PERSONS WITH HIV

Funding Formula for 

Housing Assistance 

Could Be Better 

Targeted, and 

Performance Data 

Could Be Improved

Report to Congressional Committees

April 2015

GAO-15-298

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-15-298, a report to 

congressional committees

April 2015

PERSONS WITH HIV

Funding Formula for Housing Assistance Could Be 

Better Targeted, and Performance Data Could Be 

Improved

Why GAO Did This Study

Over 1.2 million people in the United 

States are estimated to have HIV. 

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, (2) results 

achieved through HOPWA and Ryan 

White, and (3) federal oversight of 

these programs. GAO analyzed 

program data as of 2012, reviewed 

policies, and visited a nongeneralizable sample of four 

geographically diverse cities that 

received both HOPWA and Ryan 

White funding.

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.

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.

View GAO-15-298. For more information, 

contact Daniel Garcia-Diaz at (202) 512-8678 

or garciadiazd@gao.gov. 

 

 

 

 
Page i GAO-15-298 Housing for Persons with HIV 

Letter 1 

Background 5

Estimates of Housing Need for Persons with HIV Are Not Reliable, 

and the HOPWA Formula Does Not Effectively Target Funds 11

HOPWA and Ryan White Part A Provide Stable Housing for 

Persons with HIV, but Some Housing Data May Have 

Limitations 24

Federal and Local Agencies Generally Coordinate Their Efforts to 

Deliver Housing Assistance to Persons with HIV 35

HUD and HRSA Monitor Their Programs but May Be Missing 

Opportunities to Use Data to Improve Performance 44

Conclusions 52

Matter for Congressional Consideration 54

Recommendations for Executive Action 54

Agency Comments and Our Evaluation 55

Appendix I Scope and Methodology 61

Appendix II Relative Difference between Cumulative AIDS Cases and 

Living HIV Cases 69

Appendix III Comments from the Department of Housing and Urban 

Development 72

Appendix IV Comments from the Department of Health and Human Services 79

Appendix V GAO Contact and Staff Acknowledgments 82

Tables

Table 1: Selected Demographic Characteristics of HOPWA Clients 

Who Received Housing Assistance, 2012 27

Contents
Page ii GAO-15-298 Housing for Persons with HIV 

Table 2: Selected Demographic Characteristics of Ryan White 

Part A Clients Who Received Housing Assistance, 

Calendar Year 2012 30

Table 3: Comparison of Selected Eligibility Requirements for 

Selected Housing Assistance Programs 41

Table 4: Comparison of Services Funded Through Selected 

Housing Assistance Programs 42

Table 5: Examples of Potential Problems in Reporting Unmet 

Housing Need Data for Selected Grantees, 2010-2013 49

Table 6: Relative Difference between Cumulative AIDS Cases and 

Living HIV Cases, by Areas that Received Formula 

HOPWA Grants in 2012 69

Figures

Figure 1: Flow of HOPWA and Ryan White HIV/AIDS Program 

Grant Funds and Assistance 10

Figure 2: Rates of Diagnosed HIV Infection by Region, 2012 13

Figure 3: Prevalence Rates of Diagnosed HIV Infection by Region, 

2008–2011 14

Figure 4: Relative Differences in Cumulative AIDS Cases and 

Numbers of Persons Living with HIV, by Metropolitan 

Statistical Area, Fiscal Year 2012 21

Figure 5: HOPWA Expenditures, Program Year 2012 25

Figure 6: Expenditures for Various Types of HOPWA-Funded 

Housing Assistance, Program Year 2012 27

Figure 7: Ryan White Part A Supportive Services Expenditures, 

Fiscal Year 2011 29
Page iii GAO-15-298 Housing for Persons with HIV 

Abbreviations

AIDS acquired immunodeficiency syndrome

CAPER Consolidated Annual Performance and Evaluation Reports

CARE Act Ryan White Comprehensive AIDS Resource Emergency 

Act 

CDC Centers for Disease Control and Prevention

HHS Department of Health and Human Services

HIV human immunodeficiency virus

HOPWA Housing Opportunities for Persons with AIDS

HRSA Health Resources and Services Administration

HUD Department of Housing and Urban Development

HUD-VASH Department of Housing and Urban Development and 

Veterans Affairs Supportive Housing

MSA metropolitan statistical areas

RSR Ryan White HIV/AIDS Program Services Report

This is a work of the U.S. government and is not subject to copyright protection in the 

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Page 1 GAO-15-298 Housing for Persons with HIV 

441 G St. N.W.

Washington, DC 20548

April 16, 2015

Congressional Committees:

The Centers for Disease Control and Prevention (CDC) estimated that as 

of December 2011 more than 1.2 million persons in the United States 

were infected with the human immunodeficiency virus (HIV), which 

causes acquired immunodeficiency syndrome (AIDS).1

House Report 113-136, which accompanied H.R. 2610, Departments of 

Transportation, and Housing and Urban Development, and Related 

Agencies Appropriations Bill, 2014, directed GAO to review the ability of 

federal programs, including HOPWA, to meet the housing needs of 

persons with HIV. This report discusses our final results on (1) the need 

for housing assistance for persons with 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 infection is 

now considered a chronic condition that, in most persons, can be 

effectively managed with regular monitoring and appropriate medical 

care. However, research has shown that homeless or unstably housed 

persons often lack access to primary care and may not use health care 

services appropriately. Housing Opportunities for Persons with AIDS 

(HOPWA), the only federal program targeted specifically to meeting the 

housing needs of persons with HIV, was established within the 

Department of Housing and Urban Development (HUD) under the 

Cranston-Gonzalez National Affordable Housing Act, enacted in 1990. 

Congress appropriated $330 million for the HOPWA program in fiscal 

year 2014. In addition, the Ryan White HIV/AIDS program, administered 

by the Health Resources and Services Administration (HRSA) within the 

Department of Health and Human Services (HHS), may use a small 

portion of funds to support short-term housing for persons with HIV. For 

fiscal year 2014, Congress appropriated $2.3 billion for the Ryan White 

HIV/AIDS program.

 

1

Throughout this report, “persons with HIV” includes both persons with HIV and persons 

with AIDS. As of January 2015, December 2011 was the most recent date for which data 

were available on persons estimated to be HIV positive.
 

Page 2 GAO-15-298 Housing for Persons with HIV 

HIV coordinate with one another; and (4) the extent of federal oversight of 

programs that provide housing assistance to persons with HIV.

To evaluate the need for housing assistance for persons with HIV, we 

reviewed HUD’s housing needs estimates for 2010 (the earliest year for 

which reliable data were available) through 2013 and interviewed HUD 

officials about the methodology for developing them. We determined that 

the HUD data were not reliable for purposes of estimating the number of 

HOPWA-eligible individuals with an unmet housing need. We also 

analyzed CDC data on geographic and demographic trends for persons 

with HIV from 2008 through 2012. Prior to analyzing the CDC data, we 

interviewed CDC officials and reviewed documentation related to the data 

and determined that they were sufficiently reliable for this purpose. To 

identify federal programs that provide housing assistance specifically for 

persons with HIV, we reviewed relevant agency reports and interviewed 

HUD and HRSA officials as well as HIV advocacy organizations. For 

HRSA’s Ryan White HIV/AIDS program, we focused on Part A, the 

component of the program that provides most of the housing assistance.2

To assess the extent to which HOPWA and Ryan White Part A grants 

reach communities in need, we reviewed the funding formulas for each 

program and interviewed HUD and HRSA officials. 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.3

 

2

The Ryan White HIV/AIDS program consists of several programs, called Parts. The 

majority of Ryan White HIV/AIDS program funding for housing assistance has been 

expended through Part A. Throughout this report, when we refer to the “Ryan White 

HIV/AIDS program,” we are referring to the entire program, inclusive of all Parts. We refer 

specifically to Part A as “Ryan White Part A.” 

