Housing Opportunities Missed and Lost

By: Marcus J. Hopkins, Founder & Executive Director, Appalachian Learning Initiative

In December 2021, a Ryan White Part B caseworker contacted me to ask whom I knew in the West Virginia Housing Opportunities for Persons With AIDS (HOPWA) state's office. In the few months prior to this request, the Part B office had been beset with clients reaching out to their Ryan White HIV/AIDS Program (Ryan White) caseworkers in frustration and desperation:

"I've been trying to reach my HOPWA caseworker for three months, and nobody will call me back."

"I filled out the paperwork in June, but I haven't heard anything back, and it’s October."

"My electricity was just disconnected after HOPWA didn't pay the bill for three months."

"I've received an eviction notice after HOPWA didn't pay the rent for two months in a row."

"The sober living facility has told me that if HOPWA doesn’t come through with my rent payments, I’ll have to find another place to live."

It turned out that this inability to reach HOPWA caseworkers was not isolated to clients—the Ryan White caseworkers and West Virginia state officials were unable to get responses, either. In the midst of a global pandemic, when having stable housing meant the difference between being able to quarantine and being out in the elements with no protection, one of West Virginia's HOPWA grantees has all but collapsed, leaving clients scrambling to find solutions to problems they were promised would be solved and other state and federal programs scrambling just as desperately to pick up the pieces.

What is HOPWA, and How Does it Work for Grantees and Patients…or Not?

The HOPWA program was created in 1992 through the AIDS Housing Opportunity Act to address the critical housing needs of lower-income Americans living with HIV and their families (AIDS Housing Opportunity Act, 1992). This Act situated the HOPWA program in the U.S. Department of Housing and Urban Development (HUD), making it one of the only HIV-related services and assistance programs situated outside of the U.S. Department of Health and Human Service (HHS). It is also the only program dedicated to the housing needs of People Living with HIV/AIDS (PLWHA).

HOPWA is funded through two mechanisms:

1. Formula Grants:

Ninety percent (90%) of the allocated HOPWA funds are dedicated to what HUD defines as formula grantees, including states and cities within metropolitan statistical areas or jurisdictions, which either administer the funds themselves or sub-contract with local agencies. Health Centers can partner with these local grantees and agencies. THESE GRANTS ARE NON-COMPETITIVE!

2. Competitive Grants:

Ten percent (10%) of the funds fall under competitive grants, which can be awarded to state and local governments and non-profit organizations. Competitive grants are only awarded when funds are available after formula contracted grants are renewed. This means that funds can be administered by a range of entities for each community, from local HIV/AIDS service providers to city and state housing and community development departments or public health departments, and/or partnerships with health centers. (Corporation for Supportive Housing, 2018).

The funds, themselves, are designated for the following purposes:

• The acquisition, rehabilitation, or new construction of housing units
• Costs for facility operations
• Rental assistance and short-term payments to prevent homelessness.
• The coordination and delivery of support services including (but not limited to):
• Assessment and case management
• Substance abuse treatment
• Mental health treatment
• Nutritional services
• Job training and placement assistance
• Assistance with daily living (HUD Exchange, 2022a)

In 2016, outgoing President Barack Obama signed the Housing Opportunity Through Modernization Act (HOTMA) in an effort to better address housing needs across the various HUD-situated housing programs, including HOPWA (HOTMA, 2016). One of the primary changes to HOPWA included revising the statute to include “people living with HIV” rather than just those living with a clinical diagnosis of "AIDS". This effectively changed the formula from:

• Original Formula - # of cumulative AIDS cases

to:

• Modernized Formula - # of people living with HIV/AIDS (and other factors)

The change to the formula that determines funding essentially means that funds can and will shift according to the geographic jurisdictions with the highest incidence of people living with HIV from year to year. It also set a new baseline for eligible jurisdictions of 2,000 living HIV/AIDS cases. Additionally, it removed the requirement that 25% of funds be distributed to cities based on AIDS incidence and introduced a new requirement that 25% of funds be distributed based on local Fair Market Rents (FMRs) and poverty rates (HUD Exchange, 2017)

Figure 1. HOPWA Formula Modernization Through the Housing Opportunities Through Modernization Act

Source: HUD Exchange, 2017

How HOPWA Works for Grantees But Fails People Living With HIV

From the very outset, it should be made clear that the HOPWA program, along with virtually every resource available on the Internet, is geared not toward PLWHA (read: "clients" or "patients"), but toward Grantees. From the patient's perspective, finding even basic information about the HOPWA program, one’s eligibility for the program, how to apply, whom to contact, or how to resolve issues with grantees is a Sisyphean task. This issue is further complicated by the fact that there are no comprehensive lists of grantees, contact information, service provision, application processes, or housing availability.

