Persons with HIV: Funding Formula for Housing Assistance Could Be Better Targeted, and Performance Data Could Be Improved
Released: 2015-04-16T00:00:00

Letter

Background

First identified in 1981, HIV impairs the immune system and leaves affected individuals susceptible to certain cancers and infections. HIV, the virus that causes AIDS, affects specific cells of the immune system. Over time, HIV can destroy so many of these cells that the body cannot fight off infections and disease, leading to AIDS. A person who has the HIV virus can move in and out of AIDS status, which is the third stage of the disease. Despite the number of deaths from AIDS and the steady increase of HIV prevalence, there have been successes in the fight against the disease. Developments in treatment have enhanced care options and can extend the lives of those with HIV. The introduction of highly active antiretroviral therapy in 1996 was followed by a decline in the number of deaths and new AIDS cases in the United States for the first time since the beginning of the disease. Since 1981, over 1.2 million persons diagnosed with AIDS have been reported to the CDC and over 600,000 of them have died. The CDC estimates that of the more than 1.2 million persons living with HIV in December 2011, some 14 percent had not been diagnosed and might not be unaware of their status.

In 2010, the White House’s Office of National AIDS Policy issued a national strategy for addressing HIV and AIDS in the United States. The strategy has three primary goals: (1) reduce the number of persons who become infected with HIV, (2) increase access to care and improve health outcomes for persons living with HIV, and (3) reduce HIV-related health disparities. To accomplish these goals, the strategy calls for a coordinated national response to the disease.

HOPWA Program

Congress created the HOPWA program in 1990 under the National Affordable Housing Act, authorizing grants for housing activities and supportive services designed to prevent homelessness among persons with HIV. Specifically, HOPWA grants are used to provide a wide range of housing-related services, including rental assistance; operating costs for housing facilities; short-term rent, mortgage, and utility payments; permanent housing placement and housing information services; resource identification (to establish, coordinate and develop housing assistance); acquisition, rehabilitation, conversion, lease, and repair of facilities; new construction (for single-room occupancy dwellings and community residences only); and supportive services (case management and mental health, alcohol and drug abuse, and nutritional services). To be eligible for HOPWA, individuals must be HIV positive and low income (below 80 percent of area median income). HOPWA assists persons who are without stable housing arrangements, including those at severe risk of homelessness (e.g., persons in emergency shelters; persons living in a place not meant for human habitation, such as a vehicle or abandoned building; or persons living on the streets).

HUD awards 90 percent of the annual HOPWA appropriation by formula to eligible metropolitan statistical areas (MSA) and states. On the basis of the statute, MSAs with populations greater than 500,000 and more than 1,500 cumulative cases of AIDS are eligible for HOPWA formula grants. The most populous city in an eligible MSA serves as that area’s HOPWA grantee. In addition, states with more than 1,500 cumulative cases of AIDS in areas outside of eligible MSAs qualify for formula funds.aside for grants awarded on a competitive basis.

Ryan White HIV/AIDS Program

Congress enacted the Ryan White Comprehensive AIDS Resources Emergency Act of 1990 (CARE Act) to improve the availability and quality of community-based health care and support services for individuals with HIV and their families. The CARE Act was most recently reauthorized through the Ryan White HIV/AIDS Treatment Extension Act of 2009. HRSA administers the Ryan White HIV/AIDS program.program must be the payer of last resort, meaning that other sources of funds for services, including housing services, must be exhausted before using Ryan White HIV/AIDS program funds.

Ryan White Part A provides formula funds to Eligible Metropolitan Areas and Transitional Grant Areas. To qualify for Eligible Metropolitan Area status, an area must have reported at least a cumulative total of 2,000 AIDS cases in the most recent 5 years and have a population of at least 50,000. To be eligible for Transitional Grant Area status, an area must have a cumulative total of 1,000, but fewer than 2,000 cases of AIDS in the most recent 5 years and have a population of at least 50,000.absence of a waiver, Ryan White Part A grantees are required to spend at least 75 percent of their grant on core medical services and no more than 25 percent on supportive services, which include housing In the assistance. Ryan White HIV/AIDS program-funded housing assistance provides short-term aid to support emergency, temporary, or transitional housing so that an individual or family can gain or maintain health care.HRSA guidance encourages but does not require grantees to limit housing assistance to 24 months. Additionally, housing assistance must be accompanied by a strategy to transition the individual or family to stable, permanent housing.

Ryan White Part A grantees are required by the Ryan White HIV/AIDS Treatment Extension Act of 2009 to establish a Ryan White Part A Planning Council, which is appointed by the chief elected official of the city or county. The council is responsible for setting HIV-related service priorities and allocating grant funds based on the needs of persons with HIV. Planning councils are required to develop a comprehensive plan with the Ryan White Part A grantee for the provision of services. The Ryan White HIV/AIDS Treatment Extension Act of 2009 identifies 13 different parties that must be involved in the council, including representatives from community-based organizations serving affected populations, persons with HIV, and grantees providing services in the area under other federal HIV programs.

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

Both HOPWA and Ryan White Part A funds are awarded to government agencies, which are referred to as “grantees” (see fig. 1). For the HOPWA program, the formula grantee is generally either the city office dedicated to housing and community development or the city health department. HOPWA grantees may carry out eligible program activities themselves, through any of their administrative agencies, or through a project sponsor. A project sponsor can be any nonprofit organization or governmental housing agency that receives funds from a grantee to carry out eligible HOPWA activities. The grantees and project sponsors may also contract with for-profit entities to provide services associated with their HOPWA activities.

For the Ryan White Part A program, grants are awarded to the chief elected official of the city or county that provides health-care services. The chief elected official is legally the grantee but usually chooses a department or other entity to manage the grant, and that entity is then referred to as the grantee. Ryan White Part A grantees are generally county or city health departments or public departments with responsibility for health. Part A grants consist of formula and supplemental components. Formula grants are based on reported living cases of HIV and AIDS in eligible areas. Supplemental grants are awarded competitively and are based on the ability of Eligible Metropolitan or Transitional Grant Areas to document both a demonstrated need for additional funds and the capacity to use them to meet community needs. Ryan White Part A grantees can deliver services to persons with HIV (clients) directly or through a subgrantee. Subgrantees are generally community-based, nonprofit organizations. In some cases, a city’s formula HOPWA grantee and Ryan White Part A grantee are the same entity. Also, in some cases local community-based organizations receive both HOPWA and Ryan White Part A funding.

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

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

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

According to CDC estimates, there were about 50,000 HIV diagnoses each year from 2008 to 2012. In 2012, the estimated rate of diagnosed HIV infections in the United States was 15.3 per 100,000 population. Rates of diagnosis of HIV infection have varied by region from 2008 to 2012. For example, the rate of diagnosis of HIV infection increased from 2008 through 2012 in the Midwest, and decreased during this period in the Northeast, South, and West. In 2012, the rates of diagnosed HIV infection were highest in the South, followed by the Northeast, West, and Midwest, as shown in figure 2.

According to CDC data, from 2008 through 2011, the estimated number of persons in the United States living with a diagnosed HIV infection, or the prevalence of diagnosed HIV infection, increased. The prevalence rate, or the number of persons living with diagnosed HIV infection per 100,000 population, was estimated to be nearly 283 at the end of 2011.

Prevalence rates vary by region, and regional differences have remained relatively stable from 2008 through 2011. As shown in figure 3, prevalence rates of diagnosed HIV infection are highest in the Northeast, followed by the South, West, and Midwest.

The estimated rates of HIV diagnoses have varied over time across different demographic groups. For example, from 2008 through 2012 the rates of diagnosed HIV infection increased among persons aged 13 to 14 and 20 to 29 and either remained stable or decreased among other age groups. Rates of diagnoses during this period also increased for American Indian/Alaska natives and Asians, while decreasing for African- Americans, Hispanics/Latinos, and persons of multiple races. In 2012, the estimated rate of HIV diagnoses for African-Americans was 58 per 100,000 population—the highest rate compared to other racial and ethnic groups. From 2008 through 2012, rates of HIV diagnoses decreased among females and remained stable for males. In 2012, males accounted for 80 percent of all diagnoses newly reported among adults and adolescents.

Stable housing is critical for persons with HIV. Staff from several HIV/AIDS advocacy groups told us that stable housing was important because many persons with HIV were required to adhere to strict regimens for taking medicine. Some medicines require refrigeration, and some cause debilitating side effects. Health care officials from CDC told us that without stable housing, persons may not reach viral suppression In addition, the National HIV/AIDS or remain connected to medical care. Strategy states that access to housing is an important precursor to getting many people into a stable treatment regimen. Individuals living with HIV who lack stable housing are more likely to delay HIV care, have poorer access to regular care, are less likely to receive optimal antiretroviral therapy, and are less likely to adhere to therapy. A 2007 study emphasized the relationship between housing assistance provided to persons living with HIV and increased access to medical care and appropriate treatment. The need for housing is prevalent among persons living with HIV, and there is strong evidence that receipt of housing assistance has a direct impact on improved medical care outcomes.Research has also indicated that persons with HIV who live in stable housing have better health outcomes than those who are homeless or unstably housed.

