Housing for Persons Living with HIV/AIDS
Prepared for Members and Committees of Congress
Since the beginning of the acquired immunodeficiency syndrome (AIDS) epidemic in the early
1980s, many individuals living with the disease have had difficulty finding affordable, stable
housing. 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. In addition, many of
those persons living with AIDS struggled to afford housing even before being diagnosed with the
disease. The financial vulnerability associated with AIDS, as well as the human
immunodeficiency virus (HIV) that causes AIDS, results in a greater likelihood of homelessness
among persons living with the disease. Further, recent research has indicated that those
individuals living with HIV who live in stable housing have better health outcomes than those
who are homeless or unstably housed.
Congress recognized the housing needs of persons living with HIV/AIDS when it approved the
Housing Opportunities for Persons with AIDS (HOPWA) program in 1990 as part of the
Cranston-Gonzalez National Affordable Housing Act (P.L. 101-625). The HOPWA program,
administered by the Department of Housing and Urban Development (HUD), funds short-term
and permanent housing, together with supportive services, for individuals living with HIV/AIDS
and their families. In addition, a small portion of funds appropriated through the Ryan White
HIV/AIDS program, administered by the Department of Health and Human Services (HHS), may
also be used to fund short-term housing for those living with HIV/AIDS.
In FY2008, Congress appropriated $300 million for HOPWA in the Consolidated Appropriations
Act (P.L. 110-161). This is the most funding ever appropriated for the program, exceeding the
next highest appropriation (in FY2004) by approximately $6 million. HOPWA funds are
distributed to states and localities through both formula and competitive grants. HUD awards
based on population, reported cases of AIDS, and incidence of AIDS. The remaining 10% is
distributed through a grant competition. Funds are used primarily for housing activities, although
grant recipients must provide supportive services to those persons residing in HOPWA-funded
Introduc tion ..................................................................................................................................... 1
Housing Status of Persons Living with HIV/AIDS...................................................................1
Creation of the Housing Opportunities for Persons with AIDS (HOPWA) Program................2
Distribution and Use of HOPWA Funds..........................................................................................4
Eligibility for HOPWA-Funded Housing..................................................................................6
Eligible Uses of HOPWA Funds...............................................................................................6
HOPWA Program Formula and Funding.........................................................................................8
The HOPWA Formula...............................................................................................................8
Housing Funded Through the Ryan White HIV/AIDS Program...................................................10
The Relationship Between Stable Housing and Health Outcomes...............................................12
Table 1. HOPWA Funding and Eligible Jurisdictions, FY2001-FY2008......................................10
Table A-1.HOPWA Formula Allocations, FY2004-FY2008.........................................................14
Appendix. Recent HOPWA Formula Allocations..........................................................................14
Author Contact Information..........................................................................................................18
Acquired immunodeficiency syndrome (AIDS), a disease caused by the human
immunodeficiency virus (HIV), weakens the immune system, leaving individuals with the disease
susceptible to infections. As of 2006, AIDS had been diagnosed and reported in an estimated 1
448,871 individuals in the fifty states, the District of Columbia, and territories. These estimates
do not include those diagnosed with HIV where the disease has not yet progressed to AIDS or
those who have not yet been diagnosed as HIV positive but are currently living with the disease.
Currently there is no cure for HIV/AIDS, and in the early years of the AIDS epidemic, those
persons infected with AIDS often died quickly. In recent years, however, medications have
allowed persons living with HIV and AIDS to live longer and to remain in better health.
Despite improvements in health outcomes, affordable housing remains important to many who
live with HIV/AIDS. This report describes recent research that shows how housing and health
status are related and the effects of stable housing on patient health. It also describes the Housing
Opportunities for Persons with AIDS (HOPWA) program, the only federal program that provides
housing and services specifically for persons who are HIV positive or who have AIDS, together
with their families. In addition, the report describes how a small portion of funds appropriated
through the Ryan White HIV/AIDS program may be used by states and local jurisdictions to
provide short-term housing assistance for persons living with HIV/AIDS.