We also visited a purposive, or nongeneralizable, sample of four cities that met the following criteria: (1) 

included HOPWA formula grantees and Ryan White Part A grantees that 

funded short-term housing assistance; (2) were geographically diverse; 

and (3) had received grant amounts at either the higher end or middle of 

the range of all grants awarded through HOPWA and Ryan White in fiscal 

year 2011 (the most recent year that data were available at the time of 

this analysis). The selected cities were New York City, New York; New 

Orleans, Louisiana; San Francisco, California; and St. Louis, Missouri. In 

3

GAO, Standards for Internal Control in the Federal Government, GAO/AIMD-00-21.3.1

(Washington, D.C.: November 1999) and Assessing the Reliability of ComputerProcessed Data, GAO-09-680G (Washington, D.C.: July 2009).
 

Page 3 GAO-15-298 Housing for Persons with HIV 

each city, we interviewed HOPWA and Ryan White Part A grantees; at 

least one HOPWA project sponsor and at least one Ryan White Part A 

subgrantee; the local HUD field office; the local Continuum of Care 

grantee; and at least one HIV advocacy organization.4

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 2012.5

To assess the extent to which the HOPWA and Ryan White Part A 

programs coordinated with one another at the federal level, we identified 

requirements in the governing legislation for the HOPWA and Ryan White 

HIV/AIDS programs. We also identified the efforts of HUD and HRSA 

officials to coordinate the HOPWA and Ryan White Part A programs 

through interviews with HUD and HRSA staff and documentation reviews. 

We determined 

that HUD’s data on the way funds were used and client characteristics 

were sufficiently reliable for our purposes, based on interviews with HUD 

officials and HUD contractors responsible for processing and testing the 

data. For the Ryan White Part A program, we obtained and reviewed 

Ryan White Services Report data for fiscal years 2010 through 2012. We 

assessed these data by interviewing agency officials and conducting 

electronic testing and found them to be reliable for purposes of reporting 

trends in expenditures and client characteristics. We determined that 

HRSA’s data on housing-related outcomes might not be reliable, as 

discussed further in this report. 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 and studies, 

interviewed a purposive sample of program grantees, HOPWA project 

sponsors and Ryan White Part A subgrantees, and interviewed HIV 

advocates.

 

4

The Continuum of Care program is a HUD program that funds local “Continuums of 

Care,” community-based homeless assistance program planning networks that are 

composed of, among other groups, nonprofit homeless providers, faith-based 

organizations, and state and local governments within the geographic area they operate.

Among other things, the Continuums of Care program is designed to provide funding for 

efforts by nonprofit providers, state and local governments to quickly rehouse homeless 

individuals and families and connect them with mainstream programs.

5

Program year refers to the grantees’ fiscal year, which may vary from the federal fiscal 

year.
 

Page 4 GAO-15-298 Housing for Persons with HIV 

We compared these efforts to key practices related to coordination and to 

GAO criteria on program fragmentation, overlap, and duplication.6

To assess HUD’s and HRSA’s monitoring and oversight efforts, we 

identified and reviewed the relevant monitoring policies, procedures, and 

guidance. For the Ryan White Part A program, we focused on HRSA’s 

monitoring and oversight of Part A grantees’ housing-related activities. 

We also interviewed HUD headquarters and field office officials who have 

responsibilities related to HOPWA grantee monitoring, as well as HRSA 

staff who have primary responsibility for monitoring Ryan White Part A 

grantees. We compared HUD’s risk assessment policies for program 

years 2008 through 2013 to documentation of implementing these 

procedures for the four HOPWA grantees we visited, including 

documentation of risk assessments and site visits. For the Ryan White 

Part A program, we reviewed the status of five previously issued GAO 

recommendations related to program monitoring and oversight and 

analyzed updated HRSA data on site visits conducted in 2012 and 2013.

To 

describe how the HOPWA and Ryan White Part A programs coordinate 

with other programs that can fund housing and supportive services for 

persons with HIV, we identified a selection of six federal programs that 

could provide housing assistance to persons with HIV and compared 

program goals, eligibility requirements, and the services provided. To find 

out whether and how the HOPWA and Ryan White Part A programs 

coordinate with these programs, we interviewed HUD and HRSA officials, 

HOPWA and Ryan White Part A grantees, HOPWA project sponsors, 

Ryan White Part A subgrantees, and local Continuum of Care grantees 

from our purposive sample of four cities.

7

We compared HUD’s and HRSA’s monitoring efforts to federal internal 

control standards.8

 

6

GAO, Managing for Results: Implementation Approaches Used to Enhance Collaboration 

in Interagency Groups, 

We also interviewed both HUD and HRSA officials on 

GAO-14-220 (Washington, D.C.: Feb. 14, 2014) and 2014 Annual 

Report: Additional Opportunities to Reduce Fragmentation, Overlap, and Duplication and 

Achieve Other Financial Benefits, GAO 14-343SP (Washington, D.C.: Apr. 8, 2014). To 

identify criteria related to collaboration, we selected four interagency groups that met our 

key practices for enhancing and sustaining collaboration and identified successful 

approaches. To identify potential fragmentation, overlap, and duplication, we considered 

the extent of potential cost savings, opportunities for enhanced program efficiency or 

effectiveness, and the level of coordination among agency programs, among other factors.

7

GAO, Ryan White Care Act: Improvements Needed in Oversight of Grantees, 

GAO-12-610 (Washington, D.C.: June 11, 2012).

8

GAO/AIMD-00-21.3.1. 
 

Page 5 GAO-15-298 Housing for Persons with HIV 

their use of program data to monitor HOPWA and Ryan White Part A 

grantees. Appendix I provides further details of our scope and 

methodology.

We conducted this performance audit from March 2014 through 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.

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.9

 

9

The White House, National HIV/AIDS Strategy for the United States (Washington, D.C.: 

July 2010).

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.

Background
 

Page 6 GAO-15-298 Housing for Persons with HIV 

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.10 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.11 The other 10 percent of HOPWA’s annual appropriation is set 

aside for grants awarded on a competitive basis.

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 

 

10MSAs are geographic entities delineated by the Office of Management and Budget for 

use by federal statistical agencies in collecting, tabulating, and publishing federal 

statistics.

11Cumulative AIDS case counts reflect all reported cases since the first reported AIDS 

case in 1981, including persons who are deceased. 

HOPWA Program

Ryan White HIV/AIDS 

Program
 

Page 7 GAO-15-298 Housing for Persons with HIV 

HIV and their families.12 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.13

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.

The Ryan White 

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.

14

 

12Pub. L. No. 101-381, 104 Stat. 576 (codified, as amended, at 42 U.S.C. §§ 300ff 

through 300ff-121). The 1990 CARE Act added title XXVI to the Public Health Service Act. 

Unless otherwise indicated, references to the CARE Act refer to current title XXVI. The 

CARE Act programs have been reauthorized by the Ryan White CARE Act Amendments 

of 1996 (Pub. L. No. 104-146, 110 Stat. 1346), the Ryan White CARE Act Amendments of 

2000 (Pub.L. No. 106-345, 114 Stat. 1319), the Ryan White HIV/AIDS Treatment 

Modernization Act of 2006 (Pub. L. No. 109-415, 120 Stat. 2767), and the Ryan White 

HIV/AIDS Treatment Extension Act of 2009 (Pub. L. No. 111-87, 123 Stat. 2885). 

In the 

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 

13Most housing expenditures through the Ryan White HIV/AIDS program have been made 

through Part A, but the program has several other parts. Part B provides grants to states 

and territories to improve the quality, availability, and organization of HIV/AIDS health care 

and support services. Part C provides grants to service providers to fund comprehensive 

primary health care in an outpatient setting for persons with HIV. Part D provides grants to 

service providers to fund family-centered care involving outpatient or ambulatory care for 

women, infants, children, and youth with HIV/AIDS. Part F supports research, technical 

assistance, and access-to-care programs for oral health programs, special programs of 

national significance, and AIDS Education and Training Centers. HRSA’s Minority AIDS 

Initiative provides funding to improve access to HIV/AIDS care and health outcomes for 

disproportionately affected minority populations. 