However, while stable housing is critical for effective medical care, persons with HIV often have difficulty maintaining stable housing because of the financial vulnerability that can be associated with the disease. As individuals become ill, they may find themselves unable to work, while at the same time facing health care expenses that leave few resources to pay for housing. According to a recent study, housing challenges for a person living with HIV may include the growing disparity between income and the cost of rental housing, loss of income due to inability to maintain employment, and loss of spouse or partner due to HIV-related death, among other things. homelessness among persons with HIV. In addition, those who are homeless may be more likely to engage in activities through which they could transmit HIV.

Aidala and others, “Housing Need.” members from HOPWA and Ryan White Part A grantees we interviewed told us that there was an increasing need for housing assistance for persons with HIV. Some staff told us that infected persons were living longer as a result of advances in medical care. Moreover, staff from several grantees told us that these persons generally needed both medical and nonmedical supportive services. Additionally, HUD officials noted that as local housing costs increased, the need for programs that provided affordable housing increased for all low-income people, including those with HIV.

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

HUD’s estimate of the number of persons with HIV who have a housing need is not reliable. HUD requires each formula and competitive HOPWA grantee to report annually the number of HOPWA-eligible persons who have an unmet housing need within the grantee’s jurisdiction. HUD then develops an estimate of the number of persons nationwide with HIV who have an unmet housing need by totaling the numbers reported by each grantee. For 2013, HUD reported that approximately 131,000 HIV-positive persons had unmet housing needs. HUD uses this information to justify its HOPWA budget requests and to report on the program’s performance. HIV advocacy groups use HUD’s estimates in their publications and outreach efforts to Congress.

We found that HOPWA grantees used different methodologies to report unmet housing needs, limiting the reliability of the reported information. Grantees we met with used varying methods to produce the local unmet need estimates that they reported to HUD annually. For example, officials from one HOPWA grantee told us that they summed the unmet housing need data provided by their project sponsors. In contrast, officials from another HOPWA grantee use various data sources to produce both a low and high estimate of unmet housing need and have historically reported both numbers to HUD. In its 2010 and 2011 Consolidated Annual Performance and Evaluation Reports (CAPER) Reports, this grantee reported to HUD that the unmet need in its community could range from a low of approximately 7,500 persons to a high of 15,000.

HUD officials told us that, at the time of our review, they did not require HOPWA grantees to use a consistent methodology to calculate unmet housing need for each jurisdiction. They told us that this policy was intended to allow for local flexibility, so that the data were collected using the most appropriate method for each jurisdiction. According to HUD’s CAPER guidance, grantees can use one or more of seven data sources to calculate unmet need, including data from prisons or jails on persons being discharged with HIV and housing providers’ waiting lists.Grantees are required to indicate on their CAPERs all of the data sources they use to estimate unmet need. However, HUD does not provide additional guidance on how grantees should use the data sources in a comparable manner. In June 2014 HUD granted a HOPWA technical assistance contractor a 1-year contract extension to help the agency address its unmet needs methodology, to include soliciting community feedback at the U.S. Conference on HIV/AIDS. HUD convened stakeholders and HOPWA grantees at this conference to discuss how unmet needs were estimated, and participants discussed establishing a working group to develop a consistent methodology. According to HUD, as of February 2015, the agency was working with its technical assistance contractor to develop a methodology and provide communities CDC data related to persons with HIV. However, according to HUD, the agency does not have specific goals or time frames for finalizing a standard methodology.

GAO’s work on assessing data reliability indicates that data should be consistent—that is, data should be clear and well defined enough to yield similar results in similar analyses. Further, when data are entered at multiple sites or reported using multiple sources (as in the case of HOPWA program), there is a risk that data entry rules may be interpreted inconsistently, resulting in data that, taken as a whole, are unreliable. In addition, federal internal control standards state that program managers need operational data to determine whether they are meeting their goals for effective and efficient use of resources. In our 1997 report on HOPWA and the Ryan White HIV/AIDS program, we concluded that equitable distribution of resources should be consistent with the current need for such resources. Because HUD does not require grantees to use selected data sources in a consistent manner, the resulting information is not comparable. Further, the usefulness and reliability of these data as an indicator of the unmet housing needs of persons with HIV are unclear. Although data on unmet housing needs are not used to determine HOPWA formula funding amounts, such information would be helpful in determining the extent of the need for HOPWA funds in specific areas, as well as the extent to which HOPWA is meeting its goals of addressing the housing needs of persons with HIV.

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

As previously discussed, 90 percent of HOPWA funds are awarded through formula grants to eligible states and MSAs. Seventy-five percent of these formula-based funds are awarded to cities and states that meet certain threshold criteria. These criteria are based on each jurisdiction’s share of the number of cumulative AIDS cases in all eligible jurisdictions. Cumulative AIDS case counts include both living and deceased AIDS cases reported in the grantees’ jurisdiction since the beginning of the AIDS epidemic in 1981.

Use of cumulative AIDS cases rather than living HIV cases has led to MSAs with similar numbers of persons living with HIV receiving markedly different amounts of HOPWA funding. For example, in fiscal year 2012 a grantee in the South and a grantee in the Northeast both had about 2,300 persons living with HIV, according to CDC data. However, the grantee in the Northeast received about $154,000 more in HOPWA formula funding than the grantee in the South because it had approximately 776 more reported cumulative AIDS cases. Similarly, in the same fiscal year, both a HOPWA formula grantee in the West and one in the South had about 3,500 persons living with HIV. However, the grantee in the West received nearly $319,000 more in formula funding than the grantee in the South because it had about 1,600 more reported cumulative AIDS cases.

The difference between cumulative AIDS cases and living HIV cases is more pronounced in some MSAs than others. As shown in figure 4, the relative difference ranged from less than 15 percent to more than 43 percent in the MSAs that received HOPWA formula funds in 2012. In most of these MSAs (62 of 78), the number of cumulative AIDS cases was greater than the number of persons living with HIV. For example, the New York City MSA had 35 percent more cumulative AIDS cases than cases of persons living with HIV. In contrast, about one-fifth of the MSAs that received HOPWA funds in fiscal year 2012 had more persons living with HIV than cumulative AIDS cases. For example, the Charlotte, North Carolina MSA had 43 percent more cases of persons living with HIV than cumulative AIDS cases. According to CDC officials, there can be more living HIV cases than cumulative AIDS cases because not all persons with HIV progress to the third stage of the disease (AIDS). Appendix II provides additional information on the numbers of cumulative AIDS cases and living HIV cases for all MSAs that received HOPWA grants in fiscal year 2012.

We have assessed HOPWA’s funding formula in previous work. In 1997, we recommended that HUD consider the legislative changes that would be needed to make the HOPWA formula more reflective of current AIDS We also noted that the general principle of allocating grants on cases.the basis of the estimated number of persons living with HIV, excluding those who are deceased, would ensure a more equitable allocation of the available funds. In response, HUD reviewed potential changes to the formula. It compiled an analysis to show the effects of various alternatives on grantees’ funding levels, including use of 10-year weighted numbers to reflect living cases of persons with AIDS. However, at that time, HUD was reluctant to recommend any change that might disrupt funding for those who depended on HOPWA support.

In 2006, we recommended that if Congress wanted HOPWA funding to more closely reflect the distribution of persons living with AIDS, it should consider changing the program so that HOPWA formula grant eligibility would be based on a measure of living AIDS cases.the funding formula for the Ryan White HIV/AIDS programs in 2006 but did not make the same change for HOPWA. Since our 2006 report, medical treatment for HIV/AIDS and the make-up of the national population with HIV or AIDS have continued to evolve. Additionally, CDC officials now consider HIV case counts to be more accurate and reliable than counts of AIDS cases alone because persons with HIV may live many years before progressing to AIDS and may move between stages as their health changes.

HUD officials and the four HOPWA grantees we met with stated that the HOPWA funding formula was out of date. In its last three congressional budget justifications, HUD has proposed updating the formula. According to HUD’s 2015 budget justification, the HOPWA formula should be updated to better reflect the nature of the HIV epidemic that has evolved over the years through advances in HIV care and the increasingly disproportionate impact on impoverished persons with HIV. HUD has proposed basing the funding formula on living HIV rather than cumulative AIDS cases and on consideration of local housing costs and poverty rates. HUD recognized that some communities could lose funds as a result of a redistribution of grant funds. To mitigate any potential negative impacts of large funding reductions on some communities, HUD has also proposed incrementally reducing funding over time.

HUD’s projections based on its proposed formula change—using living HIV cases instead of cumulative AIDS cases and data on housing costs and poverty—show a redistribution of funds that results in funding increases for some communities and decreases for others. For example, based on HUD’s 2015 projections of HOPWA award amounts, the New York City MSA’s award would decrease by about $5 million from HUD’s 2014 estimated award amount. In contrast, smaller MSAs, such as Charlotte North, Carolina, and Cleveland, Ohio would receive increases of more than $200,000 from HUD’s 2014 estimated award amounts. Although our analysis of CDC data suggests that the proportions of living HIV cases among the cities that received HOPWA funds in 2012 are similar to the proportions of cumulative AIDS cases, these changes could result in meaningful differences in the amounts of funding that some grantees receive.

The Office of Management and Budget has also noted that the current formula for distributing HOPWA funds does not reflect the current nature of the disease. As discussed in GAO’s prior work, a cumulative count of AIDS cases that includes deceased persons does not necessarily reflect the number of living HIV cases in a particular year. In contrast, data on the number of persons living with HIV exclude the deceased and include persons in all stages of HIV infection. In addition, regional changes in the number of HIV cases may not be fully accounted for in the current HOPWA formula due to the continued inclusion of deceased persons. Reauthorizations of the Ryan White HIV/AIDS program in 2000, 2006 and 2009 required the use of living cases of both HIV and AIDS in the distribution of formula grants for Ryan White Parts A and B. Because HOPWA funds continue to be awarded based on cumulative AIDS cases, HOPWA funds are not being targeted as effectively or equitably as they could be.