Approximately 7% of Ryan White HIV/AIDS Program (RWHAP) clients had temporary housing, and nearly 5% had unstable housing in 2020, with the highest reported housing-insecure age groups being those aged 20-39. Just 72.7% of RWHAP clients experiencing housing insecurity are retained in care. 76.8% of patients experiencing housing insecurity achieved viral suppression in 2020 (Health Resources and Services Administration, 2021). Because of this, stable housing is vital for achieving and maintaining viral suppression in order to decrease the transmission of HIV in the United States.

Most HOPWA grants are non-competitive, meaning that the funds are automatically awarded to specific jurisdictions based on the formula outlined in Figure 1. Those funds are then either administered directly by those jurisdictional governments or regranted and disbursed to contracted organizations within the jurisdiction to provide direct services. The competitive granting process is contingent upon whether or not any funds remain after the non-competitive grants are awarded.

Part of what makes this process frustrating for both patients and grantees is that federal allocations for HOPWA are low relative to the actual cost of housing. For the 2017-2018 Fiscal Year (FY 2017-2018), total HUD funding amounted to $54.66 billion (HUD, 2019b). Of that, $351.5 million—just 0.6% of the total HUD Congressional allocation (Figure 2)—was dedicated to the HOPWA Program (HUD, 2019a).

Figure 2. United States Department of Housing and Urban Development Funding, FY 2018

Sources: HUD, 2019a and 2019b

This low level of federal funding for the only housing program designed explicitly for PLWHA means that grantees are only able to serve a limited number of households (meaning one patient per household). Even if patients are lucky enough to figure out how to apply for the HOPWA program, they are very likely to encounter waiting lists in virtually every jurisdiction. An excellent example of this exists in the state of Delaware:

In 2021, Delaware received a total of $1,951,658 in HOPWA funding (HUD Exchange, 2022b):

• $1,160,648 in Formula grants
• Delaware (Balance of the State) – $336,185
• Wilmington, DE – $824,463
• $791,010 in Competitive grants
• Ministry of Caring (Wilmington, DE)

While Delaware has 3,483 PLWHA living in the state (Delaware Department of Health and Social Services, 2021), its HOPWA program currently serves approximately 150 households—just 4% of the state’s PLWHA population (Delaware HIV Consortium, n.d.). Despite serving just 150 households.

Delaware is one of the more straightforward states to examine. In Ft. Lauderdale, FL, we received reports of 8-year-long waiting lists to fill just a handful of spots. These waiting lists will only grow as PLWHA live longer, earn less, and remain financially eligible for the program.

Attempting to Find Patient-Friendly HOPWA Information

As part of this research effort, the Appalachian Learning Initiative (APPLI, pronounced "apply") conducted a web search to find state-level information about HOPWA programs across the United States and Puerto Rico. Using the search term "[STATE NAME] apply for HOPWA", APPLI searched for state-sponsored websites that provide patient-centered content, including: 

• HOPWA Program Information
• Services Provided
• Eligibility Criteria
• Application Processes
• Required Documentation (e.g., identification, income verification, proof of HIV status, et cetera)
• Regional Office Contact Information
• State Office Listing and Contact Information
• Grantee Listing and Contact Information
• Processes for Client-Initiated Complaints

This search was restricted to state-level sites rather than jurisdiction- and grantee-level websites. While 27 states had websites with patient-centered content, just 8 states (FL, GA, IA, ME, NM, OR, SC, and WA) met at least 6 of the 8 information criteria. Twelve (12) states had no state-level HOPWA information (Figure 3 & Appendix 1). Download Appendix 1.

Figure 3. State Housing Opportunities for Persons With AIDS (HOPWA) Websites

Source: Appalachian Learning Initiative

While most states had some HOPWA information available on state-level websites, just 21 state websites listed the names of HOPWA grantees and subgrantees in the state, and only 18 provided contact information for those grantees. Moreover, only 12 state websites provided information about the application process and/or the documents required to apply. Virtually no website mentioned the number of clients served, the status of waitlists or the current wait times on those lists, or outlined a complaint process for client-initiated grievances (e.g., reporting grantees that fail to remit payments in a timely manner). Another unique factor to illustrate was that, for many states, finding these information points required downloading and searching multipage documents filled with complicated processes clearly designed for grantees, rather than patients (APPLI, 2022).

