In the United States, it is estimated that more than 1.1 million people are infected with HIV/AIDS (Centers for Disease Control and Prevention [CDC] 2013). Data indicate that individuals with HIV infection suffer far greater housing instability and homelessness than the general population: an estimated one-third to one-half are homeless or at risk of becoming homeless (Rourke et al. 2010). Homelessness and unstable housing are linked to higher risk of HIV infection, inadequate health care, poor health outcomes, and early death (National AIDS Housing Coalition 2007). People living with HIV/AIDS (PLWHA) who lack stable housing are more likely to delay entering HIV care and less likely to have access to regular care, to receive anti-retroviral therapy (ART), or to adhere to their HIV medication regimen (White House Office of National AIDS Policy 2010).
Unable to afford housing, some PLWHA turn to federal HIV programs for assistance. The two main sources of federal housing assistance targeted specifically for PLWHA are the Housing Opportunities for Persons With AIDS program (HOPWA), provided through the U.S. Department of Housing and Urban Development (HUD), and the Ryan White HIV/AIDS Program (RWP), provided through the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS).
In 2010, the Obama administration created a National HIV/AIDS Strategy (NHAS), designed to reduce the number of new HIV infections, increase access to HIV care, optimize health outcomes for PLWHA, and reduce related disparities (White House Office of National AIDS Policy 2010). Recognizing the role of housing in the HIV epidemic, NHAS identified ways to increase federal HIV housing supports. HHS, designated as the lead agency for implementing federal activities under the NHAS, is responsible for monitoring national progress toward meeting its goals. To address the NHAS goal of greater access to HIV care, in 2011, the HUD Office of HIV/AIDS Housing awarded seven competitive Integrated HIV/AIDS Housing Plan (IHHP) grants that were designed to integrate housing assistance with HIV care and other supports at the individual-service and community planning levels.
In 2012, the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) contracted with the Mathematica Policy Research/Cloudburst team to analyze current federal HIV housing assistance services and study best practices integrating HIV housing and health care services. This project includes a quantitative study of the costs, utilization, and outcomes of current federal HIV housing assistance, as well as a qualitative study of innovative HUD program models integrating housing assistance with HIV care. The overall goals of the project are (1) to review the current status of HIV housing programs; and (2) to document innovative, replicable program models integrating housing assistance with HIV health care.
A. Purpose of the Report
The purpose of this report is to present the findings from the project’s quantitative analysis of federal HIV housing programs and qualitative study of a set of IHHP grantees. The report aims to answer the following questions for each component:
Quantitative HIV Housing Analysis Research Questions:
- What is the prevalence and incidence of HIV/AIDS in the United States?
- What proportion of the HIV/AIDS population receives federal HIV housing assistance?
- What is the level of funding for federal HIV housing assistance?
- What federal HIV housing assistance services are provided?
- What are the characteristics of participants in federal HIV housing programs?
- What are the outcomes of federal HIV housing assistance programs?
- Can available federal data support an analysis of the association between housing assistance, enhanced housing status, increased access and retention in HIV care, and improved clinical outcomes?
Qualitative Study of Integrated HIV Housing Research Questions:
- What are best practices among HOPWA’s integrated HIV housing programs?
- How do these program models integrate housing and HIV care at the individual service, organizational data management, and community planning levels?
- How do these programs identify and enroll eligible people, assess their service needs, and integrate housing, HIV care, and other supports?
- How do these programs link housing and health care data in their organizational data systems?
- How is the planning and coordination of housing, HIV care, and other support services integrated at the community level?
- What approaches promote or hinder the integration of housing, HIV care, and other support services?
B. Information Sources and Study Methods
The quantitative study analyzed HUD and HRSA administrative data from HOPWA and RWP. In addition, the team obtained publicly available HIV surveillance data from the CDC and homeless services needs assessment and service data from the HUD Office of Special Needs Assistance Programs. The study team finalized a statistical analysis plan based on the study objectives and on the aggregate nature of the data available, and conducted descriptive analyses of each of the variables of interest and compiled state and national summaries. The team also compared HOPWA and RWP services (such as relative percentages of participants served by type of housing assistance, income level, or demographics). For HOPWA data, the average cost per person served by specific type of housing was also calculated. The analysis drew on information from multiple sources (See Appendix A for details):
- HOPWA Consolidated Annual Performance Evaluation Reports (CAPER) (2007-2010)
- HOPWA Annual Performance Reports (APR) (2007-2010)
- 2010 Annual Homeless Assessment Report (AHAR)
- Homeless Management Information System (HMIS) (2010)
- Ryan White Program Expenditure Reports (2007-2010)
- Ryan White Program Data Reports (RDR) (2007-2010)
- Ryan White Services Report (RSR) (2010)
The qualitative study selected program models drawn from HUD’s seven IHHP grantees in 2011. In May 2013, Mathematica and Cloudburst conducted in-person site visits to four of the seven sites: (1) the River Region Human Services (RRHS) FUSE project in Jacksonville, Florida; (2) the Frannie Peabody Center (FPC) statewide IHHP project; (3) the Portland (Oregon) Housing Bureau (PHB) S4H project; and (4) the Albany Corporation for AIDS Research, Education, and Services (CARES) Foundations for Living (FFL) project in upstate New York. The one-day in-person visits at each site included discussions with IHHP grantees, community partners, and RWP grantees and service providers. Interviews were conducted with IHHP grant administrators, local housing program directors, IHHP housing coordinators, RWP-funded medical case managers, local IHHP grant evaluators and data systems managers, and other local housing agencies involved in planning community-level housing. Appendix L contains the study’s site visit interview protocols.
The study collected information from the four IHHP grantees about three levels of activity: (1) the integration of program policies and practices at the client level; (2) efforts to integrate housing and health care data systems; and (3) community-level efforts to coordinate and align HIV housing, health care, and other support services. Site profiles were created using information gathered during the discussions and based on review of program documents, including grant applications, site reports, and APR data. The site profiles were systematically coded and analyzed to address the study’s research questions. The project also used a mixed-methods approach to integrate the quantitative and qualitative studies and findings. Early findings from the quantitative analysis were used to inform the selection of the four sites for the IHHP case studies and to inform site visit topics and questions. For example, in the site visits, we asked questions about the compatibility of the HOPWA and RWP data sets, based on challenges encountered in the quantitative analysis.
C. Organization of this Report
The rest of this report comprises three chapters. Chapter II presents the findings from the quantitative analysis, providing an overview of the HIV/AIDS epidemic and key features of HOPWA and RWP, including their funding, service utilization, and participant characteristics and outcomes. Chapter III presents the findings from the qualitative study, comparing the integration of housing and HIV care in four IHHP site program models, and focusing on their client services, data systems, and community planning processes. Chapter IV offers ideas for improving the integration of federal housing, HIV care, and other support services for PLWHA.