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

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

HOPWA Grantees Have Primarily Funded Housing Assistance

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

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

Housing assistance represented about 2 percent ($14 million) of the total expenditures of $592 million in fiscal year 2011 for all Ryan White Part A funding categories—including medical and supportive services. The largest category of program expenditures, $426 million, was for core medical services, followed by about $93 million for supportive services and about $73 million for clinical quality management and grantee administration. Under the Ryan White HIV/AIDS Treatment Extension Act of 2009, Ryan White Part A grantees are generally required to expend the majority of their funds on core medical services but can also fund Expenditures for the supportive services (including housing assistance).Ryan White Part A program also reflect the priorities established by Ryan White Part A Planning Councils.

Of the $93 million grantees spent on supportive services, housing assistance made up about 15 percent (see fig. 7). Ryan White Part A grantees also spent supportive services funds on nonmedical case management, emergency financial assistance, food bank/home-delivered meals, and health education.

Ryan White Part A data for calendar year 2012 indicate that the majority of the 13,556 clients who received housing assistance were African- American. The data also indicate that the majority of clients who received housing assistance had incomes at or below the federal poverty level.Table 2 summarizes selected demographic characteristics of persons who received housing assistance through Ryan White Part A in calendar year 2012.

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

HUD’s 2012 HOPWA performance data show a variety of positive outcomes related to housing stability, access to care, and homelessness. For the HOPWA program, permanent, stable housing includes private housing without a subsidy, subsidized housing, and HOPWA-funded rental assistance or facility-based housing. According to HUD’s 2012 data,

96 percent of the households that received tenant-based rental assistance or lived in a HOPWA-funded permanent housing facility had stable housing;

92 percent of households had contact with primary care;

90 percent of clients accessed medical insurance; and

5,736 formerly homeless individuals were placed in housingAdditionally, HUD’s 2013 Performance Report indicates that the HOPWA program has contributed to the agency’s goal of preserving affordable rental housing. The report states that HOPWA had funded 25,706 rental units as of the end of fiscal year 2012, helping HUD exceed its fiscal year 2012-2013 agency priority goal of continuing to serve 5.4 million families and serving an additional 61,000 families. According to the performance report, HUD exceeded this goal by nearly 82,000 families. HOPWA officials also told us that the program’s contributions to providing permanent supportive housing supported HUD’s strategic objective for ending homelessness. HOPWA officials noted that the HOPWA program helped to keep persons with HIV from becoming homeless.

HUD uses the data that grantees report on outcomes to summarize the achievements of individual grantees and the program as a whole. More specifically, HUD contractors review the information grantees submit and produce grantee-level and national summaries of performance for the formula HOPWA program, the competitive HOPWA program, and both programs combined. HUD posts these summaries, or performance profiles, on a HUD website.

HRSA officials told us that the majority of clients provided with housing assistance through the Ryan White HIV/AIDS program obtained permanent, stable housing. According to a December 2013 White House report addressing the outcomes associated with the National HIV/AIDS Strategy, increasing the percentage of Ryan White HIV/AIDS program clients with permanent housing to 86 percent is one of nine indicators in the National HIV/AIDS Strategy. For the Ryan White HIV/AIDS program, stable, permanent housing includes unsubsidized rooms, houses, or apartments; subsidized housing; and permanent housing for formerly homeless persons.

According to HRSA officials, the National HIV/AIDS Strategy indicator of Ryan White HIVAIDS program clients with permanent housing is measured using the data on the housing status that HRSA collects annually. HRSA gathers this information from Ryan White HIV/AIDS program grantees through the Ryan White HIV/AIDS Program Services (RSR) report. However, it is not clear that HRSA’s housing status data are current because HRSA does not require or encourage grantees to maintain current data on clients’ housing status. RSR instructions state that the housing status data element is the client’s housing status at the end of the reporting period. HRSA officials told us that the instructions were not intended to be used as guidance for local jurisdictions in determining how often each client’s housing status should be collected. The officials added that the frequency with which a client’s housing status should be updated was decided at the local level and that currently HRSA does not require grantees to assess a client’s housing status beyond the initial intake period. Staff from one Ryan White Part A grantee told us that information on housing status in the RSR report was not very reliable because each client’s housing status was recorded at the point of intake but might or might not be updated subsequently. Another Ryan White Part A grantee told us that some of its subgrantees only reported on clients’ housing status at the point of intake, even though they recertified clients’ eligibility for the program every 6 months.

Internal control standards for the federal government state that events should be promptly recorded to maintain their relevance and value to management in controlling operations and making decisions. Because HRSA does not require grantees to ensure that their subgrantees regularly update data on each client’s housing status, the usefulness of these data to support housing-related outcomes is unclear. Among these outcomes, for example, the extent to which the Ryan White HIV/AIDS program is contributing to the National HIV/AIDS Strategy goal of improving access to permanent housing. Further, because the Ryan White HIV/AIDS program provides temporary housing assistance and clients’ housing status is likely to change frequently, housing data may not be as accurate and current as possible if they are not updated regularly.

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

HOPWA grantees, project sponsors, and HIV advocacy groups noted several strengths of the design of the HOPWA program. For example, three of the eight HOPWA project sponsors that GAO interviewed and an HIV advocacy group stated that one strength of the program was that clients must be provided with supportive services. These stakeholders noted that HOPWA clients or other persons with HIV often had substance abuse issues and a mental illness and that supportive services that helped address these issues were critical to helping some clients become stable. Three HOPWA grantees noted that another strength of the program was the flexibility it offered to grantees, allowing them to fund the type of housing assistance that was most needed in their communities. Grantees that we visited funded a wide range of housing types, including a facility for persons with HIV who had mental, physical, or drug abuse issues; a facility for single adults who had progressed to AIDS and had a history of homelessness; and a hospice for HIV-positive persons. Finally, officials from four organizations that received both HOPWA and Ryan White Part A funding explained that HOPWA worked well with the Ryan White HIV/AIDS program. These officials explained that they took steps to transition Ryan White Part A clients who received temporary housing assistance into the HOPWA program, which offered permanent housing assistance. Also, in one of the cities we visited local program administrators emphasized that the programs were complementary and said that they used Ryan White Part A funds only for core medical services and nonmedical case management and HOPWA funds only for housing assistance.

HOPWA grantees and project sponsors also identified weaknesses in the HOPWA program, including certain requirements, administrative fees, and the funding formula. Specifically, two of the four HOPWA grantees we met with noted that rental assistance generally could not exceed Fair Market Rent amounts, which HUD determined annually. Limiting rental assistance to Fair Market Rents is challenging, particularly in high-cost cities like New York City and San Francisco, where officials noted that the average price of an apartment was double the amount of the Fair Market Rent. Also, two of the four HOPWA grantees that we interviewed and HUD administrators of the HOPWA program stated that the administrative fee of 3 percent that grantees could retain from their HOPWA grant was low. HUD officials stated that other HUD programs had higher fees, including Community Development Block Grants (20 percent) and the Home Investment Partnerships Program (10 percent). Finally, staff from three HOPWA grantees, five organizations that receive HOPWA or Ryan White Part A funding, and HUD officials with responsibility for administering the HOPWA program told us that the funding formula needed to be updated so that it was based on the number of persons living with HIV. Officials from one HOPWA grantee stated that they understood the need to update the HOPWA funding formula but had concerns about potentially losing funding if cumulative HIV cases were excluded from the formula. As previously discussed, in congressional budget justifications for fiscal years 2013 through 2015, HUD proposed updating the funding formula to incorporate local housing costs and poverty rates. HUD has also proposed increasing the percentage of HOPWA grant amounts that may be used for administrative expenses from 3 percent to 6 percent of the grantee’s awarded amount.

Ryan White Part A grantees, subgrantees, and HIV advocacy groups that we met with noted several strengths and weaknesses of the Ryan White HIV/AIDS program. For example, three of the four Ryan White Part A grantees we met with, as well as two HIV advocacy organizations, stated that the Ryan White HIV/AIDS program complemented the HOPWA program. Grantee staff told us that persons with HIV could receive temporary housing assistance through Ryan White Part A and then transition to permanent assistance through HOPWA. Also, members of two HIV advocacy groups with whom we met stated that local Ryan White Part A Planning Councils were beneficial because they identified the unique, local needs of persons with HIV. Some Ryan White Part A subgrantees and staff from an HIV advocacy group stated that the inability to use Ryan White Part A funds for permanent housing assistance created challenges. For example, the subgrantees told us that it was generally difficult to address all of the issues that their clients face, including substance abuse and mental illness, within the 2-year time frame. As previously noted, HRSA guidance encourages but does not require grantees to limit housing assistance to 24 months. Additionally, staff from an advocacy group told us that because the Ryan White Part A program could fund only temporary housing, recipients of this assistance were still faced with a lack of stable, permanent housing.