14Eligible Metropolitan Area and Transitional Grant Area boundaries are based on the 

U.S. Census designation of MSAs. 
 

Page 8 GAO-15-298 Housing for Persons with HIV 

assistance.15 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.16

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.

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.

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 

 

15The expenditure requirements do not include grantee administrative and clinical quality 

management requirements. Core medical services include outpatient and ambulatory 

health care, oral health care, home health care, hospice care, mental health services, 

medical case management, substance abuse services, health insurance premium and 

cost-sharing assistance, and prescription medications, among other things. Whereas 

HOPWA considers supportive services and housing assistance to be separate categories, 

the Ryan White HIV/AIDS program considers housing assistance to fall within supportive 

services necessary to promote effective medical care. 

16HRSA guidance states that short-term or emergency housing is understood as 

transitional in nature. Such assistance cannot be permanent and must be accompanied by 

a strategy to identify, relocate, or ensure that the individual or family is moved to, or 

capable of maintaining, a long-term, stable living situation.

Local Government Role in 

the HOPWA and Ryan 

White HIV/AIDS Programs
 

Page 9 GAO-15-298 Housing for Persons with HIV 

HOPWA activities. The grantees and project sponsors may also contract 

with for-profit entities to provide services associated with their HOPWA 

activities.
 

Page 10 GAO-15-298 Housing for Persons with HIV 

Figure 1: Flow of HOPWA and Ryan White HIV/AIDS Program Grant Funds and Assistance
 

Page 11 GAO-15-298 Housing for Persons with HIV 

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.

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.

According to CDC estimates, there were about 50,000 HIV diagnoses 

each year from 2008 to 2012.17

 

17CDC, HIV Surveillance Report, 2012, vol. 24, November 2014. The most recent CDC 

data available at the time of our review were for calendar years 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 

Estimates of Housing 

Need for Persons 

with HIV Are Not 

Reliable, and the 

HOPWA Formula 

Does Not Effectively 

Target Funds

With the Number of HIV 

Cases Increasing, Stable 

Housing Is Critical
 

Page 12 GAO-15-298 Housing for Persons with HIV 

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 2.18

 

18CDC, HIV Surveillance Report, 2012, p. 7. 
 

Page 13 GAO-15-298 Housing for Persons with HIV 

Figure 2: Rates of Diagnosed HIV Infection by Region, 2012

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 
 

Page 14 GAO-15-298 Housing for Persons with HIV 

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 2011.19

Figure 3: Prevalence Rates of Diagnosed HIV Infection by Region, 2008–2011

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 

 

19At the time of our review, 2011 was the most recent year for which prevalence data were 

available.
 

Page 15 GAO-15-298 Housing for Persons with HIV 

American Indian/Alaska natives and Asians, while decreasing for AfricanAmericans, 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.20

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 

or remain connected to medical care.

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.

21 In addition, the National HIV/AIDS 

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.22

 

20In 2012, the rates per 100,000 population were 19 for Hispanics/Latinos, 17 for persons 

of multiple races, 15 for Native Hawaiians/other Pacific Islanders, 10 for American 

Indians/Alaska Natives, 7 for white persons, and 6 for Asians. 

Research has also indicated that persons with HIV who live in stable 

21Viral suppression means having very low levels of HIV in the body. Achieving viral 

suppression greatly reduces the chance of transmitting the virus. 

22Angela A. Aidala, Gunjeong Lee, David M. Abramson, Peter Messeri, and Anne Siegler. 

“Housing Need, Housing Assistance, and Connection to HIV Medical Care,” AIDS 

Behavior 11 (June 2007). 
 

Page 16 GAO-15-298 Housing for Persons with HIV 

housing have better health outcomes than those who are homeless or 

unstably housed.23

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.24

We identified HOPWA and the Ryan White HIV/AIDS program as the only 

two federal programs that target housing assistance to persons with HIV. 

According to a recent study related to housing assistance and HIV, about 

1 in 10 persons with HIV were receiving housing assistance from HOPWA 

or the Ryan White HIV/AIDS program in 2010.

As result, there is a greater likelihood of 

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.

25 According to studies we 

reviewed, there continues to be a need for housing assistance for 

persons with HIV, despite advances in drug therapies.26

 

23Daniel P. Kidder, Richard J. Wolitski, Michael L. Campsmith, and Glenn V. Nakamura, 

“Health Status, Health Care Use, Medication Use, and Medication Adherence Among 

Homeless and Housed People Living with HIV/AIDS,” American Journal of Public Health 

97 (December 2007).

Several staff 

24Aidala and others, “Housing Need.” 

25Mathematica Policy Research (Margaret Hargreaves and Vanessa Oddo) and The 

Cloudburst Group (Lindsey Stillman, Jonathan Sherwood, and Steven Sullivan), prepared 

for the Dept. of Health and Human Services, Analysis of Integrated HIV Housing and Care 

Services, Mathematica Policy Research, Ref. no. 40148.400 (Cambridge, Mass.: February 

2014).

26David Buchanan, Romini Kee, Laura S. Sadowski, and Diana Garcia, “The Health 

Impact of Supportive Housing for HIV-Positive Homeless Patients: A Randomized 

Controlled Trial”, American Journal of Public Health 99, No. S3 (2009); Richard J. Wolitski, 

Daniel P. Kidder, Sherri L. Pals, Scott Royal, Angela Aidala, Ron Stall, David R. 

Holtgrave, David Harre, and Cari Courtenay-Quirk, prepared for the Dept. of Health and 

Human Services and the Centers for Disease Control and Prevention,”Randomized Trial 

of the Effects of Housing Assistance on the Health and Risk Behaviors of Homeless and 

Unstably Housed People Living with HIV,” AIDS Behavior (December 2009).
 

Page 17 GAO-15-298 Housing for Persons with HIV 

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’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 

HUD Does Not Reliably 

Estimate the Extent of 

Housing Needs among 

Persons with HIV
 

Page 18 GAO-15-298 Housing for Persons with HIV 

being discharged with HIV and housing providers’ waiting lists.27

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.

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.

28 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.29 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.30

 

27HUD’s guidance suggests grantees use data from housing planning coordination efforts 

such as the Continuum of Care program, client information within Homeless Management 

Information Systems, data from project sponsors including waiting lists, data from local 

prisons on those being released, data from Ryan White Planning Councils, and data from 

HIV/AIDS surveillance reports, such as those from CDC. 

Because HUD does not require grantees to 

use selected data sources in a consistent manner, the resulting 

28GAO-09-680G. 

29GAO/AIMD-00-21.3.1. 

30GAO, Housing: HUD’s Program for Persons With AIDS, GAO/RCED-97-62 

(Washington, D.C.: Mar. 24, 1997).
 

Page 19 GAO-15-298 Housing for Persons with HIV 

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.

As previously discussed, 90 percent of HOPWA funds are awarded 

through formula grants to eligible states and MSAs.31 Seventy-five 

percent of these formula-based funds are awarded to cities and states 

that meet certain threshold criteria.32

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.

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.

33

 

31The remaining 10 percent is awarded through competitive grants to (1) jurisdictions that 

are not eligible for formula funding and (2) states, local government, or nonprofit entities 

that propose “special projects of national significance.” 

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.

32The remaining 25 percent is allocated to cities that meet the threshold criteria in 

amounts that are based on the rate of new AIDS cases (not the number of cumulative 

AIDS cases).

33For the MSAs that received HOPWA funds in 2012, the median grant amount was 

$900,656. 

The HOPWA Formula 

Does Not Target Funds 

Based on Persons Living 

with HIV
 

Page 20 GAO-15-298 Housing for Persons with HIV 

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 2012.34 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.35 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.36

 

34The (absolute) relative difference is measured as a ratio of the absolute difference 

between the two measures to the number of cumulative AIDS cases, expressed as a 

percentage for areas that received a formula HOPWA grant in 2012. We use absolute 

value because some MSAs have a higher number of cumulative AIDS cases than living 

HIV cases, while for other MSAs the reverse is true. This value is a measure of closeness 

between the cumulative number of AIDS cases and the number of persons living with HIV, 

and is always greater than or equal to zero. The lower the value, the more similar the 

number of cumulative AIDS cases is to the number of persons living with HIV in a given 

MSA. In 58 of the 78 MSAs that received formula HOPWA funding in 2012, the relative 

difference between cumulative AIDS cases and living HIV cases was 10 percent or higher.