The Need for a Better Resource

The primary issue that APPLI’s research has uncovered is a vast dearth of patient-centered and patient-friendly information available to PLWHA about the HOPWA program. It is, essentially, a program that serves relatively few clients compared to the number of patients in need of housing assistance. This has created an environment where HIV advocates consistently highlight the need for more funding but rarely examine how PLWHA are impacted by how those funds are allocated, disbursed, and utilized.

With this in mind, the Appalachian Learning Initiative has entered into the planning phase of developing a national HOPWA Directory and a patient-centric HOPWA research initiative.

This idea is in its infancy, but I firmly believe that the patient voice is vital to initiating change, as with most public health issues. There will be obstacles to overcome—funding for these initiatives being one of the greatest—but ensuring that patients are easily able to access information about housing assistance for PLWHA is most certainly worth the effort.

Stay tuned for more information as it becomes available.

References:

• AIDS Housing Opportunity Act, 42 U.S.C. Ch. 131 §§12901-12912 (1992). http://uscode.house.gov/view.xhtml?path=/prelim@title42/chapter131&edition=prelim
• Appalachian Learning Initiative. (2022, June 07). State Housing Opportunity for Persons with AIDS Websites. Unpublished.
• Corporation for Supportive Housing. (2018). HUD Policy Brief: Understanding the Impact and Potential for Health Centers. New York, NY: Corporation for Supportive Housing. https://www.csh.org/wp-content/uploads/2018/03/CSH_HUD-Briefs_-HOPWA.pdf
• Delaware Department of Health and Social Services. (2021, January 22). DELAWARE HIV SURVEILLANCE REPORT FOR CASES DIAGNOSED THROUGH DECEMBER 2019. New Castle, DE: Delaware Department of Health and Social Services: Department of Public Health: Health Data and Statistics: HIV Statistics – Epidemiology/Surveillance Profile. https://www.dhss.delaware.gov/dhss/dph/epi/files/2020hivepiprofile.pdf
• Delaware HIV Consortium. (n.d.). HIV Housing Programs. Wilmington, DE: Delaware HIV Consortium: Housing Programs. https://www.delawarehiv.org/housing-programs/
• Department of Housing and Urban Development. (2019a). FY 2020 CONGRESSIONAL JUSTIFICATIONS: COMMUNITY PLANNING AND DEVELOPMENT: HOUSING OPPORTUNITIES FOR PERSONS WITH AIDS (HOPWA). Washington, DC: United States Department of Housing and Urban Development: Program Offices: Chief Financial Officer: Reports. https://www.hud.gov/sites/dfiles/CFO/documents/2020CJ-HOPWA.pdf
• Department of Housing and Urban Development. (2019b). FY 2020 CONGRESSIONAL JUSTIFICATIONS: INTRODUCTION. Washington, DC: United States Department of Housing and Urban Development: Program Offices: Chief Financial Officer: Reports. https://www.hud.gov/sites/dfiles/CFO/documents/2020CJ-INTRODUCTION.pdf
• Health Resources and Services Administration. (2021, December). Ryan White HIV/AIDS Program Annual Client-Level Data Report 2020. Rockville, MD: United States Department of Health and Human Services: Health Resources and Services Administration: HIV/AIDS Bureau: Division of Policy and Data. https://ryanwhite.hrsa.gov/sites/default/files/ryanwhite/data/rwhap-annual-client-level-data-report-2020.pdf
• Housing Opportunities Through Modernization Act, Pub. L. No. 114-201, § (a) 130 Stat. 782 (2016). https://uscode.house.gov/view.xhtml?req=%22Housing+Opportunity+Through+Modernization+Act%22&f=treesort&fq=true&num=0&hl=true&edition=prelim&granuleId=USC-prelim-title42-section1437
• HUD Exchange. (2017, July 17). HOPWA Modernization: What Communities Need to Know. Washington, DC: United States Department of Housing and Urban Development: HUD Exchange: Trainings. http://www.meeting-support.com/downloads/244402/10944/PPT%20V2.pdf
• HUD Exchange. (2022a). HOPWA Eligibility Requirements. Washington, DC: United States Department of Housing and Urban Development: HUD Exchange: Programs: Housing Opportunities for Persons With AIDS. https://www.hudexchange.info/programs/hopwa/hopwa-eligibility-requirements/
• HUD Exchange. (2022b). HUD Awards and Allocations: HOPWA. Washington, DC: United States Department of Housing and Urban Development: HUD Exchange: About Grantees: Awards and Allocations. https://www.hudexchange.info/grantees/allocations-awards/?params=%7B%22limit%22%3A20%2C%22COC%22%3Afalse%2C%22sort%22%3A%22%22%2C%22min%22%3A%22%22%2C%22years%22%3A%5B%5D%2C%22dir%22%3A%22%22%2C%22grantees%22%3A%5B%5D%2C%22state%22%3A%22%22%2C%22programs% 

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.