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

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

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

The White House’s 2010 National HIV/AIDS Strategy and its Implementation Plan encourage coordination among federal agencies and between federal agencies and state, territorial, tribal, and local governments, to achieve a more coordinated response to HIV. To address the National HIV/AIDS Strategy, HUD, HRSA, and other federal agencies have taken several steps. First, they have participated in a federal interagency working group led by the White House Office of National AIDS Policy. According to the July 2010 National HIV/AIDS Strategy Federal Implementation Plan, the working group convened to review public recommendations, assess scientific evidence, and make recommendations related to the National HIV/AIDS Strategy. Additionally, in July 2013, an Executive Order established an HIV Care Continuum Working Group to coordinate federal efforts to improve outcomes nationally across the HIV care continuum. This group is co-chaired by the White House Office of National AIDS Policy and HHS. According to HRSA officials, in September 2014 an HIV Care Continuum Initiative meeting was held to examine best practices in implementing care continuum recommendations and to provide agencies with the opportunity to learn from each other. Staff from HRSA, HUD, and other agencies attended the meeting. We have found that collaboration is enhanced when common outcomes are defined, mutually reinforcing strategies are established, and roles and responsibilities are agreed upon, among other things. The efforts of HUD and HRSA to work together to help address the National HIV/AIDS Strategy suggest that they have taken steps to enhance collaboration.

Second, HUD and HRSA have taken steps to share information. HRSA officials told us that, as required by statute, HHS issued a report to Congress in 2012 describing the coordinated efforts at the federal, state, and local levels to address HIV, including a description of barriers to HIV According to this report, between 2005 and 2008: program integration.

HRSA worked with several federal agencies including HUD to examine case management models and examples of coordinated and collaborative case management guidelines;

HRSA and HUD participated in the Interagency HIV/AIDS Case Management Workgroup to develop a set of guidelines around collaborative or coordinated case management services; and

HUD and CDC collaborated in a study to examine housing assistance for homeless people with HIV to determine the impact of such assistance on the progression of their disease and the risk of transmitting HIV.

HUD and HRSA officials with responsibility for the HOPWA and Ryan White HIV/AIDS programs told us that they had also met informally to share information and data on their grantees. For example, in June 2014 staff from both agencies met to discuss data collection that could be helpful to HUD in assessing the impact of the HOPWA program. During this meeting, HRSA also discussed the results of efforts that began in 2014 to identify HOPWA and Ryan White HIV/AIDS program grantees that collected both health and housing indicators. Additionally, HUD and HRSA are collaborating to provide both remote and onsite technical assistance to HOPWA grantees and project sponsors on improving program participants’ access to health care. We have found that collaboration is enhanced when two or more organizations engage in a joint activity that is intended to produce more public value than could be produced when the organizations act alone.

HUD and HRSA also worked together to refine HRSA’s policy related to the length of time individuals can receive housing assistance through the Ryan White HIV/AIDS program. In 2008, HRSA issued a policy that imposed a 24-month cumulative cap on short-term and emergency housing assistance for recipients of Ryan White HIV/AIDS program housing assistance, to be effective beginning in March 2010. In consultation with HUD, HRSA rescinded this policy in February 2010 in response to feedback from Ryan White HIV/AIDS program grantees and others that the time limits could negatively impact recipients of the assistance. Ryan White Part A grantees with whom we met told us that their clients generally had both substance abuse and mental health issues that took time to address. They noted that 2 years was not always sufficient for someone to be able to move out of temporary housing. In May 2011 HRSA released a final notice that encourages, but does not require, grantees to limit assistance to 24 months. HUD’s efforts to work with HRSA on this housing policy are consistent with practices that we have found can enhance collaboration among federal agencies.

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

Although some overlap exists between the HOPWA and Ryan White HIV/AIDS programs, different emphases and local coordination help to ensure that the programs complement rather than duplicate each other. HOPWA and the Ryan White HIV/AIDS program overlap in the areas of temporary housing and supportive services for persons with HIV, which both programs can fund. However, housing assistance for persons with HIV involves both housing- and health-related issues, and HUD and HRSA bring different types of expertise to these areas. HUD programs focus on the provision of housing assistance and HUD awards the bulk of federal housing-related resources. In contrast, HRSA’s primary focus is to provide health care for medically vulnerable people, among others. HRSA’s policy indicates that Ryan White HIV/AIDS program funds can be used for short-term or emergency housing only to the extent that such support is necessary for clients to gain or maintain access to medical care. Additionally, the Ryan White HIV/AIDS Treatment Extension Act of 2009 requires Ryan White HIV/AIDS program grantees to be the payer of last resort. In order to receive housing assistance through the Ryan White HIV/AIDS program, individuals must not have HOPWA or other forms of subsidized housing assistance available to them, even if they are eligible for the programs. However, they may receive Ryan White HIV/AIDS program assistance for other needs, such as medical care. The different program emphases and requirements helps prevent duplication between these programs.

Coordination among local entities helps ensure that assistance provided by HOPWA and the Ryan White HIV/AIDS program complement each other and mitigates the potential for the programs to provide duplicative services. Coordination in the delivery of housing assistance to persons with HIV occurs at the local level through formal planning processes. As a condition of receiving a HOPWA grant, grantees must consult with other public and private entities, as well as local citizens, in implementing the HOPWA program and any other HUD Community Planning and Development grant funds that the community receives. Community Planning and Development grantees, including HOPWA grantees, contribute to the development of a consolidated plan and annual action plans. Through these plans, the grantees must describe the agencies, groups, and others who participated in the planning process; their consultations with social service agencies and other entities; and their activities to enhance coordination between public and assisted housing providers and private and governmental health, mental health, and service agencies.

The Ryan White Part A program requires local planning councils to help facilitate coordination between Ryan White Part A and HOPWA grantees. As we have seen, the Ryan White HIV/AIDS Treatment Extension Act of 2009 requires planning councils to have members from various groups and organizations. For instance, at least one-third of the planning council members must be persons with HIV who receive Ryan White Part A services and are consumers who do not have a conflict of interest, meaning that they are not staff, consultants, or board members of Ryan White Part A ‐funded agencies. The planning council and the grantee work together to identify the needs of people with HIV and to prepare a comprehensive plan on how to meet those needs. Both the planning council and the grantee work together to make sure that other sources of funding work well with Ryan White HIV/AIDS program funds and that the Ryan White HIV/AIDS program is the payer of last resort. While the Ryan White HIV/AIDS Treatment Extension Act of 2009 does not require that the HOPWA program be represented on planning councils, there is a requirement that other federal HIV programs be represented on the council (which could include HOPWA). In addition, the 2015 Part A funding announcement and 2013 program manual both indicate that the planning council could include a HOPWA or housing service representative.

Informal efforts to coordinate the delivery of housing assistance also help to reduce the potential for duplication. Staff from four Ryan White Part A subgrantees, which can provide clients with housing assistance for only a limited period of time, told us that they consistently reached out to local providers of subsidized housing. These providers may include other city agencies, nonprofit organizations, and owners of single-room occupancy hotels. Such coordination efforts could help to minimize the potential for program duplication.

Coordination between the HOPWA and Ryan White Part A programs does not appear to require formal agreements and processes when the same local agency is the grant recipient of both programs. In two of the four cities we visited, the same city agency was both the formula HOPWA project sponsor and the Ryan White Part A grantee. As a result, coordination between the activities funded and efforts to move clients from temporary to permanent housing occurred through the agencies’ regular business practices. Officials from one of these city agencies stated that different staff members were dedicated to each program, but that they worked together and shared information related to clients’ needs and the services provided. Officials from another city agency said that the same city staff focused on both HOPWA and Ryan White Part A funds. In this case, the same staff member reviewed performance information and invoices from the local HOPWA sponsors and Ryan White Part A subgrantees.

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

Persons with HIV may be eligible to receive housing assistance from other federal programs that are focused on assisting persons with low or no income, including the following:

Public Housing provides housing aid for eligible low-income families, the elderly, and persons with disabilities. HUD administers this federal subsidy to participants of local public housing authorities that manage the housing for low-income residents at rents they can afford.

The Housing Choice Vouchers program assists very low-income families, the elderly, and persons with disabilities. Participants may choose any housing that meets the requirements of the program and is not limited to units located in subsidized public housing projects. HUD administers the Housing Choice Voucher program, public housing agencies manage it.

As we have seen, Continuum of Care is a HUD program that provides funding to nonprofit providers and state and local governments to quickly rehouse homeless individuals and families.

Emergency Solutions Grant is a HUD program that provides funding to state and local governments for emergency shelters and services for homeless individuals and families. It also provides services to prevent families from becoming homeless.

The HUD Veterans Affairs Supportive Housing program combines HUD’s Housing Choice Voucher rental assistance for homeless veterans with case management and clinical services provided by the Department of Veterans Affairs.

Home Investment Partnerships Program is a HUD program that provides formula grants to states and localities to fund a wide range of activities, including building, buying, or rehabilitating affordable housing for rent or ownership or providing direct rental assistance to low-income people.

While these programs have similar goals related to providing housing assistance, they have varying eligibility requirements (see table 3). For example, only homeless veterans are eligible for HUD-VASH, and an individual must be homeless or at risk of homelessness to be eligible for the Continuum of Care and Emergency Solutions Grant programs.