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.

35The MSA associated with New York City includes New York City, Northern New Jersey, 

and Long Island.

36The Charlotte, North Carolina MSA includes Charlotte, North Carolina; Gastonia, North 

Carolina, and Concord, South Carolina. 
 

Page 21 GAO-15-298 Housing for Persons with HIV 

Figure 4: Relative Differences in Cumulative AIDS Cases and Numbers of Persons Living with HIV, by Metropolitan Statistical 

Area, Fiscal Year 2012

Notes: CDC data on cumulative AIDS cases and persons living with HIV (including AIDS) are as of 

March 2011 (the most recent comparable data available as of January 2015). Appendix I provides 

additional information about the data. The relative difference is measured as ratio of the absolute 

difference between the two measures to the number of cumulative AIDS cases.

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 
 

Page 22 GAO-15-298 Housing for Persons with HIV 

cases.37

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.

We also noted that the general principle of allocating grants on 

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.

38

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.

Congress changed 

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.

 

37GAO/RCED-97-62. 

38GAO, HIV/AIDS: Changes Needed to Improve the Distribution of Ryan White CARE Act 

and Housing Funds, GAO-06-332 (Washington, D.C.: Feb. 28, 2006). 
 

Page 23 GAO-15-298 Housing for Persons with HIV 

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.
 

Page 24 GAO-15-298 Housing for Persons with HIV 

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.39 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 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 5.40

 

39For the HOPWA program, HUD defines extremely low income as household earnings of 

0-30 percent of area median income (AMI), very low income as household earnings of 31-

50 percent of AMI, and low income as 51-80 percent of AMI.

The total number of persons with HIV 

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.

40HOPWA grantees generally have 3 years to expend obligated funds. Thus, expenditures 

for 2012 likely include HOPWA grant funds awarded in 2010, 2011, and 2012. 

HOPWA and Ryan 

White Part A Provide 

Stable Housing for 

Persons with HIV, but 

Some Housing Data 

May Have Limitations

HOPWA Grantees Have 

Primarily Funded Housing 

Assistance
 

Page 25 GAO-15-298 Housing for Persons with HIV 

Figure 5: HOPWA Expenditures, Program Year 2012

Note: Percentages may not total to 100 percent due to rounding.

The funds HOPWA grantees spent on housing assistance fell into several 

categories.

• Tenant-based rental assistance. As shown in figure 6, 51 percent was 

spent on tenant-based rental assistance, which pays the difference 

between the HUD published Fair Market Rent and the tenant’s portion 

of the rent. Through tenant-based rental assistance, a HOPWA 

grantee or project sponsor makes rental subsidy payments directly to 

property owners or property management agencies.

• Operating subsidies for permanent facilities. About 25 percent of 

funds was spent on operating subsidies for permanent facilities. 

Operating subsidies pay for housing expenses, including utilities, 

maintenance, equipment, insurance, security, furnishings, supplies, 

and salary for housing project staff.
 

Page 26 GAO-15-298 Housing for Persons with HIV 

• Short-term rent, mortgage, and utility assistance. About 11 percent of 

housing expenditures went to short-term rent, mortgage, and utility 

assistance. This support is time-limited housing assistance that is 

intended to prevent homelessness and increase housing stability. In 

order to receive assistance, a client must be currently housed, must 

document the legal right to occupy the premises (or responsibility for 

the utility payment), and must show documentation proving that he or 

she lacks the resources to meet rent, mortgage, or utility payments.

The remainder of housing-related expenditures provided operating 

subsidies for facilities that offered short-term housing (10 percent); 

permanent housing placement services, including identifying available 

units and working with private landlords (2 percent); and capital funding 

for the development of facilities that provided either permanent or shortterm housing (1 percent). The amounts of HOPWA housing assistance 

provided for the categories shown in figure 6 have generally been similar 

from 2009 through 2012.41

 

41HUD did not have 2009 or 2010 data on dollars expended on permanent housing 

placement services. Expenditures for tenant-based rental assistance increased from about 

$95 million in 2009 to nearly $108 million in 2012.
 

Page 27 GAO-15-298 Housing for Persons with HIV 

Figure 6: Expenditures for Various Types of HOPWA-Funded Housing Assistance, 

Program Year 2012

HOPWA program data for 2012 indicate that the majority of the nearly 

56,000 clients that received housing assistance were African-American 

and extremely low-income. Table 1 summarizes selected demographic 

characteristics of persons who received housing assistance through 

HOPWA in 2012.

Table 1: Selected Demographic Characteristics of HOPWA Clients Who Received 

Housing Assistance, 2012

Demographic Characteristic Percentage of Clients

Sex 

Male 63%

Female 36%

Transgender 2%

Race

African-American 54%
 

Page 28 GAO-15-298 Housing for Persons with HIV 

Demographic Characteristic Percentage of Clients

White 37%

All other 10%

Ethnicity 

Hispanic or Latino 17%

Non-Hispanic or Latino 83%

Income

Low income 5%

Very low income 15%

Extremely low income 79%

Source: GAO Analysis of HOPWA program data for formula and competitive grantees. | GAO-15-298

Note: Percentages may not total to 100 percent due to rounding. The table includes demographic 

information for those clients for whom this information was recorded.

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.42 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 

supportive services (including housing assistance).43

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 

Expenditures for the 

Ryan White Part A program also reflect the priorities established by Ryan 

White Part A Planning Councils.

 

42In 2011, Part A grantees spent $5.7 million from the prior fiscal year’s carryover funds 

and about $587 million from 2011 funding. Expenditures for fiscal year 2011 were the 

most recently available data at the time of our review.

43Ryan White HIV/AIDS program-funded supportive services include nonmedical case 

management, food bank/home delivered meals, health education/risk reduction, 

transportation services, psychosocial support, child care, pediatric development 

assessment, emergency financial assistance, housing services, legal services, linguistic 

services, outreach services, permanency services, rehabilitation services, respite 

services, residential substance abuse services, and treatment adherence counseling.

Ryan White Part A 

Grantees Spent a Small 

Share of Supportive 

Services Funds on 

Housing in 2011
 

Page 29 GAO-15-298 Housing for Persons with HIV 

management, emergency financial assistance, food bank/home-delivered 

meals, and health education.

Figure 7: Ryan White Part A Supportive Services Expenditures, Fiscal Year 2011

Ryan White Part A data for calendar year 2012 indicate that the majority 

of the 13,556 clients who received housing assistance were AfricanAmerican. The data also indicate that the majority of clients who received 

housing assistance had incomes at or below the federal poverty level.44

 

44The Census Bureau publishes poverty thresholds—dollar-value benchmarks for 

determining poverty status—and HHS provides poverty guidelines, which are derived from 

the poverty thresholds. The approaches used to determine these poverty measures affect, 

respectively, poverty population statistics and income eligibility of individuals and families 

for certain need-based federal assistance. If a family’s income is less than the assigned 

threshold, the family and each of its members is considered to be in poverty.

Table 2 summarizes selected demographic characteristics of persons 

who received housing assistance through Ryan White Part A in calendar 

year 2012.
 

Page 30 GAO-15-298 Housing for Persons with HIV 

Table 2: Selected Demographic Characteristics of Ryan White Part A Clients Who 

Received Housing Assistance, Calendar Year 2012

Demographic Characteristic Percentage of Clients

Sex 

Male 67%

Female 32%

Transgender 2%

Race

African-American 54%

White 33%

Other or race not reported 13%

Ethnicity

Hispanic or Latino 19%

Non-Hispanic or Latino 80%

Unreported 2%

Earnings Relative to Federal Poverty Level

Equal to or below 65%

Between 101 and 200 percent 18%

201 percent or more 6% 

Not reported 12% 

Source: GAO analysis of Ryan White Services Report data for Part A, calendar year 2012. | GAO-15-298

Note: Percentages may not total to 100 percent due to rounding.

