Persons with HIV: Funding Formula for Housing Assistance Could Be Better Targeted, and Performance Data Could Be Improved
Highlights
What GAO Found
The extent to which persons with human immunodeficiency virus (HIV) need housing assistance is not known, in part because the Department of Housing and Urban Development's (HUD) estimate of the housing needs of persons with HIV, including those with Acquired Immune Deficiency Syndrome (AIDS), is not reliable. HUD does not require Housing Opportunities for Persons with AIDS (HOPWA) grantees to use a consistent methodology to calculate unmet need. The agency has taken steps towards developing a standard methodology, but it has not established time frames for finalizing these efforts. GAO's work on assessing data reliability indicates that data should be consistent. Because HUD does not require grantees to use selected data sources in a consistent manner, the reported information on unmet housing needs of persons with HIV are not comparable across jurisdictions and are not useful and reliable. In addition, the statutory HOPWA funding formula is based on cumulative AIDS cases since 1981, including persons who have died, rather than on current numbers of persons living with HIV (including those with AIDS). This approach has led to areas with similar numbers of living HIV cases receiving different amounts of funding. Because HOPWA funds are awarded based on cumulative AIDS cases, these funds are not being targeted as effectively or equitably as they could be.
Agency data for HOPWA and the Health Resources and Services Administration's (HRSA) Ryan White program indicate most recipients of assistance obtained stable, permanent housing, but Ryan White housing data may have limitations. HRSA, within the Department of Health and Human Services, does not require Ryan White grantees to maintain current data on clients' housing status. However, it uses the data that grantees report to calculate the proportion of clients that have stable housing. HRSA is charged with tracking Ryan White clients' housing status as a part of the White House's National HIV/AIDS Strategy. Federal internal control standards state that events should be promptly recorded to maintain their relevance and value to management in controlling operations and making decisions. Because HRSA does not require grantees to maintain current data on clients' housing status, HRSA's data may be of limited usefulness in tracking the National HIV/AIDS Strategy goal of improving clients' housing status.
HUD and HRSA perform oversight activities but may be missing opportunities to use data to improve performance. HUD staff conduct risk-based monitoring of HOPWA grantees, and HRSA staff have improved monitoring of Ryan White grantees. HUD and HRSA both collect performance data from their grantees and take steps to ensure that the data are complete and submitted in a timely manner. HUD uses performance data to create summaries of program performance but does not have a specific process for comparing individual grantees' year-to-year data for unmet housing need. Federal internal control standards note the importance of such comparisons. By not analyzing these trends, HUD may not be identifying and addressing reporting problems. In addition, HRSA staff responsible for monitoring Ryan White grantees do not review grantee data on housing assistance provided. Federal internal control standards state that activities need to be established to monitor performance measures. By not focusing attention on housing data, HRSA staff with monitoring responsibility are not proactively using available resources to monitor individual grantees' contributions to the National HIV/AIDS Strategy goal of improving clients' housing status.
Why GAO Did This Study
Over 1.2 million people in the United States are estimated to have HIV, and about 50,000 new infections occur each year. Research has shown that persons with HIV who lack stable housing are less likely to adhere to HIV care. HUD's HOPWA program and HRSA's Ryan White program provide grants to localities that can be used to fund housing and supportive services specifically for persons with HIV.
GAO was mandated to review housing assistance for persons with HIV. This report addresses (1) the need for housing assistance for persons with HIV and the extent to which assistance reaches communities in need, (2) results achieved through HOPWA and Ryan White, and (3) federal oversight of these programs. For both programs, GAO analyzed program data on persons served and outcomes achieved as of 2012, reviewed policies, interviewed agency officials, and visited a non-generalizable sample of four geographically diverse cities that received varying amounts of both HOPWA and Ryan White funding.
Recommendations
If Congress wishes HOPWA funding to be more effectively targeted, it should consider revising the funding formula to reflect the number of living persons with HIV. GAO also recommends that (1) HUD require a consistent methodology for estimating unmet housing needs and (2) both HUD and HRSA improve the reliability and use of performance data to manage their programs. HRSA agreed with GAO's recommendations. HUD agreed with the first recommendation but disagreed with the second, stating that it already assesses trends in some program data. GAO clarified that HUD should identify reporting issues by analyzing trends in its unmet housing need data.
Matter for Congressional Consideration
| Matter | Status | Comments |
|---|---|---|
| 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. | On July 29, 2016, the President signed into law the Housing Opportunity Through Modernization Act of 2016. The law directs the Department of Housing and Urban Development (HUD) to allocate Housing Opportunities for Persons with AIDS (HOPWA) funds to jurisdictions based on the number of persons living with HIV or AIDS, according to the most current Centers for Disease Control and Prevention data available. The law also directs HUD to develop an allocation method that accounts for differences in housing costs and poverty rates. By allocating HOPWA funds based on the number of persons with HIV (including AIDS), and taking into consideration both housing costs and poverty rates, HUD will be better able to help ensure that HOPWA funding more closely accounts for housing needs among persons living with HIV. |
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Housing and Urban Development | To improve information on the unmet housing needs of persons with HIV and follow through on its efforts to develop a standard methodology, the Secretary of HUD should 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 December 2016, HUD provided GAO with documentation of a standard methodology for annually estimating unmet housing need for persons with HIV by metropolitan statistical area and state. Through this approach, HUD will use a methodology that incorporates Centers for Disease Control (CDC) data on persons living with HIV, as well as a CDC estimate on the percentage of persons with HIV that live in poverty.
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| Health Resources and Services Administration | In order to improve the reliability of the housing data HRSA collects from Ryan White HIV/AIDS program grantees, the Administrator of HRSA should 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. |
The Health Resources and Services Administration (HRSA) updated the 2015 Ryan White HIV/AIDS Services Report instruction manual to state that grantees should be continually aware of clients' housing status. In addition, HRSA conducted training for Ryan White grantees in October 2015 and highlighted this update. Training materials note that grantees should be continually aware of their clients' housing status. By updating its guidance and providing training to those that are responsible for collecting housing status data, HRSA has taken steps to improve the reliability of data on the housing status of persons receiving housing assistance through the Ryan White program.
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| Department of Housing and Urban Development | To help ensure that HUD is using grantee performance data to identify and address any irregularities or issues in grantee reporting, the Secretary of HUD should 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 December 2016, HUD provided GAO with an updated methodology for estimating unmet housing need among persons living with HIV. As a part of the updated methodology, HUD will no longer rely on unmet need data submitted by individual grantees. Rather, HUD will use a methodology that is standard across all HOPWA grantees to estimate the number of persons living with HIV that may have an unmet housing need. By taking steps to standardize its methodology, and calculate unmet need itself, HUD has addressed the potential for irregularities in grantee reporting that can affect the reliability of its estimates.
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| Health Resources and Services Administration | In order to promote the use of housing assistance data to monitor program performance, the Administrator of HRSA should 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. |
According to the Health Resources and Services Administration's (HRSA) June 2015 letter to GAO and supporting documentation it provided, the agency developed grantee level data reports to facilitate better monitoring of grantee performance indicators, including housing status. Monitoring staff were provided with these reports in October 2014 and April 2015, and will be provided with annual updates. The agency provided training to HRSA staff with primary responsibility for monitoring Ryan White HIV/AIDS program grants on how to use the grantee level data reports. For example, according to the training materials, monitoring staff will use the information to facilitate discussions with grantees about clients' housing status as well as steps that could be taken to improve clients' housing status. By establishing and implementing these procedures, HRSA has taken steps to help ensure that HRSA staff are using available tools to more effectively monitor grantee performance related to housing.
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