Despite Coronavirus, Trump Administration Proposes 15 Percent Cut To HOPWA Funding

By: Marcus J. Hopkins, Policy Consultant & Guest Contributor 

UPDATE: This piece was authored prior to the passage of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, on March 30th, 2020. This Act included $65 million in additional funding for the HOPWA program. As a result of these additional funds, the “$80 million” cut to the HOPWA program proposed by the Trump Administration will be temporarily abated (assuming that the proposed cut makes it into the annual budget bill).

It should be noted that this $65m is a one-time infusion of funds included only in the CARES Act, and is unlikely to be a permanent fixture in future budgets. The Trump Administration is still proposing the $85m cut to the overall budget.

There are currently efforts underway by HIV advocates and activists to include an additional $65 million in funds in the forthcoming fourth stimulus bill related to COVID-19.

The Trump Administration is, once again, demonstrating its attempt to end social safety nets via deaths by 1,000 cuts. In its latest budget proposal, the Trump Administration is proposing $8.6 billion in funding cuts for the HUD (Housing and Urban Development) program, including $80 million cut from the Housing Opportunities for People With AIDS (HOPWA).

Photo Source: New York Magazine

HOPWA was created in the AIDS Housing Opportunities Act, as part of the Cranston-Gonzales National Affordable Housing Act of 1990, and has consistently been one of the best-intentioned, but worst funded, managed, and disbursed elements of the various HIV-specific social safety net programs. Plagued by mismanagement at both the federal and state levels, in no small part because of the way the program is administered.

Unlike the overall Ryan White Program, which applies to virtually anyone in a state living with HIV, so long as they meet income verification and upper limit requirements, the HOPWA program operates through the HUD program via a series of grants and relies upon the availability of Section 8 low-income housing.

For example, when I lived in Los Angeles and was in need of a new housing situation when I was separating from my partner, I attempted to sign up for HOPWA via my Ryan White caseworker, only to find that there was, at the time, a waiting list of several years in order to qualify for a Section 8 voucher. What this meant was that, in effect, there were no available Section 8-eligible units available, and I would have to enter my name on a wait list. Should a unit become available, a call would go out, and whomever got there first and qualified was the lucky recipient of a place to live.

This is just on the front-end of HOPWA, however; on the back-end, where the program is administered by state and local governments, inefficiencies, personal and local politics, and failures to may payments to programs on time have created huge issues for people whose housing depends upon the program. There are few places where this is truer than Atlanta, GA:

The City of Atlanta failed to spend $41 million since 2014 meant for the HOPWA program in a dispute involving unpaid contractors, unspent development funds, and a multi-year failure to properly allocate and disburse funds. As a result, in the summer of 2019, hundreds of People Living with HIV/AIDS (PLWHA) were facing eviction as Living Room, the non-profit contractor with whom the City of Atlanta had contracted with to connect PLWHA with low incomes to safe, affordable housing, declared bankruptcy and closed.

Living Room announced in June 2019 that it was unable to pay the rents for roughly 250 clients because the City of Atlanta was several months late in disbursing $500,000 in reimbursement funds for expenses. As a result, those clients’ landlords filed for eviction, resulting in the Atlanta Legal Aid Society being swamped with requests for assistance to the point where they set up a special team just to address the issue. The city responded by paying $371,600 (Mariano, 2019), but those funds arrived too late for Living Room to continue operating.

The problems did not, however, originate with the current administration (Mayor Keisha Lance Bottoms); even when she stood for election in 2017, payments from the City of Atlanta to nonprofit contractors ran so late that many had to borrow against lines of credit and stop taking on new clients (Mariano). Bottoms, who vowed to get to the bottom (as it were) of why these programs were shutting down due to unpaid reimbursement requests has largely failed to live up to the promises she’s made over the past three years, in no small part because her administration has fundamentally failed to properly propose, explain, and implement changes in a timely manner, or to satisfaction of HUD, which has repeatedly expressed public concerns about the administration of Atlanta’s HUD grant.