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 housing45

 

4551 percent of these individuals were chronically homeless.

HOPWA and Ryan White 

Information Suggest 

Positive Outcomes in 

Housing Stability, but Ryan 

White Data May Have 

Limitations
 

Page 31 GAO-15-298 Housing for Persons with HIV 

Additionally, HUD’s 2013 Performance Report indicates that the HOPWA 

program has contributed to the agency’s goal of preserving affordable 

rental housing.46 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.47

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.

HOPWA officials noted that the HOPWA 

program helped to keep persons with HIV from becoming homeless.

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.48

 

46HUD, FY 2013 Annual Performance Report and FY 2015 Annual Performance Plan

(Washington, D.C.: July 2014). 

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.

47HUD, Strategic Plan 2014-2018 (Washington, D.C.: April 2014). 

48The White House, Office of National AIDS Policy, National HIV/AIDS Strategy: 

Improving Outcomes: Accelerating Progress along the HIV Care Continuum (December 

2013). Other indicators include lowering new HIV infections, increasing knowledge of HIVpositive status, reducing HIV transmission rates, increasing the linkage of newly 

diagnosed persons to HIV medical care, increasing the percentage of Ryan White 

program clients in continuous care, and increasing viral suppression among males who 

have sex with males, African-Americans, and Latinos.
 

Page 32 GAO-15-298 Housing for Persons with HIV 

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.49

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.

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.

50

 

49The National HIV/AIDS Strategy indicator is calculated based on all Ryan White 

HIV/AIDS program clients with a reported housing status (not just clients assisted through 

Part A). The RSR collects housing status data for clients that received outpatient 

ambulatory medical care, medical case management, nonmedical case management, and 

housing services. 

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 

50GAO/AIMD-00-21.3.1. 
 

Page 33 GAO-15-298 Housing for Persons with HIV 

not be as accurate and current as possible if they are not updated 

regularly. 

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 

Stakeholders Cite 

Strengths and 

Weaknesses of Programs 

That Provide Housing 

Assistance for Persons 

with HIV
 

Page 34 GAO-15-298 Housing for Persons with HIV 

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.
 

Page 35 GAO-15-298 Housing for 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.

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.51 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.52 This group is co-chaired by 

the White House Office of National AIDS Policy and HHS.53

 

51The White House, National HIV/AIDS Strategy for the United States, July 2010 and 

National HIV/AIDS Strategy: Federal Implementation Plan, July 2010.

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 

52Executive Order 13569: Accelerating Improvements in HIV Prevention and Care in the 

United States through the HIV Care Continuum Initiative, July 15, 2013.

53Members of the working group include the Department of Justice, the Department of 

Labor, the Department of Veterans Affairs, HUD, and the Office of Management and 

Budget.

Federal and Local 

Agencies Generally 

Coordinate Their 

Efforts to Deliver 

Housing Assistance 

to Persons with HIV

HUD and HRSA Have 

Coordinated to Address 

the National HIV/AIDS 

Strategy, Share 

Information, and Develop 

Guidance
 

Page 36 GAO-15-298 Housing for Persons with HIV 

when common outcomes are defined, mutually reinforcing strategies are 

established, and roles and responsibilities are agreed upon, among other 

things.54

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 

program integration.

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.

55

• HRSA worked with several federal agencies including HUD to 

examine case management models and examples of coordinated and 

collaborative case management guidelines;

According to this report, between 2005 and 2008:

• 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; and56

• 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.57

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 

 

54GAO-14-220. 

55Section 2681(b) of the Public Health Service Act (codified at 42 U.S.C. § 300ff-81(b)). 

As of February 2015, HRSA’s draft Report to Congress on the Coordination of Federal 

HIV Programs, 2009-2013, was undergoing the agency’s internal clearance process.

56In 2008, the workgroup developed recommendations for case management 

collaboration in federally funded HIV/AIDS programs. 

57Wolitsky and others, “Randomized Trial of the Effects of Housing Assistance.” 
 

Page 37 GAO-15-298 Housing for Persons with HIV 

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.

58

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.59

 

58GAO-06-15. 

59GAO-06-15. 
 

Page 38 GAO-15-298 Housing for Persons with HIV 

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.60

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 

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.

 

60Since March 2011, GAO has issued annual reports addressing fragmentation, overlap, 

and duplication across the federal government. In these reports, we define fragmentation 

as occurring when more than one agency is involved in the same broad area of national 

need. We define overlap as occurring when multiple agencies or programs have similar 

goals, engage in similar activities or strategies to achieve them, or target similar 

beneficiaries. Finally, we define duplication as occurring when two or more agencies or 

programs are engaged in the same activities or provide the same services to the same 

beneficiaries. For more information on GAO’s work on fragmentation, overlap, and 

duplication in the federal government, see GAO 14-343SP; GAO, 2013 Annual Report: 

Actions Needed to Reduce Fragmentation, Overlap, and Duplication and Achieve Other 

Financial Benefits, GAO-12-279SP (Washington, D.C.: Apr. 9, 2013); 2012 Annual Report: 

Opportunities to Reduce Duplication, Overlap and Fragmentation, Achieve Savings, and 

Enhance Revenue, GAO-12-342SP (Washington, D.C.: Feb. 28, 2012); and Opportunities 

to Reduce Potential Duplication in Government Programs, Save Tax Dollars, and 

Enhance Revenue, GAO-11-318SP (Washington, D.C.: Mar. 1, 2011). 

Different Emphases and 

Local Coordination Help 

Ensure That the HOPWA 

and Ryan White Part A 

Programs Complement 

Each Other
 

Page 39 GAO-15-298 Housing for Persons with HIV 

services.61 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.62

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 

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.

 

61GAO has previously noted that interagency mechanisms or strategies to coordinate 

programs that address crosscutting issues may reduce potentially duplicative, 

overlapping, and fragmented efforts. See GAO, Managing for Results: Key Considerations 

for Implementing Interagency Collaborative Mechanisms, GAO-12-1022 (Washington, 

D.C.: Sept. 27, 2012), and Managing For Results: GPRA Modernization Act 

Implementation Provides Important Opportunities to Address Government Challenges, 

GAO-11-617T (Washington D.C.: May 10, 2011). 

62CPD grants include HOPWA, HOME Investment Partnerships Program, Emergency 

Solutions Grants, and Community Development Block Grants.
 

Page 40 GAO-15-298 Housing for Persons with HIV 

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 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 

Persons with HIV May Be 

Eligible for Other Housing 

Programs but May Not 

Receive Timely or 

Appropriate Assistance 

from Them
 

Page 41 GAO-15-298 Housing for Persons with HIV 

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.

Table 3: Comparison of Selected Eligibility Requirements for Selected Housing Assistance Programs

Income restricted HIV positive Homeless or at risk of homelessness Veteran

HOPWA x x 

Ryan White HIV/AIDS Program (Part A) x a

Public Housing x 

Housing Choice Vouchers x 

Continuum of Care x x 

Emergency Solutions Grant x x 

HUD-VASH x x x 

HOME Investment Partnerships Program x 
 

Page 42 GAO-15-298 Housing for Persons with HIV 

Source: GAO analysis of agency information. | GAO-15-289. 

a

Individual grantees establish their Ryan White HIV/AIDS program income requirement and the 

program must be the payer of last resort.

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.

