and demographic characteristics (e.g., sex, race, ethnicity, age,  income). For the Ryan White HIV/AIDS program, we analyzed RSR data  on the number and proportion of clients who received housing assistance  through Part A. For those clients who did receive housing assistance, we  analyzed demographic characteristics (sex, race, ethnicity, age, earnings  relative to the federal poverty level).
To describe the strengths of the HOPWA and Ryan White Part A  programs, as well as any weaknesses associated with these programs,  we reviewed program requirements; identified studies through a search of  various databases using keywords such as “HOPWA” and “Ryan White”;  and interviewed a purposive sample of program grantees, HOPWA  project sponsors, and Ryan White Part A subgrantees. We also  interviewed HIV advocates, HUD and HRSA officials with responsibilities  related to the HOPWA and Ryan White HIV/AIDS programs, and an  academic researcher on HIV and housing who had co-authored various  articles on housing for persons with HIV in New York City. Upon  completion of our initial search, we identified eight studies that discussed  the effects of housing assistance programs on persons with HIV. We  reviewed the studies’ methodology, limitations, and conclusions for the  purposes of excluding studies that did not ensure a minimal level of  methodological rigor and excluded two studies. Of the six remaining  studies, two were randomized control trial studies, one was a cross- sectional study, and one used a quasi-experimental design. Two had  weaker research designs but were retained since they were sufficiently  rigorous and, given the limited number of empirical studies on this  subject, provided useful information on the importance of access to  housing for medical outcomes for people living with HIV.
To assess the extent to which the HOPWA and Ryan White Part A  programs coordinated with each other at the federal level, we identified  program requirements in the governing legislation for the HOPWA and  Ryan White HIV/AIDS programs. We also obtained and reviewed  documentation of HUD’s and HRSA’s efforts to coordinate with each  other, interviewed HUD and HRSA officials about these efforts, and  compared the efforts to GAO’s criteria related to coordination and  program overlap.
GAO, Housing Assistance: Opportunities Exist to Increase Collaboration and Consider  Consolidation, GAO-12-554 (Washington, D.C.: Aug. 16, 2012) and Housing Assistance:  An Inventory of Fiscal Year 2010 Programs, Tax Expenditures, and Other Activities,  GAO-12-555SP (Washington, D.C.: Aug. 16, 2012), an E-supplement to GAO-12-554. the list of housing programs. For the five programs, we compared their  primary goals, client eligibility requirements, requirements related to  supportive services, and the specific types of housing assistance that  could be provided. We also discussed whether and how HOPWA and  Ryan White Part A grantees coordinated with these programs during our  site visits to the purposive sample of cities. Additionally, we reviewed the  Catalog of Federal Domestic Assistance program descriptions, program  information from each program’s website, and prior GAO reports to  determine each program’s size, administering agency, and assistance  type. Finally, we interviewed HIV advocacy groups, HOPWA and Ryan  White Part A grantees, HUD and HRSA officials, and an academic  researcher about housing assistance and services for persons with HIV.
To assess HUD and HRSA’s monitoring and oversight efforts, we  identified and reviewed their monitoring policies, procedures, and  guidance. We also interviewed HUD headquarters and field office staff  with responsibilities related to HOPWA grantee monitoring, as well as  HRSA staff who had primary responsibility for monitoring Ryan White Part  A grantees. We compared HUD’s risk assessment policies for program  years 2008 through 2013 to documentation on the implementation of  these procedures for the four HOPWA grantees we visited, including  documentation of risk assessments and site visits conducted. For the  Ryan White HIV/AIDS program, we reviewed the status of five previously  issued GAO recommendations related to program monitoring and  oversight and summarized HRSA’s efforts to address these  recommendations. We also analyzed updated HRSA data on Part A site  visits conducted in 2012 and 2013. Additionally, we interviewed both HUD  and HRSA officials on how they use performance data to monitor  HOPWA and Ryan White Part A grantees. For HOPWA, we reviewed  documentation of HUD’s use of performance data for program years 2009  through 2013. For the Ryan White HIV/AIDS program, we reviewed  published reports on the agency’s use of housing-related performance  data. We compared HUD and HRSA’s monitoring efforts to federal  internal control standards as well as practices that leading organizations  used related to managing for results.
We conducted this performance audit from March 2014 to April 2015 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on the audit objectives.

Appendix II: Relative Difference between Cumulative AIDS Cases and Living HIV Cases

In 2012, the Department of Housing and Urban Development (HUD)  awarded formula Housing Opportunities for Persons with AIDS (HOPWA)  grants to 78 metropolitan statistical areas (MSA), with the most populous  city in each area serving as that area’s formula HOPWA grantee. Formula  grant funding criteria are based on each MSA’s share of cumulative  Acquired Immune Deficiency Syndrome (AIDS) cases. Table 6 shows the  number of cumulative AIDS cases, the number of persons living with  human immunodeficiency virus (HIV), and the relative difference between  these two numbers for each MSA.