The problems also do not stop in Atlanta. The HOPWA program has consistently been underfunded and unable to address the needs of PLWHA. The original language in the program focused primarily on people living in urban areas, but changes began, in 2015, to address the needs of PLWHA living in suburban and rural areas. Unfortunately, none of those changes have effectively increased the amount of funding needed, nor increased the availability of housing units.

Where other countries address low-income housing by building government-owned/operated council flats or apartment buildings, the U.S. has stubbornly (and stupidly, in my opinion) insisted upon “public/private partnerships” to address Section 8 housing, relying upon individual property companies and landlords to supply housing and qualify for/accept Section 8 vouchers. This is, no doubt, an artifact of the “Socialism Scare” of the 1950s and beyond, where any sort of social safety net or housing program was deemed “Creeping Socialism” that would doom the U.S. to become a Communist hellhole with never ending breadlines and (shudder) paying to support the Poors.

This decades-long failure on the part of federal and state governments to purchase land and build public housing sufficient to meet the needs of lower-income individuals and families (because, why that just wouldn’t generate a profit, you Pinko Commie bastard!) has resulted in an affordable housing crunch exacerbated by municipalities’ [stupid] desire to approve and build only “luxury” housing units that are, in actuality, little different from the medium-range housing units that were built in the late-90s and early-00s, but have the word “luxury” slapped on the development so that they can increase property values and rents.

In rural states, HOPWA funds are largely allocated in the more densely populated regions, where housing is already overpriced and affordable housing is unavailable. This means that people who could find housing outside of these areas are unable to do so, because the HUD grant for HOPWA only covers people if they live inside of those areas…where housing is over-priced and unavailable, creating waiting lists, backlogs, and people struggling to figure where to live and work, all while attempting to manage their HIV and achieve and maintain viral suppression.

In short, even before the proposed budget cuts for HOPWA (for the second consecutive year), HOPWA is a mess of an operation that is in desperate need of nationalization, centralization, and a massive increase in funds to continue to exist.

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.

Ryan White & HOPWA Funding Increases in Coronavirus Stimulus Package

By: Marcus J. Hopkins, Policy Consultant & Guest Contributor 

The Coronavirus Aid, Relief, and Economic Security (CARES) Act was signed into law by sitting president, Donald J. Trump, on March 27th, 2020, and in this act, two HIV-specific programs – the Ryan White Program (RW) and the Housing Opportunities for Persons With AIDS (HOPWA) – received a combined total of $155m (Johnson, 2020). While the funds have been allocated for these programs, there is little guidance on how those funds will be disbursed or distributed once they are received.

Photo Source: cpabr.com

RW received $90m for “existing contracts” under the law and the Public Health Service Act (Johnson). These funds come at a time when many People Living With HIV/AIDS (PLWHA) are at risk of losing health insurance coverage as a result of job losses or financial hardship during the Coronavirus (COVID-19) outbreak. Loss of hours or employment may end up disqualifying many PLWHA from receiving employer-provided health insurance coverage, and loss of those wages may result in losing coverage purchased on the Affordable Care Act Health Insurance Exchange market. These losses in coverage will, inevitably, lead to more people turning to RW as their payor of last resort to cover the costs of medications and doctor visits.

A bigger question, however, is how are the $65m allocated to the HOPWA program going to be distributed to the states? Because of the way the HOPWA program is administered, using a series of grant awards that are then administered by states and metro regions, who then often contract out the management of those funds’ disbursal for rent payments. This relies on a lot of moving parts, not all of which consistently work. In a blog that will be posted to aaa+, later this month, we will take a look at one such situation, where the city government of Atlanta has consistently failed over nearly a decade to properly reimburse funds to a contracted organization, resulting in several hundred HOPWA recipients being evicted from their homes and the closure of the organization that was so far in debt from Atlanta’s failure to remit payment, they were forced to declare bankruptcy.

Both of these funding inclusions are fantastic, especially during a time when it is clear that these services will be vitally important for PLWHA. We will continue to monitor the situation as more news emerges.

References:

• Johnson, C. (2020, March 26). HIV programs get big money in stimulus deal to fight coronavirus. Washington, DC: Washington Blade. Retrieved from: https://www.washingtonblade.com/2020/03/26/hiv-programs-get-big-money-in-stimulus-deal-to-fight-coronavirus/

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.