Table 4: Comparison of Services Funded Through Selected Housing Assistance 

Programs

Must provide

supportive 

services

Funds 

temporary 

housing

Funds 

permanent 

housing

HOPWA x x a x e

Ryan White HIV/AIDS Program (Part A) x b f

Public Housing x 

Housing Choice Vouchers x 
 

Page 43 GAO-15-298 Housing for Persons with HIV 

Must provide

supportive 

services

Funds 

temporary 

housing

Funds 

permanent 

housing

Continuum of Care x x c x 

Emergency Solutions Grant x x d g

HUD-VASH x x 

Source: GAO analysis of agency information. | GAO-15-298

Note: Temporary housing provides stability and support for a limited time and is not intended to be 

used for long-term occupancy. In contrast, permanent housing is intended for long-term occupancy 

and does not limit the length of stay.

a

Supportive services must be provided as a part of any HOPWA housing assistance, but HOPWA 

funds may also be used to provide services independently of any housing activity.

b

Up to 25 percent of Ryan White HIV/AIDS (Part A) funding may be used for supportive services 

without a waiver.

c

Supportive services are required in connection with certain housing that the grant recipient may offer. 

For example, for a transitional housing project (whose purpose is to facilitate the movement of 

homeless individuals and families into permanent housing within 24 months), supportive services 

must be made available to residents throughout the duration of their residence in the project.

d

If the grant recipient offers “street outreach”(reaching out to unsheltered homeless individuals and 

families), it must offer essential services at least for the period during which the Emergency Solutions 

Grant funds are provided. For this component, essential services include case management, 

emergency health and mental health services, and transportation. Similarly, if the grant recipient uses 

its grant funds solely to provide essential services to homeless individuals and families in homeless 

shelters, it must provide the services at least for the period during which the funds are provided. For 

this component, essential services include case management, child care, and education services.

e

HOPWA can fund short-term rent, mortgage, and utility assistance for up to 21 weeks in any 52-

week period.

f

A May 2011 HRSA policy notes that HRSA housing assistance is intended to be transitional in nature 

and cannot be permanent.

g

The Emergency Solutions Grant program can be used to fund the development of shelters for 

homeless individuals and families, improve existing shelters, subsidize the costs of operating the 

shelters, and provide supportive services.

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 
 

Page 44 GAO-15-298 Housing for Persons with HIV 

may not be eligible for public housing and HCVs.63

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.

In contrast, both the 

HOPWA and Ryan White HIV/AIDS programs can provide housing 

assistance to persons with HIV who have criminal records.

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.64

 

6324 CFR §960.203, §960. 204, §982.553.

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 

64HUD field staff conduct risk assessments of and produce a numerical score for each 

Community Planning and Development grant that a grantee receives. All of the scores are 

averaged to create a total score for the grantee. Scores are based on a 100-point rating 

scale and are used to place grantees into one of three risk categories: high risk (a total 

score of 51 or more); medium risk (between 30 and 50); and low risk (less than 30). 

HUD and HRSA 

Monitor Their 

Programs but May Be 

Missing Opportunities 

to Use Data to 

Improve Performance

HUD Field Office Staff 

Generally Follow 

Monitoring Policies for 

Selected Grantees
 

Page 45 GAO-15-298 Housing for Persons with HIV 

field office’s travel and staffing resources.65

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.

During site visits, HUD staff 

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.

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.

 

65Any grantee with an average risk score of 51 or higher or a single program score of 51 

or higher is subject to onsite monitoring unless the grant meets the allowable exceptions 

that are noted in HUD’s Risk Analysis Policy Notices.
 

Page 46 GAO-15-298 Housing for Persons with HIV 

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.66 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.67

 

66The Single Audit Act as amended, 31 U.S.C. §§ 7502 et seq., requires states, local 

governments, and nonprofit organizations expending $500,000 or more in federal awards 

in a year to obtain an audit in accordance with the requirements set forth in the act. A 

single audit consists of (1) an audit and opinions on the fair presentation of the financial 

statements and the Schedule of Expenditures of Federal Awards; (2) gaining an 

understanding of and testing internal control over financial reporting and the entity’s 

compliance with laws, regulations, and contract or grant provisions that have a direct and 

material effect on certain federal programs (i.e., the program requirements); and (3) an 

audit and an opinion on compliance with applicable program requirements for certain 

federal programs. We refer to these audits as single audits—they are also commonly 

referred to as A-133 audits. See Office of Management and Budget Circular No. A-133.

Requirements for single audits are currently found at 2 C.F.R. Part 200, Subpart F.

HRSA staff also conducted monthly calls to grantees and 

summarized the discussions in electronic files. Additionally, HRSA staff 

67One grantee’s single audit report did not include findings specific to its HRSA award, so

HRSA determined that the entity did not warrant a drawdown restriction or corrective 

action. HRSA required that the other grantee take corrective action to address the internal 

control findings.

HRSA Headquarters Staff 

Monitor Ryan White Part A 

Grantees and Reported 

Following Updated 

Monitoring Policies
 

Page 47 GAO-15-298 Housing for Persons with HIV 

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 2011.68

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.

We 

recommended, among other things, that HRSA develop a strategic, riskbased 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.

69

• 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;

The steps taken include the following:

 

68GAO, Ryan White Care Act: Improvements Needed in Oversight of Grantees, 

GAO-12-610 (Washington, D.C.: June 11, 2012).

69We recommended that the Administrator of HRSA (1) ensure that the agency was 

implementing key elements of grantee oversight consistent with agency guidance; (2) 

assess and revise its record retention program; (3) update and maintain a program 

manual for grantees; and (4) use the results of HRSA’s survey of grantees to identify 

grantees’ training needs. 
 

Page 48 GAO-15-298 Housing for Persons with HIV 

• 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 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.70

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 

 

70See https://www.hudexchange.info/manage-a-program/hopwa-performance-profiles/. 

HUD Collects 

Performance Data but 

Does Not Assess Trends

in Unmet Housing Need
 

Page 49 GAO-15-298 Housing for Persons with HIV 

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 currentyear 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.71

Table 5: Examples of Potential Problems in Reporting Unmet Housing Need Data for

Selected Grantees, 2010-2013

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.

2010 2011 2012 2013

Grantee A 121 145 525,957 2,000

Grantee B 721 1,271 8,000 3,901

Grantee C 267 367 3,337 0 

Source: HUD summary of data submitted by HOPWA grantees. | GAO-15-298

Notes: In response to our review, HUD officials determined that the unmet need data for Grantee A 

had been incorrectly recorded by HUD’s contractor. According to HUD, this grantee reported that the 

numbers of HIV-positive persons with an unmet housing need were 145, 175, 2,000, and 200 in 2010, 

2011, 2012, and 2013, respectively. The data presented here reflect Grantee A’s data as it was 

originally recorded and provided to GAO. Grantee C reported that zero persons had an unmet 

housing need in 2013.

 

71Changes from 2011 to 2012 include both increases and decreases in the number of 

persons with an unmet housing need.
 

Page 50 GAO-15-298 Housing for Persons with HIV 

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.72

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.

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.

73 Additionally, as our prior work 

has shown, leading organizations use performance information to identify 

gaps in performance, improve organizational processes, and improve 

their performance.74 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.

 

72In response to our review, HUD determined that its contractor had made data entry 

errors when recording the information that Grantee A reported. According to HUD, this 

grantee reported that the numbers of HIV-positive persons with an unmet housing need 

were 145, 175, 2,000, and 200 in 2010, 2011, 2012, and 2013, respectively. HUD officials 

told us that, as a result of our review, their contractor would correct the unmet need data 

in each of the grantees’ performance profiles, as well as in the performance profiles for the 

program as a whole.

73GAO/AIMD-00-21.3.1. 

74GAO, Managing for Results: Enhancing Agency Use of Performance Information for 

Management Decision Making, GAO-05-927 (Washington, D.C.: September 2005).
 

Page 51 GAO-15-298 Housing for Persons with HIV 

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.75

 

75HIV/AIDS Policy Notice 11-01, 76 Fed. Reg. 27649 (May 12, 2011). According to HRSA 

officials, individualized housing plans are to be tracked at the local level unless housing 

needs have been identified as a priority by the grantee and HRSA staff with responsibility 

for monitoring the grant.

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.