Housing assistance programs that are not targeted to persons with HIV, such as Public Housing and the Housing Choice Voucher programs, may not be able to provide timely assistance because they may not be readily available. HOPWA and Ryan White Part A grantees from three of the cities we visited, as well as staff from six organizations that received funding from these grantees, told us that the local public housing agencies had very long waiting lists and sometimes closed their Public Housing and the Housing Choice Voucher programs to new applicants. Staff from one non-profit agency that receives both HOPWA and Ryan White Part A funding told us that they require recipients of HOPWA or Ryan White Part A housing assistance to apply for public housing and the Housing Choice Voucher programs. However, staff said the local public housing agency has a long waiting list for both types of housing, and thus the client would not likely be able to benefit from these programs. Also, two of the HOPWA grantees with whom we met told us that even though the local public housing agencies had set up a preference for homeless persons with HIV, these agencies made few units available through this preference system.

According to officials from organizations that receive HOPWA and Ryan White Part A grant funds, housing assistance programs that are not targeted to persons with HIV, such as public housing and the Housing Choice Voucher programs, may not be appropriate because they are not required to provide supportive services. Table 4 shows the kinds of services these and other housing assistance programs provide, such as substance abuse or mental health counseling. While not required to do so, administrators of these programs may help individuals receive supportive services through other funding sources.

HIV advocates and a researcher told us that providing housing assistance without necessary medical care or other types of supportive services may not effectively facilitate housing stability or improved health for persons with HIV. Several of the organizations that received funding from HOPWA or Ryan White Part A grantees told us that their clients generally had mental health and substance abuse issues and would not thrive without intensive counseling. While some public housing agencies may offer their public housing residents access to a case manager or a staff member who can help the resident obtain the services that they need, public housing agencies are not required to offer this service. Additionally, HIV positive persons with criminal records or who engage in criminal activity may not be eligible for public housing and HCVs.HOPWA and Ryan White HIV/AIDS programs can provide housing assistance to persons with HIV who have criminal records.

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

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

HUD Field Office Staff Generally Follow Monitoring Policies for Selected Grantees

HUD’s field office staff have primary responsibility for monitoring HOPWA grantees, and we found that they were generally following monitoring policies for the four grantees that we visited. Field staff are responsible for conducting annual risk assessments of all Community Planning and Development grantees, which include recipients of HOPWA grants. To conduct these assessments, field staff must adhere to Risk Analysis Policy Notices and rate each grantee based on specific factors, including financial factors, the physical condition of projects, and staff capacity, among others. HUD field office staff use these factors to assess the risk level for each grantee and assign a numeric score. Grantees with risk assessments above a certain threshold are to receive onsite monitoring, unless the local HUD field office determines that the grantee can be excepted on the basis of additional HUD criteria and consideration of the field office’s travel and staffing resources.meet with HOPWA sponsor staff and review documentation related to the sponsor’s implementation of the program. HUD staff may identify findings that the sponsor is required to address. In conducting site visits, HUD staff are required to follow specific monitoring guidance related to the HOPWA program.

During site visits, HUD staff HUD has documented that it conducted risk assessments and onsite monitoring visits for formula and competitive HOPWA grantees from fiscal years 2008 through 2013. For the four formula HOPWA grantees we visited, HUD’s field office staff conducted 24 risk assessments— one assessment per year for each of the four HOPWA grants from 2008 through 2013. Nine of the 24 assessments indicated that the HOPWA grant met HUD’s criteria for triggering onsite monitoring. HUD field office staff subsequently conducted onsite monitoring for six of these nine grantees. For the three HOPWA grantees that HUD did not visit for onsite monitoring, the local HUD field office either did not have the resources to conduct the review or the site visit was excepted because the grantee had received a site visit within the previous 2 years, according to HUD.

HUD headquarters monitors HOPWA grantees’ compliance with the requirement to submit annual performance reports—the CAPER for formula grantees and the Annual Performance Report for competitive grantees. These reports include information on the activities funded, client characteristics, and outcomes related to housing stability, homelessness, and access to care and support. According to HUD officials and contractor staff, a contractor sends HOPWA grantees reminders prior to report deadlines, tracks receipt of the reports, and reviews the reports for completeness and internal consistency. HUD’s contractor also tracks the timeliness of the initial submissions of performance reports. According to the contractor’s data, 93 percent of the CAPERs and Annual Performance Reports for program year 2013 were submitted within 30 days of their due date. HUD’s contractor staff told us that they assisted grantees with any technical difficulties or internal inconsistencies until the report was submitted and met the contractor’s standards for reliability.

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

HRSA headquarters staff have primary responsibility for routine and onsite monitoring of Ryan White HIV/AIDS program grantees. Routine monitoring includes regularly scheduled phone calls and reviews of grantee reports. The purpose of routine monitoring is to assess grantees’ performance and compliance with statutory requirements, regulations, and guidance. HRSA staff are also responsible for conducting site visits with the grantees. Site visits are intended to provide an opportunity to review the grantee’s program and may serve as a technical-assistance session for the grantee. HRSA guidance states that site visits should be viewed as an opportunity to expand on information grantees have provided in their grant application, reports, and conference calls. During site visits, HRSA staff meet with grantee staff and may meet with staff from one or more of the subgrantees to obtain feedback on how the program is functioning. HRSA staff may also visit various locations at which subgrantees deliver services and review grantee and subgrantee program documentation.

HRSA staff with responsibility for the four Ryan White Part A grantees we visited reviewed risk-related information, conducted monthly monitoring calls, and provided technical assistance. HRSA staff reviewed single audit documentation, including risk-related information. Two of the four risk assessments indicated that the grantees had no major issues, and the other two showed deficiencies with internal controls. For the latter two, HRSA determined that these issues did not warrant a restriction in HRSA funding. HRSA staff also conducted monthly calls to grantees and summarized the discussions in electronic files. Additionally, HRSA staff provided technical assistance to Ryan White Part A grantees. For example, in 2013 HRSA arranged for a consultant to provide on-site technical assistance to one of the Part A grantees that we visited.

HRSA has increased onsite monitoring visits for Ryan White HIV/AIDS program grantees in response to our past recommendations. Specifically, our June 2012 report found that HRSA did not have written guidance describing its policy for selecting grantees to visit and did not prioritize site visits in the manner described to us. Moreover, 44 percent of all grantees did not receive a site visit from 2008 through 2011. We recommended, among other things, that HRSA develop a strategic, risk- based approach for selecting grantees for site visits to ensure that the visits were made at regular and timely intervals. HRSA addressed this recommendation by developing a risk-based approach for selecting grantees for site visits. Additionally, beginning in 2012, HRSA implemented a policy that all Part A and Part B grantees would receive site visits at least once every 5 years and more often if needed. According to our analysis of HRSA’s Part A site visits through 2013, HRSA staff conducted site visits to 11 of the 13 Part A grantees that had not been visited from 2008 through 2012. Additionally, 32 of 53 Eligible Metropolitan Areas and Transitional Grant Areas received a comprehensive site visit between July 2012 and July 2013.

HRSA has taken additional steps to address four other recommendations we made in 2012 to improve oversight of Ryan White HIV/AIDS program grantees. As of October 2014, all four of these recommendations had been implemented. The steps taken include the following: improved the functionality of an information system, the Electronic Handbook, to enable staff to better document their oversight and monitoring activities, including monthly calls, emails, and technical assistance; assessed, revised, and updated records management policies for HRSA staff with primary responsibility for monitoring grantees; created updated program manuals and posted the manuals on HRSA’s technical assistance website; and updated its monitoring standards and worked with grantees that faced challenges with implementing the standards.

Additionally, HRSA grantees are responsible for monitoring subgrantees, which are the organizations that grantees contract with to provide services to persons with HIV. In 2011 HRSA developed National Monitoring Standards for Parts A and B of the Ryan White HIV/AIDS program. These standards are designed to help Ryan White Part A and Part B grantees meet federal requirements for program and fiscal management, monitoring, and reporting. The standards were developed because of the need to establish specific standards governing the frequency and nature of grantee monitoring of subgrantees and create a clear role for HRSA staff in monitoring grantee oversight of subgrantees. HRSA staff with whom we met told us that they used these standards and expected grantees to use them to monitor subgrantees.

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

HUD headquarters staff collect annual performance data from HOPWA grantees on activities funded; client characteristics; and outcomes related to housing stability, access to health care, and unmet housing need. As noted earlier, HUD uses this information to create “performance profiles”—two-page summaries of this information—for each HOPWA grantee for each program year. Additionally, HUD creates annual performance profiles for the formula HOPWA program, the competitive HOPWA program, and both programs combined. Profiles are not cumulative—that is, they do not show the total number of clients served up to a point in time. Rather, the profiles provide data on the clients served during the previous program year. A HUD contractor posts all of the performance profiles on a HUD website.

HUD contractors are responsible for collecting Annual Performance Reports and CAPERs and using the data grantees report to create performance profiles. The contractors review the data for completeness and follow up with grantees regarding inconsistencies. According to HUD, its contractors also identify and document inconsistencies in data using current and previously submitted data for four areas: access to care, cost per unit, stability, and administrative costs. The contractors also document efforts to clarify and correct data related to these issues. However, HUD’s contractors told us that they do not compare current- year data to prior-year data for unmet housing need. In addition, HUD field office staff with whom we met stated that they did not compare grantee data from year to year to identify any potential data reporting errors.