State Departments of Corrections Lack Focus on HIV Care for Former Inmates

By: Marcus J. Hopkins, Consultant, Community Access National Network (CANN)

It has been nearly 40 years since the HIV/AIDS epidemic began showing up across the United States, and after all this time, with the amazing level of resources and support available for those living with the disease, it became clear that there was little information publicly available concerning incarcerated populations. To that end, all 50 states’ and the District of Columbia’s respective Departments of Correction (DOCs) were contacted by the ADAP Advocacy Association and Community Access National Network (CANN) to inquire about their procedures for preparing inmates living with HIV for reentry into the general population. Not surprisingly, our research re-confirmed the disparities that exist in serving former inmates.

A few of the disparities are highlighted in the findings presented earlier this week in an infographic, which was made available by the ADAP Advocacy Association as part of its ongoing Correctional Health Project. The infographic can be downloaded from their website.

HIV is currently a disease that requires lifelong treatment that must be adhered to regularly in order to achieve and maintain Viral Suppression – when the Viral Load (the number of HIV virus cells active in the body) measures below 40 copies per milliliter (aka – Undetectable). With new data showing that Undetectable = Untransmittable, it is more important than ever for people living with HIV to have access to their medications in order to both stay healthy, and to prevent transmission of the disease to others. Former inmates deserve the same access to care and treatment as the general population, especially upon their discharge from prison.

We found that 31.3% of state DOCs fail to disclose the amount of meds inmates are provided upon release, making it difficult to track or accurately report the circumstances inmates face upon reentering the general population. In addition, 27.4% of states provide NO policy information on their reentry programs, whatsoever.

Rhode Island’s DOC has perhaps the most comprehensive HIV care program in the U.S. justice system, both during and post-incarceration. The state contracts with the state university to provide care throughout the inmate’s stay at state facilities and ensures that continuity of care continues by keeping inmates with their same providers after they leave (should they stay in the state). Additionally, inmates are provided with an excellent comprehensive reentry program that integrates the state’s Ryan White program and assists with the Medicaid application process. They also look into accessing HOPWA (Housing Opportunities for Persons With AIDS) to help provide housing if they are returning without a reliable home.

New Hampshire's DOC was unaware of the Ryan White Program. We were able to provide them information about the program and connect them with the state's Ryan White Director. NH is currently determining whether or not to incorporate Ryan White as part of their Reentry Program for inmates living with HIV/AIDS who do not qualify for Medicaid.

The latter story should be considered a success story for the Correctional Health Project – introducing state DOC’s to resources for reentering inmates living with HIV that can help them to maintain continuity of care between incarceration and reintegration into the general population is one of the primary goals. Additional resources will be made available on this project continues to unfold this year.


Read our related blogs on this topic:

• Improving Access to Care Among Formerly Incarcerated Populations with HIV/AIDS under the AIDS Drug Assistance Program (October 27, 2017)
• Linkages to Care During Post-Incarceration (July 5, 2017)

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.

Linkages to Care - Housing is Healthcare: Linking Stable Housing & Medication Adherence

By: Brandon M. Macsata, CEO, ADAP Advocacy Association

Find me a physician who treats patients living with HIV/AIDS, and I'm certain the physician stresses medication adherence to anyone who will listen (yes, probably even Dr. Ben Carson). Find me a patient living with HIV/AIDS, and I'm certain the patient notes an equally important message: I cannot worry about my medications unless I have a roof over my head (yes, someone needs to tell Dr. Ben Carson). Intertwined are these two important facts.

The important linkage between housing and healthcare was spelled out last year in a blog by Kathie Hiers, who serves as the President & CEO for AIDS Alabama. In her blog, Housing=Healthcare, Hiers stated the following key points:

According to the National Low Income Housing Coalition’s 2015 Out of Reach Report, not a single state in our nation offers a one-room apartment that a person working full time and making minimum wage can afford. In fact, federal minimum wage has not increased since 2009 while rents have risen in almost all metropolitan areas. For PLWH, the need for housing assistance is far too commonplace. According to the National AIDS Housing Coalition, at any given time about 50% of 1.2 million PLWH in our country experience homelessness or housing instability. Additionally, research indicates that people who are unstably housed or homeless have HIV rates up to 16 times as high as persons in stable housing. Unfortunately the need substantially outstrips the resources. But here’s the bottom line: housing for PLWH improves medical outcomes, reduces new transmissions through a reduction in risky behaviors, and provides cost savings. So much research exists to confirm these results that AIDS and Behavior in 2007 dedicated an entire issue to illustrate the findings.[1]

Unfortunately, there aren't enough affordable, stable housing units available to keep up with demand. The shortage undermines efforts to achieve positive health outcomes in many areas of the country, both in rural and urban areas. Efforts are underway to modernize the federal housing programs designed to help those in need, including the Housing Opportunities for Persons with AIDS (HOPWA). But not all of the "efforts" are necessarily good for the people the programs are designed to assist.