HRSA Collects Program 

Data but Does Not Monitor 

Housing Information
 

Page 52 GAO-15-298 Housing for Persons with HIV 

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.76 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.77

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.

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 

 

76GAO/AIMD-00-21.3.1

77GAO, Managing for Results: Agencies’ Trends in the Use of Performance Information to 

Make Decisions, GAO-14-747 (Washington, D.C.: Sept. 26, 2014). 

Conclusions
 

Page 53 GAO-15-298 Housing for Persons with HIV 

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.78

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.

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.

 

78Pub. L. No. 106-345, Pub. L. No. 109-415, and Pub. L. 111-87. 
 

Page 54 GAO-15-298 Housing for Persons with HIV 

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.

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.

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 

Matter for 

Congressional 

Consideration

Recommendations for 

Executive Action
 

Page 55 GAO-15-298 Housing for Persons with HIV 

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.

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 

Agency Comments

and Our Evaluation
 

Page 56 GAO-15-298 Housing for Persons with HIV 

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.
 

Page 57 GAO-15-298 Housing for Persons with HIV 

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 
 

Page 58 GAO-15-298 Housing for Persons with HIV 

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 followup 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 
 

Page 59 GAO-15-298 Housing for Persons with HIV 

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.

Daniel Garcia-Diaz

Director, Financial Markets

 and Community Investment
 

Page 60 GAO-15-298 Housing for Persons with HIV 

List of Committees

The Honorable Susan Collins

Chairman

The Honorable Jack Reed

Ranking Member

Subcommittee on Transportation, Housing and Urban Development, and 

Related Agencies 

Committee on Appropriations

United States Senate

The Honorable Mario Diaz-Balart

Chairman

The Honorable David E. Price

Ranking Member

Subcommittee on Transportation, Housing and Urban Development, and 

Related Agencies

Committee on Appropriations

House of Representatives
Appendix I: Scope and Methodology

Page 61 GAO-15-298 Housing for Persons with HIV 

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 HOPWAeligible 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.1

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 

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.

 

1

GAO, Standards for Internal Control in the Federal Government, GAO/AIMD-00-21.3.1 

(Washington, D.C.: November 1999) and Assessing the Reliability of ComputerProcessed Data, GAO-09-680G (Washington, D.C.: July 2009).

Appendix I: Scope and Methodology
Appendix I: Scope and Methodology

Page 62 GAO-15-298 Housing for Persons with HIV 

demographic characteristics of persons diagnosed with HIV.2

To assess whether formula HOPWA grant funds were reaching 

communities with the greatest number of persons with HIV, we reviewed 

documentation of the current HOPWA funding formula. Through the 

current formula, grantees are identified and funds are awarded based on 

cumulative cases of acquired immunodeficiency syndrome (AIDS) since 

1981, which includes deceased persons. We compared the number of 

cumulative AIDS cases to the number of persons living with HIV by 

metropolitan statistical areas (MSA) that received HOPWA formula funds 

in fiscal year 2012.

To assess

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.

3

 

2

For CDC data, the Northeast includes Connecticut, Maine, Massachusetts, New 

Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. The 

Midwest includes Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, 

Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. The South includes 

Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, 

Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, 

Texas, Virginia, and West Virginia. The West includes Alaska, Arizona, California, 

Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and 

Wyoming. Rates are per 100,000 population.

For this comparison, we used CDC data on 

cumulative AIDS cases and persons living with HIV that were current as 

3

The MSA delineations are based on the 2000 Office of Management and Budget 

Standards for Delineating Metropolitan and Micropolitan Statistical Areas (implemented in 

2003).
Appendix I: Scope and Methodology

Page 63 GAO-15-298 Housing for Persons with HIV 

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).4

We also compared the current HOPWA funding formula to our previous 

work that addressed funding grants based on cumulative AIDS cases, 

including the deceased.

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.

5

Additionally, we obtained the views of formula HOPWA and Ryan White 

Part A grantees on the need for the HOPWA and Ryan White HIV/AIDS 

programs, as well as the extent to which the programs addressed the 

housing needs of persons with HIV. We visited and interviewed a 

purposive, or non-generalizable, sample of grantees of each program. To 

identify the purposive sample, we identified the cities in which all 90 of the 

2011 formula HOPWA grantees and 53 of the 2011 Ryan White Part A 

grantees were located. We then identified 47 common grantees that 

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.

 

4

The (absolute) relative difference is measured as a ratio of the absolute difference 

between the two measures to the number of cumulative AIDS cases, expressed as a 

percentage for areas that received a formula HOPWA grant in 2012. We use absolute 

value because some MSAs have a higher number of cumulative AIDS cases than living 

HIV cases and others have a higher number of living than cumulative cases. This value is 

a measure of closeness between the cumulative number of AIDS cases and the number 

of persons living with HIV and is always greater than or equal to zero. The lower the value, 

the closer the number of cumulative AIDS cases is to the number of persons living with 

HIV in a given MSA.

5

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).
Appendix I: Scope and Methodology

Page 64 GAO-15-298 Housing for Persons with HIV 

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.6

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 

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.

 

6

Continuum of Care is a HUD program that funds, among other groups, nonprofit 

homeless providers, faith-based organizations, and state and local governments within the 

geographic area they operate.
Appendix I: Scope and Methodology

Page 65 GAO-15-298 Housing for Persons with HIV 

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 
Appendix I: Scope and Methodology

Page 66 GAO-15-298 Housing for Persons with HIV 

methodological rigor and excluded two studies. Of the six remaining 

studies, two were randomized control trial studies, one was a crosssectional 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.7

To determine how the HOPWA and Ryan White Part A programs 

coordinated with other federal housing assistance programs that were not 

targeted to persons with HIV but could potentially be used by such 

persons, we took several steps. First, we identified a list of 87 housing 

assistance programs based on previous GAO reports on fragmentation, 

overlap, and duplication among housing assistance programs and 

discussions with HUD and HRSA officials.8

 

7

GAO, 2012 Annual Report: Opportunities to Reduce Duplication, Overlap and 

Fragmentation, Achieve Savings, and Enhance Revenue, 

Second, we used criteria to 

narrow the list of programs. For example, we excluded programs that 

provided mortgage assistance, loan guarantees, and community 

development assistance that were not focused on housing. We also 

excluded programs that were not receiving new funding. Based on this 

methodology, we identified five programs: Public Housing, Housing 

Choice Vouchers, Continuum of Care, Emergency Solutions Grants, and 

the HUD-Veterans Affairs Supportive Housing. HUD officials agreed with 

GAO-12-342SP (Washington, 

D.C.: Feb. 28,2012) and U.S. Government Accountability Office: Opportunities to Reduce 

Potential Duplication in Government Programs, Save Tax Dollars, and Enhance Revenue,

GAO-11-318SP (Washington D.C.: Mar. 1, 2011).

8

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. 
Appendix I: Scope and Methodology

Page 67 GAO-15-298 Housing for Persons with HIV 

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.9

 

9

GAO, Ryan White CARE Act: Improvements Needed in Oversight of Grantees, 

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 

GAO-12-610 (Washington, D.C.: June 11, 2012).
Appendix I: Scope and Methodology

Page 68 GAO-15-298 Housing for Persons with HIV 

internal control standards as well as practices that leading organizations 

used related to managing for results.10

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.

 

10GAO/AIMD-00-21.3.1; GAO, Managing for Results: Enhancing Agency Use of 

Performance Information for Management Decision Making, GAO-05-927 (Washington, 

D.C.: September 2005); and Managing for Results: Agencies’ Trends in the Use of 

Performance Information to Make Decisions, GAO-14-747 (Washington, D.C.: Sept. 26, 

2014).
Appendix II: Relative Difference between 

Cumulative AIDS Cases and Living HIV Cases

Page 69 GAO-15-298 Housing for Persons with HIV 

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.