Appendix III: Comments from the Department of Housing and Urban Development

Appendix IV: Comments from the Department of Health and Human Services

Appendix V: GAO Contact and Staff Acknowledgments

	GAO Contact

	Staff Acknowledgments

In addition to the contact named above, Paul Schmidt, Assistant Director;  Lisa M. Moore, Analyst-in-Charge; Imoni Hampton, John McGrail, John  Mingus, Roberto Pinero, Jennifer Schwartz, and Jena Sinkfield made key  contributions to this report.

Summary:
Why GAO Did This Study

Over 1.2 million people in the United States are estimated to have HIV, and about 50,000 new infections occur each year. Research has shown that persons with HIV who lack stable housing are less likely to adhere to HIV care. HUD's HOPWA program and HRSA's Ryan White program provide grants to localities that can be used to fund housing and supportive services specifically for persons with HIV.
GAO was mandated to review housing assistance for persons with HIV. This report addresses (1) the need for housing assistance for persons with HIV and the extent to which assistance reaches communities in need, (2) results achieved through HOPWA and Ryan White, and (3) federal oversight of these programs. For both programs, GAO analyzed program data on persons served and outcomes achieved as of 2012, reviewed policies, interviewed agency officials, and visited a non-generalizable sample of four geographically diverse cities that received varying amounts of both HOPWA and Ryan White funding.

What GAO Found

The extent to which persons with human immunodeficiency virus (HIV) need housing assistance is not known, in part because the Department of Housing and Urban Development's (HUD) estimate of the housing needs of persons with HIV, including those with Acquired Immune Deficiency Syndrome (AIDS), is not reliable. HUD does not require Housing Opportunities for Persons with AIDS (HOPWA) grantees to use a consistent methodology to calculate unmet need. The agency has taken steps towards developing a standard methodology, but it has not established time frames for finalizing these efforts. GAO's work on assessing data reliability indicates that data should be consistent. Because HUD does not require grantees to use selected data sources in a consistent manner, the reported information on unmet housing needs of persons with HIV are not comparable across jurisdictions and are not useful and reliable. In addition, the statutory HOPWA funding formula is based on cumulative AIDS cases since 1981, including persons who have died, rather than on current numbers of persons living with HIV (including those with AIDS). This approach has led to areas with similar numbers of living HIV cases receiving different amounts of funding. Because HOPWA funds are awarded based on cumulative AIDS cases, these funds are not being targeted as effectively or equitably as they could be.
Agency data for HOPWA and the Health Resources and Services Administration's (HRSA) Ryan White program indicate most recipients of assistance obtained stable, permanent housing, but Ryan White housing data may have limitations. HRSA, within the Department of Health and Human Services, does not require Ryan White grantees to maintain current data on clients' housing status. However, it uses the data that grantees report to calculate the proportion of clients that have stable housing. HRSA is charged with tracking Ryan White clients' housing status as a part of the White House's National HIV/AIDS Strategy. Federal internal control standards state that events should be promptly recorded to maintain their relevance and value to management in controlling operations and making decisions. Because HRSA does not require grantees to maintain current data on clients' housing status, HRSA's data may be of limited usefulness in tracking the National HIV/AIDS Strategy goal of improving clients' housing status.
HUD and HRSA perform oversight activities but may be missing opportunities to use data to improve performance. HUD staff conduct risk-based monitoring of HOPWA grantees, and HRSA staff have improved monitoring of Ryan White grantees. HUD and HRSA both collect performance data from their grantees and take steps to ensure that the data are complete and submitted in a timely manner. HUD uses performance data to create summaries of program performance but does not have a specific process for comparing individual grantees' year-to-year data for unmet housing need. Federal internal control standards note the importance of such comparisons. By not analyzing these trends, HUD may not be identifying and addressing reporting problems. In addition, HRSA staff responsible for monitoring Ryan White grantees do not review grantee data on housing assistance provided. Federal internal control standards state that activities need to be established to monitor performance measures. By not focusing attention on housing data, HRSA staff with monitoring responsibility are not proactively using available resources to monitor individual grantees' contributions to the National HIV/AIDS Strategy goal of improving clients' housing status.

What GAO Recommends

If Congress wishes HOPWA funding to be more effectively targeted, it should consider revising the funding formula to reflect the number of living persons with HIV. GAO also recommends that (1) HUD require a consistent methodology for estimating unmet housing needs and (2) both HUD and HRSA improve the reliability and use of performance data to manage their programs. HRSA agreed with GAO's recommendations. HUD agreed with the first recommendation but disagreed with the second, stating that it already assesses trends in some program data. GAO clarified that HUD should identify reporting issues by analyzing trends in its unmet housing need data.