Photo Source: Slate.com

Testifying earlier this week before the U.S. Senate Committee on Appropriations Subcommittee on Transportation, Housing and Urban Development, Dr. Ben Carson, Secretary of the U.S. Department of Housing & Urban Development (HUD), summarized some of these changes to the federal government's housing policy:

"Last year’s changes to the formula for Housing Opportunities for Persons with AIDS (HOPWA) was a great step towards efficiency, shifting funding to areas with higher numbers of HIV/AIDS cases, rather than historical incidents. This is the kind of targeted efficiency that will help us do the most with limited Federal resources. We provide a phased-in approach to the new formula to provide communities time to adjust. The additional funding in 2017 also will help provide communities more time to adjust to the new formula. The 2018 Budget provides $330 million for HOPWA."[2]

Ironically, Secretary Carson failed to mention that the Trump Administration's proposed Fiscal Year 2018 budget calls for a $26 million funding cut from HOPWA and that "these cuts will certainly increase the number of people living with HIV who will not have stable housing."[3] The proposed reduction represents nearly a 7 percent cut in funding.

Concerns have been mounting over the potential impact of funding cuts to housing programs, as well as healthcare programs. David Reiss' Op-Ed earlier this year characterized the proposed budget as "bad news."[4]

Photo Source: Community Partnership of the Ozarks

In an effort to raise awareness about affordable, stable housing and how it improves medication adherence for people living with HIV/AIDS and/or viral hepatitis, we will host an educational training webinar on June 28, 2017. The webinar, "Housing is Healthcare: Linking Stable Housing & Medication Adherence," will discuss the research that supports housing as a structural intervention that improves health outcomes through improved adherence to treatment. Presenters will share successful housing models where residents have seen this success. It will provide webinar attendees with how to use research to show the direct causation between health outcomes and housing placement, and understand strategies to the connection between medication adherence and stable housing.

Registration is open to all stakeholders. Registration is complimentary for PASWHA members, and it is also complimentary for patients living with HIV/AIDS. Use this scholarship link if you are a patient living with HIV/AIDS applying for a webinar scholarship.

Additional information about the webinar is available online at https://www.123signup.com/event?id=nhjqn.

__________
[1] Hiers, Kathie (2016, May 6); ADA Blog; Housing=Healthcare; ADAP Advocacy Association. Retrieved from http://adapadvocacyassociation.blogspot.com/2016/05/by-kathie-hiers-president-ceo-aids.html.
[2] Carson, M.D., Ben (2017, June 7); Written Testimony on Review of the FY2018 Budget Request
for the U.S. Department of Housing & Urban Development; Committee on Appropriations Subcommittee on Transportation, Housing and Urban Development. Retrieved from https://www.appropriations.senate.gov/imo/media/doc/060717-Carson-Testimony.pdf.
[3] Schmid, Carl (2017, May 23); TRUMP BUDGET: A SETBACK TO HIV AND HEPATITIS ELIMINATION; The AIDS Institute. Retrieved from http://www.theaidsinstitute.org/sites/default/files/attachments/TAI%20FY18%20Budget%20Press%20Release%20FINAL.pdf. 
[4] Reiss, David (2017, March 16); Trump's budget proposal is bad news for housing across the nation; The Hill. Retrieved from http://thehill.com/blogs/pundits-blog/economy-budget/324211-how-trumps-budget-cuts-could-affect-housing-for-thousands.

Housing=Healthcare

By: Kathie Hiers, President & CEO, AIDS Alabama

What is the greatest unmet need for people living with HIV (PLWH)? Medical care and medications?  Transportation? Food and nutritional needs? Many, many surveys and research findings provide very a different answer: housing. When you think about it, the need for safe, decent, affordable housing is a no brainer. How can you and your family possibly succeed in medical care or in the workplace or any place else without a place to lay your head, to keep your meds, and to protect your children? I would go so far as to say housing = healthcare!