Table 6: Relative Difference between Cumulative AIDS Cases and Living HIV Cases, by Areas that Received Formula HOPWA 

Grants in 2012

HOPWA grantee

Cumulative AIDS 

cases

Persons living with HIV 

(including AIDS) Relative difference

Albany-Schenectady-Troy, NY

a

2,530 2,115 16%

Albuquerque, NM 1,651 1,296 22%

Allentown-Bethlehem-Easton, PA-NJ 1,642 1,521 7%

Atlanta-Sandy Springs-Marietta, GA 26,634 23,650 11%

Augusta-Richmond County, GA-SC 2,152 2,075 4%

Austin-Round Rock, TX 5,560 4,643 16%

Bakersfield, CA 1,945 1,863 4%

Baltimore-Towson, MD 23,728 18,779 21%

Baton Rouge, LA 4,782 4,412 8%

Birmingham-Hoover, AL 2,942 3,503 19%

Boston-Cambridge-Quincy, MA-NH 14,898 10,249 31%

Bridgeport-Stamford-Norwalk, CT 4,191 2,877 31%

Buffalo-Niagara Falls, NY 2,783 2,288 18%

Cape Coral-Fort Myers, FL 2,079 1,699 18%

Charleston-North Charleston, SC 2,482 2,191 12%

Charlotte-Gastonia-Concord, NC-SC 4,199 6,004 43%

Chicago-Naperville-Joliet, IL-IN-WI 34,617 29,390 15%

Cincinnati-Middletown, OH-KY-IN 3,400 3,281 4%

Cleveland-Elyria-Mentor, OH 4,888 4,579 6%

Columbia, SC 4,010 3,986 1%

Columbus, OH 4,012 4,539 13%

Dallas-Fort Worth-Arlington, TX 23,447 21,161 10%

Denver-Aurora, CO 7,954 8,736 10%

Detroit-Warren-Livonia, MI 12,111 9,440 22%

El Paso, TX 1,796 1,686 6%

Appendix II: Relative Difference between 

Cumulative AIDS Cases and Living HIV 

Cases
Appendix II: Relative Difference between 

Cumulative AIDS Cases and Living HIV Cases

Page 70 GAO-15-298 Housing for Persons with HIV 

HOPWA grantee

Cumulative AIDS 

cases

Persons living with HIV 

(including AIDS) Relative difference

Fresno, CA

a

1,811 1,357 25%

Greensboro-High Point, NC 1,598 2,189 37%

Greenville, SC 1,502 1,266 16%

Hartford-West Hartford-East Hartford, CT 5,694 3,667 36%

Honolulu, HI 2,415 1,602 34%

Houston-Baytown-Sugar Land, TX 30,155 23,162 23%

Indianapolis, IN 4,526 4,244 6%

Jackson, MS 2,973 3,147 6%

Jacksonville, FL 7,372 6,092 17%

Kansas City, MO-KS 5,636 4,678 17%

Lakeland-Winter Haven, FL 2,280 1,795 21%

Las Vegas-Paradise, NV 5,672 5,900 4%

Little Rock-North Little Rock, AR 1,620 1,745 8%

Los Angeles-Long Beach-Santa Ana, CA 66,034 48,093 27%

Louisville, KY-IN 2,818 2,895 3%

Memphis, TN-MS-AR 6,104 7,260 19%

Miami-Fort Lauderdale-Miami Beach, FL 64,948 51,363 21%

Milwaukee-Waukesha-West Allis, WI 2,926 2,879 2%

Minneapolis-St. Paul-Bloomington, MN-WI 5,152 5,953 16%

Nashville-Davidson—Murfreesboro, TN 4,551 4,994 10%

New Haven-Milford, CT 5,003 3,308 34%

New Orleans-Metairie-Kenner, LA 10,178 8,002 21%

New York-Northern New Jersey-Long Island, NY-NJ-PA 218,340 140,839 35%

Oklahoma City, OK 2,623 2,382 9%

Orlando, FL 10,654 10,199 4%

Palm Bay-Melbourne-Titusville, FL 1,723 1,288 25%

Philadelphia-Camden-Wilmington, PA-NJ-DE-MD 32,963 27,289 17%

Phoenix-Mesa-Scottsdale, AZ 9,141 9,295 2%

Pittsburgh, PA 3,695 3,010 19%

Portland-Vancouver-Beaverton, OR-WA 5,512 4,316 22%

Poughkeepsie-Newburgh-Middletown, NY 3,399 2,302 32%

Providence-New Bedford-Fall River, RI-MA 4,432 2,888 35%

Raleigh-Cary, NC 2,696 3,202 19%

Richmond, VA 4,032 4,262 6%

Riverside-San Bernardino-Ontario, CA 10,014 8,003 20%

Rochester, NY 3,495 3,061 12%
Appendix II: Relative Difference between 

Cumulative AIDS Cases and Living HIV Cases

Page 71 GAO-15-298 Housing for Persons with HIV 

HOPWA grantee

Cumulative AIDS 

cases

Persons living with HIV 

(including AIDS) Relative difference

Sacramento—Arden-Arcade—Roseville, CA

a

4,552 3,546 22%

St. Louis, MO-IL 7,049 6,560 7%

Salt Lake City, UT 1,955 1,854 5%

San Antonio, TX 6,003 4,930 18%

San Diego-Carlsbad-San Marcos, CA 14,570 11,654 20%

San Francisco-Oakland-Fremont, CA 44,062 24,100 45%

San Jose-Sunnyvale-Santa Clara, CA 4,438 3,105 30%

San Juan-Caguas-Guaynabo, PR 23,713 13,338 44%

Sarasota-Bradenton-Venice, FL 2,313 1,744 25%

Seattle-Tacoma-Bellevue, WA 10,338 8,565 17%

Springfield, MA 2,396 1,728 28%

Tampa-St. Petersburg-Clearwater, FL 13,251 10,596 20%

Tucson, AZ 2,320 1,975 15%

Tulsa, OK 1,764 1,534 13%

Virginia Beach-Norfolk-Newport News, VA-NC 5,505 6,047 10%

Washington-Arlington-Alexandria, DC-VA-MD-WV 37,422 31,353 16%

Worcester, MA 2,048 1,460 29%

Source: CDC data as of March 2011. | GAO-15-298

a

The (absolute) relative difference is measured as a ratio of the absolute difference between the two 

measures to the number of cumulative AIDS cases, expressed as a percentage for areas that 

received a formula HOPWA grant in 2012. This value is a measure of closeness between the 

cumulative number of AIDS cases and the number of persons living with HIV, and is always greater 

than or equal to zero.
Appendix III: Comments from the Department 

of Housing and Urban Development

Page 72 GAO-15-298 Housing for Persons with HIV 

Appendix III: Comments from the 

Department of Housing and Urban 

Development
Appendix III: Comments from the Department 

of Housing and Urban Development

Page 73 GAO-15-298 Housing for Persons with HIV 
Appendix III: Comments from the Department 

of Housing and Urban Development

Page 74 GAO-15-298 Housing for Persons with HIV 
Appendix III: Comments from the Department 

of Housing and Urban Development

Page 75 GAO-15-298 Housing for Persons with HIV 
Appendix III: Comments from the Department 

of Housing and Urban Development

Page 76 GAO-15-298 Housing for Persons with HIV 
Appendix III: Comments from the Department 

of Housing and Urban Development

Page 77 GAO-15-298 Housing for Persons with HIV 
Appendix III: Comments from the Department 

of Housing and Urban Development

Page 78 GAO-15-298 Housing for Persons with HIV 
Appendix IV: Comments from the Department 

of Health and Human Services

Page 79 GAO-15-298 Housing for Persons with HIV 

Appendix IV: Comments from the 

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

of Health and Human Services

Page 80 GAO-15-298 Housing for Persons with HIV 
Appendix IV: Comments from the Department 

of Health and Human Services

Page 81 GAO-15-298 Housing for Persons with HIV 
Appendix V: GAO Contact and Staff 

Acknowledgments

Page 82 GAO-15-298 Housing for Persons with HIV 

Daniel Garcia-Diaz, (202) 512-8678 or garciadiazd@gao.gov

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.

Appendix V: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(100011)
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