Our analysis of the unmet housing need data collected through CAPERs from 2010 through 2013 found that some formula grantees reported significant changes in the number of HOPWA-eligible persons with an unmet housing need. For example, HUD data for 2012 indicated that 47 percent of the grantees reported changes of 30 percent or more in the number of persons with an unmet housing need compared with 2011 numbers. According to HUD’s data, in 2011 one grantee had 145 persons with HIV with unmet housing needs and 525,957 in 2012. Although changes in these estimates could be the result of increases or decreases in the need for housing assistance for persons living with HIV, large annual changes could also signal reporting errors. This and other examples are shown in table 5.

HUD headquarters officials told us that the dramatic differences could be the result of a change in the methodology used to report the figure, staff turnover among grantees, or changes in grantee capacity. Prior to our review, HUD officials had not followed up with grantees that had reported significant changes in unmet need between 2010 and 2013. In response to our review, HUD officials determined that one of the significant changes in unmet housing need from year to year was the result of a data entry error made by HUD’s contractor. Although HUD staff have requirements for reviewing the accuracy of CAPER and Annual Performance Reports, the requirements do not contain specific instructions for assessing performance data over time.

Federal internal control standards state that monitoring should assess the quality of performance over time and that activities need to be established to monitor performance measures and indicators. These controls could call for comparisons and assessments so that relationships can be analyzed and appropriate actions taken. has shown, leading organizations use performance information to identify gaps in performance, improve organizational processes, and improve their performance. By not analyzing trends in the unmet housing need data grantees are required to report, HUD may be missing opportunities to identify and address problems in grantee reporting. Moreover, by not following up on significant changes in the unmet housing need data submitted, HUD may be missing indications that these data for the program as a whole may not be reliable.

GAO/AIMD-00-21.3.1.

HRSA Collects Program Data but Does Not Monitor Housing Information

Although HRSA headquarters staff conduct routine monitoring of Ryan White HIV/AIDS program grantees, they do not focus on housing information. HRSA staff are responsible for overseeing Ryan White HIV/AIDS program grantees by routinely monitoring grantees’ performance and compliance with statutory requirements, regulations, and guidance. Routine monitoring includes regularly scheduled monitoring calls, reviews of grantee reports, and the provision of technical assistance to grantees. If during the course of routine monitoring HRSA staff find that a grantee has not met its program or financial requirements, the staff are responsible for determining whether the grantee requires more intensive monitoring. According to HRSA officials, agency staff with responsibility for monitoring can use resources like the National HIV/AIDS Strategy indicators to help grantees assess clients’ ability to access HIV care and treatment. HRSA staff are also responsible for monitoring any special conditions that are put in place. HRSA staff with responsibilities related to monitoring are the agency’s primary contact with grantees, and they are to communicate with their assigned grantees at least monthly.

HRSA’s routine monitoring efforts for the Ryan White HIV/AIDS program do not focus on housing assistance. For example, monthly monitoring calls between HRSA staff and grantees generally follow a standard agenda, and housing is not an agenda item. According to HRSA officials, housing is included when matters pertaining to housing assistance need to be discussed. Also, according to HRSA’s 2011 Housing Policy, Ryan White HIV/AIDS program grantees must provide an individualized written housing plan to HRSA staff if they request one. The plan must cover each client who is receiving short-term, transitional, or emergency housing services. However, the four HRSA staff members we visited who had responsibility for monitoring the grantees told us that they had never requested or reviewed individualized housing plans. According to HRSA officials, documents related to housing are reviewed only if housing needs are identified as a priority by the grantee and HRSA staff. In addition, while HRSA staff are responsible for monitoring grantee reports, including whether RSR reports are submitted to HRSA on time, they are not required to review or monitor the housing-related data submitted in these reports.

As noted earlier, federal internal control standards state that activities need to be established to monitor performance measures and indicators. These controls could call for comparisons and assessments so that analysis of the relationships can be made and appropriate actions taken. Controls should also be aimed at validating the integrity of performance indicators. In addition, our previous body of work has demonstrated the importance of using performance management indicators for various management activities and decision making. We have previously found that there are five leading practices that can enhance or facilitate the use of performance information: (1) aligning agency-wide goals, objectives, and measures; (2) improving the usefulness of performance information; (3) developing agency capacity to use performance information; (4) demonstrating management commitment; and (5) communicating performance information frequently and effectively.

HRSA staff with responsibility for monitoring grantees stated that they did not focus their monitoring efforts on housing because the primary focus of the program was medical care and because grantees spend a small portion of their grant funds on housing assistance. However, as previously noted the National HIV/AIDS Strategy emphasizes the importance of stable housing as a means of improving access to medical care for persons with HIV. The strategy states that access to housing is an important precursor to getting many people into a stable treatment regimen and emphasizes the importance of policies that promote access to housing. By not focusing attention on the housing data that grantees are required to report, such as housing status, HRSA staff with responsibility for program monitoring may be missing an opportunity to improve their management of grantees’ performance. Among other things, they may not be monitoring an important indicator in the National HIV/AIDS Strategy—the extent to which grantees are contributing to housing stability for persons with HIV.

Conclusions

HIV continues to pose a serious health threat even with advances in medicine. In order to manage programs that provide housing assistance for persons with HIV, agencies need to have reliable data and effective practices for using that data to manage program performance. First, HUD’s estimate of HOPWA-eligible individuals with an unmet housing need is based on data that HOPWA grantees develop using varying methodologies. While HUD advises grantees to use one or more of seven specific data sources, HUD does not require grantees to use these sources in a consistent and therefore comparable manner, as suggested by federal internal control standards and our work on data reliability. HUD has taken steps toward developing a standard methodology but has not established time frames for finalizing these efforts. As a result, the usefulness of HUD’s overall estimate is not clear. Furthermore, Congress may not have a complete understanding of the continuing need for programs that provide housing assistance to persons with HIV.

Second, the funding provided under HOPWA has filled important gaps in the availability of affordable housing in communities throughout the country. However, the current statutory formula for HOPWA has not kept pace with the changing nature of the disease. Congress recognized this shift in the 2000, 2006, and 2009 reauthorizations of the Ryan White HIV/AIDS program that required HIV case counts to be used in the distribution of Ryan White HIV/AIDS program funds. While we recognize that it may not be appropriate to use precisely the same formula for both HOPWA and the Ryan White HIV/AIDS program, the rationale for allocating funds on the basis of those currently living with HIV applies to both grant programs. Because HOPWA funds are awarded based on cumulative AIDS cases, these funds are not being targeted as effectively or equitably as they could be.

Third, HRSA relies on housing data reported by Ryan White HIV/AIDS program grantees to report on its progress in addressing one of the goals of the National HIV/AIDS Strategy but does not require grantees to ensure that these data are current. Internal control standards for the federal government state that events should be promptly recorded to maintain their relevance and value to management in controlling operations and making decisions. Without taking steps to ensure that grantee-reported housing status data are current, HRSA may not have reliable information to use in reporting on the extent to which Ryan White HIV/AIDS program clients are reaching the National HIV/AIDS Strategy goals for attainment of permanent housing.

We also found that HUD had not optimized its use of the performance information it required HOPWA grantees to collect. While HUD has processes in place to review the completeness and internal consistency of each grantee’s annual data submission, HUD has not established specific procedures to compare the unmet housing need data individual grantees submit from year to year. The extent to which persons with HIV have an unmet housing need speaks to the continuing need for the HOPWA program. Reported data on unmet housing need may vary significantly, and HUD does not have steps in place to determine if the local unmet housing need has changed or whether the grantee may need technical assistance. Without a specific process to make comparisons among the unmet housing need data individual grantees submit from year to year, in accordance with federal internal control standards, HUD may not be able to ensure that significant changes are identified and addressed if necessary.

Finally, HRSA has missed opportunities to help ensure that HRSA staff are using all available tools to effectively monitor grantee performance related to housing. While housing is not the primary objective of the Ryan White HIV/AIDS program, stable housing is critical to the health of persons with HIV, as HHS has acknowledged. Internal controls for the federal government note that activities need to be established to monitor performance measures and indicators. Moreover, we have reported on the importance of using performance management indicators for management activities and decision making. Without requiring HRSA staff with monitoring responsibility to review the housing data that individual Ryan White Part A grantees submit, HRSA may not be able to proactively identify performance issues, including the extent to which individual grantees are contributing towards housing stability.

Matter for Congressional Consideration

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

Recommendations for Executive Action

We make the following four recommendations:

To improve information on the unmet housing needs of persons with HIV and follow through on its efforts to develop a standard methodology, we recommend that the Secretary of HUD direct the Assistant Secretary for Community Planning and Development to require grantees to use comparable methodologies to analyze HUD’s recommended data sources on unmet housing need.

In order to improve the reliability of the housing data HRSA collects from Ryan White HIV/AIDS program grantees, we recommend that the Administrator of HRSA require program grantees that provide housing assistance to reflect each client’s current (within the previous 12 months) housing status in the client-level housing status data that they report to HRSA.

To help ensure that HUD is using grantee performance data to identify and address any irregularities or issues in grantee reporting, we recommend that the Secretary of HUD direct the Assistant Secretary for Community Planning and Development to develop and implement a specific process to make comparisons between the unmet housing need data submitted by individual grantees from year to year, including a process to follow up with grantees when significant changes are identified.

In order to promote the use of housing assistance data to monitor program performance, we recommend that the Administrator of HRSA require the HRSA staff who have primary responsibility for monitoring Ryan White HIV/AIDS program grants to monitor indicators of grantees’ performance in contributing towards housing stability, an HHS-identified indicator of HIV care.