According to the National Low Income Housing Coalition’s 2015 Out of Reach Report, not a single state in our nation offers a one-room apartment that a person working full time and making minimum wage can afford. In fact, federal minimum wage has not increased since 2009 while rents have risen in almost all metropolitan areas. For PLWH, the need for housing assistance is far too commonplace. According to the National AIDS Housing Coalition, at any given time about 50% of 1.2 million PLWH in our country experience homelessness or housing instability. Additionally, research indicates that people who are unstably housed or homeless have HIV rates up to 16 times as high as persons in stable housing. Unfortunately the need substantially outstrips the resources. But here’s the bottom line: housing for PLWH improves medical outcomes, reduces new transmissions through a reduction in risky behaviors, and provides cost savings. So much research exists to confirm these results that AIDS and Behavior in 2007 dedicated an entire issue to illustrate the findings.

Photo Source: National Low Income Housing Coalition

The only HIV-specific funding source from the U. S. Department of Housing and Urban Development (HUD) is the legislation known as Housing Opportunities for Persons with AIDS (HOPWA). Although HOPWA is relatively small within the HUD portfolio at about $335 million, the program has been extraordinarily effective and well rated, enjoying bipartisan support. Research from New York City shows that clients assisted by HOPWA collectively have a viral load suppression of about 73%, more than double the national average of about 30%. HOPWA was created in 1992 to address the housing and service needs of PLWH. Currently, however, the statutory funding distribution methodology is based on cumulative AIDS cases and counts more deceased cases (over 650,000) than living cases. On top of the formula distribution (don’t forget: based on deceased people and AIDS only), urban areas with higher-than-national averages also receive 25% of the formula funds as a bonus, based on three-year AIDS incidence, providing disproportionate funding to these jurisdictions. As a result of this antiquated methodology, I once saw the Director of the Office of HIV/AIDS Housing, David Vos, tell a group of advocates that the per-case funding can range from $200 to $10,000. Should funding this important really be based on deceased cases and distributed in a roller coaster ride of injustice?

The National AIDS Housing Coalition (NAHC) and many other HIV organizations have been advocating for an update to this formula distribution for many years in an effort to distribute the resources in a way that better reflects the current HIV epidemic. Both the Obama Administration and HUD are working in concert with NAHC and elected officials to promote modernization that would include the following changes:

• A shift from cumulative AIDS to living HIV/AIDS, a change that occurred within the Ryan White legislation in 2009;
• The inclusion of an area’s housing costs and poverty rates as formula factors; and
• A gradual implementation over a five-year period to include a provision to cap annual losses at 5% and gains at 10% (U. S. Congress, House, H.R. 3700 and H. R. 4707; and Senate, S. 2668).

These changes would provide substantial additional resources to many rural areas, small to mid-sized cities, and states, based on the jurisdiction’s burden of cases, Fair Market Rent, and poverty index.

Although funding to support stable housing may never fully meet the needs of PLWH, advocates must continue to elevate this topic and to integrate housing needs into other HIV resources, such and the Ryan White HIV/AIDS Program and other programs within the Centers for Medicare and Medicaid Services. Innovative collaborations between branches of government and funding opportunities that combine structural interventions, such as housing, with other medical and supportive services could only help to alleviate barriers to good health caused by a lack of housing for PLWH.

AIDS Alabama provides an innovative approach to the use of our state HOPWA funds. Through partnerships with all of the AIDS Service Organizations, AIDS Alabama makes HOPWA rental assistance and supportive services available in all 67 counties of the state. We believe that housing is a human right and that people in need should have access to assistance no matter what zip code they call home. But we don’t stop with HOPWA! Our agency has continued to develop HIV-specific housing across the state and in the Birmingham area that we can make affordable to our clients.  AIDS Alabama is extremely active in our local Continuum of Care to serve the area’s homeless population. We believe in HUD’s Housing First model, which gets people into safe housing and then allows us to assess and address other needs that will keep our new residents healthy and independent.  Through these homeless funds we offer substance use treatment and mental health services for our residents. We are able to access Shelter Plus Care vouchers, which work like Section 8 assistance for people with disabilities. We work especially hard to serve the chronically homeless and to get them into care. In order to do that, we provide about 20,000 legs of transportation to medical appointments each year. We are extremely excited about our newest project that will begin in October 2016, which will target young, homeless LGBTQ populations. And, of course, case management services are available to all of our clients.  Navigating the worlds of health care, housing, and insurance is hard for anyone!

At AIDS Alabama our employees, residents, and clients living with HIV play a critical role in making sure that we remember who we serve and that we serve in the most efficient and helpful way possible. Persons living with HIV must have meaningful involvement in shaping everything that we do as an agency. Hopefully one day soon we can end this epidemic in the United States.  Until that happy day we will work together toward this goal…and make sure that everyone has a place to call home while we do this work!

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Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.