Agency Comments and Our Evaluation

We provided a copy of this report to HUD and HHS for their review. In its written comments, which are reprinted in appendix III, HUD agreed with one of the two recommendations directed toward it and expressed concerns about the report’s description of the agency’s use of grantee data. In its written comments, which are reprinted in appendix IV, HHS agreed with both of our recommendations.

HUD agreed with our recommendation that it require HOPWA grantees to use comparable methodologies to analyze HUD’s recommended data sources on unmet housing need. However, the agency said that our report did not acknowledge the agency’s efforts to provide further guidance to communities beginning in the first quarter of fiscal year 2014. We requested documentation of such efforts, but HUD was unable to provide it. Our report notes that the Consolidated Annual Performance and Evaluation Reports (CAPER reports) describe the data sources that grantees can use to estimate unmet need. Our report also acknowledges an October 2014 meeting between HUD, stakeholders, and HOPWA grantees to discuss identifying and reporting on unmet housing need as well as HUD’s efforts to work with a contractor to develop a standard methodology. While these efforts are helpful steps toward developing a standard methodology, HUD does not have specific goals or time frames for finalizing this methodology.

HUD disagreed without our recommendation that it develop and implement a specific process to make comparisons between the data submitted by individual grantees from year to year, including a process to follow up with grantees when significant changes are identified. In its written response, HUD stated that the agency already conducts this type of analysis with contractor support. More specifically, HUD stated that data analysis is conducted using current and previously submitted data. However, HUD’s documentation of the contractor’s grantee-level analysis indicates that its trend analysis is focused on four areas: access to care, cost per unit, stability, and administrative costs. HUD’s documentation of its contractor’s analysis of data trends among formula grantees does not include other data elements collected through CAPER reports, including unmet housing need. Moreover, during the course of our review, HUD’s contractors told us that they do not assess grantee-level, year-to-year changes in unmet housing need. Based on our analysis of unmet housing need data collected from CAPER reports from 2010 through 2013, we found that some formula grantees reported significant changes in unmet housing need from year to year. As noted in the report, in response to our review HUD determined that its contractor had made data entry errors in some cases. In other cases, HUD had not followed up with the grantee and stated that dramatic differences could be attributed to a variety of causes, including grantee staff turnover or changes in grantee capacity. In addition, staff from the four HUD field offices we visited told us that they review CAPER reports but do not compare the information grantees report from year to year. We revised our recommendation to clarify that we are recommending that HUD analyze year-to-year trends in the unmet housing need data that individual grantees submit.

HUD also agreed with our matter for congressional consideration. Specifically, HUD agreed that HOPWA funds are not being targeted as effectively or equitably as they could be, based on the outdated HOPWA statute. HUD noted that it has continued to seek congressional action on a legislative proposal, which includes statutory changes that reflect advances in both HIV health care and surveillance. Our report acknowledges HUD’s efforts by discussing its proposal for updating the formula in its last three budget justifications.

In its general comments, HUD stated that the introductory part of the draft report (highlights page) would benefit from a more balanced approach to the discussion of the HOPWA program’s strengths and weaknesses. The report discusses the strengths of the HOPWA program as part of one of our research objectives. Additionally, the section of the report that focuses on coordination describes HUD’s and HRSA’s efforts to collaborate with one another and provides examples of formal and informal coordination at the local level to avoid providing duplicative services. We also revised our highlights page to note that HUD has taken steps toward developing a standard methodology for grantees to use to assess unmet housing needs.

In its letter, HUD also provided technical comments, which we addressed as appropriate. HUD disagreed that it uses unmet housing need data to justify its HOPWA budget request and to assess the performance of the program. Regarding the first part of this statement—that HUD uses unmet housing need data to justify its HOPWA budget request—we did not make a change to the characterization of HUD’s use of the data in its budget requests, and our analysis of HUD’s budget requests supports our characterization. While HUD’s technical comments characterized the agency’s use of unmet need data in its budget requests as an anecdotal data point, HUD uses this information to justify the continuing need for the program. As an example, HUD’s 2015 budget request notes that 131,164 HIV-positive households had unmet housing needs in the portion of the budget request that describes why the program is necessary. Regarding the second part of the statement with which HUD disagreed—that HUD uses unmet housing need to assess the performance of the program—we revised the report to state that HUD uses unmet housing need data for reporting on the performance of the program, rather than assessing the performance of the program. Specifically, the agency reports this information to the public not only through budget justification documents, but also through individual grantee and program-wide performance reports.

HUD also disagreed with the statement that the agency does not require HOPWA grantees to use a consistent methodology to calculate unmet need, and noted that formula grantees are required to report this need through CAPER reports. Our analysis of CAPER report guidance and grantees’ implementation of this guidance supports our characterization. As described in the report, according to CAPER guidance formula HOPWA grantees can use one or more of seven data sources to calculate unmet need, including housing providers’ waiting lists. However, HUD does not provide additional guidance on how these sources should be analyzed. As a result, grantees could use different methods for analyzing the same data sources. The report provides examples of how HOPWA grantees we interviewed use different methodologies to calculate unmet housing needs.

HUD also disagreed with the statement that agency officials had not followed up with grantees that had reported significant changes in unmet housing needs between 2010 and 2013, and stated that contracted support plays a role in the review and analysis of HOPWA data. Our report acknowledges contractors’ efforts to review HOPWA data for completeness and follow up with grantees regarding inconsistencies. However, our work supports our description of HUD’s efforts to follow up with grantees that reported significant changes in unmet needs between 2010 and 2013, and therefore we did not make changes. As an example, our analysis of the unmet need data grantees reported to HUD found that one grantee reported an unmet need of 145 persons in 2011 and 525,957 persons in 2012. HUD did not research this anomaly until presented with our analysis. Furthermore, the documentation HUD provided of its follow- up efforts with grantees did not include information about unmet housing need data.

HHS agreed with our recommendation that HRSA require program grantees that provide housing assistance to reflect each client’s current (within the previous 12 months) housing status in the client-level housing data that they report to HRSA. In its written comments, HHS also stated that HRSA does require Ryan White HIV/AIDS program grantees to maintain current clients’ housing status. As we discuss in the report, HRSA requires grantees to report data on clients’ housing status to HRSA every year. However, during the course of our review, HRSA officials told us that the frequency with which this information is updated is determined at the local level, and we found that this information may not be current. In its written comments, HRSA stated that it will update data instructions and provide a webinar for HRSA monitoring staff and Ryan White HIV/AIDS program grantees to help ensure that grantees are collecting data consistently and correctly. These actions, if implemented effectively, would address the intent of our recommendation.

HHS also agreed with our recommendation that HRSA staff who have primary responsibility for monitoring Ryan White HIV/AIDS program grants monitor indicators of grantees’ performance in contributing towards housing stability. HHS noted that HRSA had taken steps to provide monitoring staff with reports that show grantee-level data and HHS indicators. According to HHS, these reports support the monitoring of performance indicators, including housing status. Additionally, HHS stated that monitoring staff have begun to be trained on how to interpret these data. These are positive steps that should help HHS to more effectively monitor individual grantees’ contributions towards housing stability. HHS also provided technical comments, which we incorporated as appropriate.

We are sending copies of this report to the Secretary of Housing and Urban Development, the Secretary of Health and Human Services, and interested congressional committees. In addition, the report will be available at no charge on the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact me at (202) 512-8678 or garciadiazd@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs are listed on the last page of this report. GAO staff who made key contributions to this report are listed in appendix V.

Appendix I: Scope and Methodology

Our objectives were to discuss (1) the need for housing assistance for persons with the human immunodeficiency virus (HIV) and the extent to which federal assistance reaches communities in need; (2) the results that have been achieved through federal programs that provide housing assistance for persons with HIV and what is known about the strengths and weaknesses of these programs; (3) the extent to which federal programs that provide housing assistance and supportive services for persons with HIV coordinate with one another; and (4) the extent of federal oversight of programs that provide housing assistance to persons with HIV.

To identify information on the housing needs of persons living with HIV, we obtained and reviewed available data from the Department of Housing and Urban Development (HUD) on the unmet housing needs of HOPWA- eligible persons for program years 2010 (the earliest year for which HUD considered the data to be reliable) through 2013 (program year refers to grantees’ fiscal years, which may vary from the federal fiscal year). To assess the reliability of this information, we interviewed HUD officials, conducted electronic testing of the data to identify outliers as well as missing or duplicated data, and interviewed grantees of HUD’s Housing Opportunities for Persons with AIDS (HOPWA) program. We compared HUD’s methodology for calculating unmet housing need to internal control standards for the federal government, as well as GAO guidance on preparing reliable data. We determined that HUD’s unmet housing need data were not sufficiently reliable for the purposes of estimating the number of HOPWA-eligible individuals with an unmet need because they were based on data developed by HOPWA grantees using inconsistent methodologies.

We also analyzed the Centers for Disease Control and Prevention’s (CDC) fiscal year 2012 HIV surveillance data—the most recent data available at the time of our review—to identify and describe geographic trends in persons living with diagnised HIV infections as well as the demographic characteristics of persons diagnosed with HIV.the reliability of this information, we interviewed CDC officials and reviewed documentation of CDC’s methodology for collecting the data. We determined that the data were sufficiently reliable for the purpose of describing trends in HIV infection. To determine whether the Health Resources and Services Administration (HRSA) assessed the number of HIV-infected persons that might need emergency housing assistance, we reviewed HRSA guidance and interviewed HRSA officials. In addition, we reviewed requirements for Ryan White Planning Councils to assess local needs for HIV-related services. To identify the federal programs that provide housing assistance specifically for persons with HIV, we reviewed Congressional Research Service, GAO, HUD, and HRSA reports issued from 1997 through 2014 on housing for persons with HIV and interviewed HUD and HRSA officials. For HRSA’s Ryan White HIV/AIDS program, we focused on Part A because it can fund housing assistance; because Part A grantees expended significantly more of their funding on housing assistance than Part B grantees in 2011, and because, like HOPWA grants, Part A grants are generally awarded to local governments.

The MSA delineations are based on the 2000 Office of Management and Budget Standards for Delineating Metropolitan and Micropolitan Statistical Areas (implemented in 2003). of March 2011. This approach helped ensure that the two data sets were comparable to one another and corresponded to the data that would have been available in fiscal year 2012. These data were not adjusted for reporting delays. According to the CDC, estimates of persons living with HIV (i.e., HIV prevalence data) in a given year are generally more accurate when at least 12 months have elapsed since the end of the measurement period, as both diagnoses and deaths are often subject to reporting delays. The specific direction of any bias is unclear and may vary by jurisdiction. For each MSA, we calculated the absolute relative difference between cumulative AIDS cases and the number of cases of persons living with HIV (including AIDS). Additionally, we identified examples of MSAs that had similar numbers of persons living with HIV but received notably different amounts of HOPWA formula funds for fiscal year 2012.

We also compared the current HOPWA funding formula to our previous work that addressed funding grants based on cumulative AIDS cases, including the deceased. To describe HUD’s proposed changes to the HOPWA funding formula, we reviewed HUD’s congressional budget justifications for fiscal years 2013, 2014, and 2015.

GAO, Housing: HUD’s Program for Persons with AIDS, GAO/RCED-97-62 (Mar. 24, 1997) and HIV/AIDS: Changes Needed to Improve the Distribution of Ryan White CARE Act and Housing Funds, GAO-06-332 (Feb. 28, 2006). received both HOPWA and Ryan White Part A grants. We used HRSA’s 2011 Ryan White HIV/AIDS program expenditure data to identify grantees that had spent Ryan White Part A funds on housing assistance. We compared the locations of the Ryan White Part A grantees that had funded housing assistance to locations of the formula HOPWA grantees and selected four cities that had both. We based our selection on grant size (i.e., grant amounts at either the higher end or middle of the range in fiscal year 2011), the presence of Ryan White Part A grantees that had expended Ryan White Part A funds on housing assistance, and geographic diversity. Based on this analysis, we selected New York City, New York; New Orleans, Louisiana; San Francisco, California; and St. Louis, Missouri. In each city, we interviewed officials from the formula HOPWA grantees and Ryan White Part A grantees; one or more HOPWA project sponsors; one or more Ryan White Part A subgrantees; the local HUD field office; the local Continuum of Care grantee; and at least one HIV advocacy organization. We selected HOPWA project sponsors and Ryan White Part A grantees based on discussions with grantee staff and selected advocacy organizations based on information from a national HIV advocacy organization about active local HIV advocacy organizations. We also toured housing that was funded through formula HOPWA funds or Ryan White Part A in each city, including emergency housing, a permanent housing facility, and a hospice, to see how the funds had been used. To obtain views on the impact of the HOPWA and Ryan White HIV/AIDS Programs in rural areas, we also interviewed the State AIDS Directors for California, Louisiana, Missouri, and New York.

To determine the results that have been achieved through federal programs that provide housing assistance to persons with HIV, we obtained and analyzed HOPWA data on how funds were used and client characteristics for program years 2009 through 2012. To assess the reliability of the HOPWA data, we interviewed HUD officials and contractors that had responsibility for processing information about their data reliability procedures. We also conducted electronic testing for missing data, outliers, or obvious errors. We found that most data were reliable for the purposes of describing how funds were used and identifying the characteristics of the persons who benefitted from housing assistance. As previously noted, we found that HUD’s data on unmet housing need were not sufficiently reliable for our purposes.

For the Ryan White HIV/AIDS program, we obtained and reviewed Ryan White HIV/AIDS Program Services Report (RSR) data for Part A, and for fiscal years 2010 through 2012. Agency officials told us that 2009 data were only available in aggregate form and not by Part A grantee. To assess the reliability of HRSA’s Ryan White Part A data related to housing assistance, we reviewed HRSA guidance and policies, interviewed HRSA officials with responsibility for processing the data, interviewed four HRSA Program Officers, and conducted electronic testing. We also compared HRSA’s methodology for calculating the percentage of Ryan White HIV/AIDS program clients who had stable housing to internal control standards for the federal government. Because HRSA does not require grantees to regularly update each client’s housing status, we determined that housing status data were not sufficiently reliable for our purposes. Also, we obtained and analyzed expenditure data for both programs. For HOPWA and Ryan White Part A, the most recent years of expenditure data were 2012 and 2011, respectively. For HOPWA, we analyzed program data on activities funded (e.g., housing assistance, housing development, supportive services); types of housing assistance funded (e.g., tenant-based rental assistance, permanent facilities); and demographic characteristics (e.g., sex, race, ethnicity, age, income). For the Ryan White HIV/AIDS program, we analyzed RSR data on the number and proportion of clients who received housing assistance through Part A. For those clients who did receive housing assistance, we analyzed demographic characteristics (sex, race, ethnicity, age, earnings relative to the federal poverty level).

To describe the strengths of the HOPWA and Ryan White Part A programs, as well as any weaknesses associated with these programs, we reviewed program requirements; identified studies through a search of various databases using keywords such as “HOPWA” and “Ryan White”; and interviewed a purposive sample of program grantees, HOPWA project sponsors, and Ryan White Part A subgrantees. We also interviewed HIV advocates, HUD and HRSA officials with responsibilities related to the HOPWA and Ryan White HIV/AIDS programs, and an academic researcher on HIV and housing who had co-authored various articles on housing for persons with HIV in New York City. Upon completion of our initial search, we identified eight studies that discussed the effects of housing assistance programs on persons with HIV. We reviewed the studies’ methodology, limitations, and conclusions for the purposes of excluding studies that did not ensure a minimal level of methodological rigor and excluded two studies. Of the six remaining studies, two were randomized control trial studies, one was a cross- sectional study, and one used a quasi-experimental design. Two had weaker research designs but were retained since they were sufficiently rigorous and, given the limited number of empirical studies on this subject, provided useful information on the importance of access to housing for medical outcomes for people living with HIV.

To assess the extent to which the HOPWA and Ryan White Part A programs coordinated with each other at the federal level, we identified program requirements in the governing legislation for the HOPWA and Ryan White HIV/AIDS programs. We also obtained and reviewed documentation of HUD’s and HRSA’s efforts to coordinate with each other, interviewed HUD and HRSA officials about these efforts, and compared the efforts to GAO’s criteria related to coordination and program overlap.

GAO, Housing Assistance: Opportunities Exist to Increase Collaboration and Consider Consolidation, GAO-12-554 (Washington, D.C.: Aug. 16, 2012) and Housing Assistance: An Inventory of Fiscal Year 2010 Programs, Tax Expenditures, and Other Activities, GAO-12-555SP (Washington, D.C.: Aug. 16, 2012), an E-supplement to GAO-12-554. the list of housing programs. For the five programs, we compared their primary goals, client eligibility requirements, requirements related to supportive services, and the specific types of housing assistance that could be provided. We also discussed whether and how HOPWA and Ryan White Part A grantees coordinated with these programs during our site visits to the purposive sample of cities. Additionally, we reviewed the Catalog of Federal Domestic Assistance program descriptions, program information from each program’s website, and prior GAO reports to determine each program’s size, administering agency, and assistance type. Finally, we interviewed HIV advocacy groups, HOPWA and Ryan White Part A grantees, HUD and HRSA officials, and an academic researcher about housing assistance and services for persons with HIV.

To assess HUD and HRSA’s monitoring and oversight efforts, we identified and reviewed their monitoring policies, procedures, and guidance. We also interviewed HUD headquarters and field office staff with responsibilities related to HOPWA grantee monitoring, as well as HRSA staff who had primary responsibility for monitoring Ryan White Part A grantees. We compared HUD’s risk assessment policies for program years 2008 through 2013 to documentation on the implementation of these procedures for the four HOPWA grantees we visited, including documentation of risk assessments and site visits conducted. For the Ryan White HIV/AIDS program, we reviewed the status of five previously issued GAO recommendations related to program monitoring and oversight and summarized HRSA’s efforts to address these recommendations. We also analyzed updated HRSA data on Part A site visits conducted in 2012 and 2013. Additionally, we interviewed both HUD and HRSA officials on how they use performance data to monitor HOPWA and Ryan White Part A grantees. For HOPWA, we reviewed documentation of HUD’s use of performance data for program years 2009 through 2013. For the Ryan White HIV/AIDS program, we reviewed published reports on the agency’s use of housing-related performance data. We compared HUD and HRSA’s monitoring efforts to federal internal control standards as well as practices that leading organizations used related to managing for results.

We conducted this performance audit from March 2014 to April 2015 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on the audit objectives.

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

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

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

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

Appendix V: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

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