The availability of adequate, affordable housing for persons living with HIV and AIDS has been
an issue since AIDS was first identified in U.S. patients in the early 1980s. The inability to afford
housing and the threat of homelessness confront many individuals living with HIV/AIDS. From
the early years of the epidemic, those individuals who have been infected with HIV/AIDS face
impoverishment as they become unable to work, experience high medical costs, or lose private
health insurance coverage. In recent years, the incidence of HIV/AIDS has grown among low-2
income individuals who were economically vulnerable even before onset of the disease.
Not surprisingly, researchers have found a co-occurrence between HIV/AIDS and homelessness.
Homeless persons have a higher incidence of HIV/AIDS infection than the general population, 3
while many individuals with HIV/AIDS are at risk of becoming homeless. Research has found
that rates of HIV among homeless people may be as much as three to nine times higher than
1 U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, HIV/AIDS Surveillance
Report 2006, vol. 18, Atlanta, GA, 2008, pp. 24-25, table 12, http://www.cdc.gov/hiv/topics/surveillance/resources/
2 John M. Karon, Patricia L. Fleming, Richard W. Steketee, and Kevin M. DeCock, “HIV in the United States at the
Turn of the Century: An Epidemic in Transition,” American Journal of Public Health 91, no. 7 (July 2001): 1064-1065.
3 See, for example, D.P. Culhane, E. Gollub, R. Kuhn, and M. Shpaner, “The Co-Occurrence of AIDS and
Homelessness: Results from the Integration of Administrative Databases for AIDS Surveillance and Public Shelter
Utilization in Philadelphia,” Journal of Epidemiology and Community Health 55, no. 7 (2001): 515-520. Marjorie
Robertson, et al., “HIV Seroprevalence Among Homeless and Marginally Housed Adults in San Francisco,” American
Journal of Public Health 94, no. 7 (2004): 1207-1217. Angela A. Aidala and Gunjeong Lee, Housing Services and
Housing Stability Among Persons Living with HIV/AIDS, Joseph L. Mailman School of Public Health, May 30, 2000,
among those living in stable housing.4 Further, those who are HIV positive and homeless have
been found to be more likely than those who are HIV positive and housed to engage in behaviors
associated with the spread of HIV/AIDS. In one study, the use of injectable drugs, sharing
needles, and exchanging sex for drugs or money were more likely among both homeless 5
individuals and those who were unstably housed compared to those with stable housing. (Those
who were considered unstably housing lived in transitional housing, in jail, drug treatment or a 6
halfway house, or were doubled up in someone else’s home.) When housing improved for
individuals in the study, their odds of engaging in these behaviors were reduced. Another study
found that homeless persons living with HIV/AIDS were almost twice as likely to engage in 7
unprotected sex compared to those who had housing. (Individuals were considered housed if
they lived in a house or apartment alone or with others, a medical care facility, or a correctional 8
In 1988, Congress established the National Commission on AIDS as part of the Health Omnibus
Extension Act (P.L. 100-607) to “promote the development of a national consensus on policy
concerning acquired immune deficiency syndrome (AIDS); and to study and make
recommendations for a consistent national policy concerning AIDS.” In April 1990, in its second
interim report to the President, the Commission recommended that Congress and the President
provide “[f]ederal housing aid to address the multiple problems posed by HIV infection and 9
AIDS.” About the same time that the Commission released its report, in March of 1990, the
House Committee on Banking, Finance, and Urban Affairs held a hearing about the need for
housing among persons living with HIV/AIDS. Witnesses as well as committee members
discussed various barriers to housing for persons living with HIV/AIDS. Among the issues
confronting those persons that were discussed at the hearing were poverty, homelessness, and 10 11
discrimination in attempting to secure housing. Another issue discussed at the hearing was the
4 Daniel P. Kidder, Richard J. Wolitski, and Scott Royal, et al., “Access to Housing as a Structural Intervention for
Homeless and Unstably Housed People Living with HIV: Rational, Methods, and Implementation of the Housing and
Health Study,” AIDS and Behavior, vol. 11, no. 6 (November 2007, supplement), pp. 149-150.
5 Angela Aidala, Jay E. Cross, Ron Stall, David Harre, and Esther Sumartojo, “Housing Status and HIV Risk
Behaviors: Implications for Prevention and Policy,” AIDS and Behavior 9, no. 3 (2005): 251-265.
6 Ibid., p. 254
7 Daniel P. Kidder, Richard J. Wolitski, and Sherri L. Pals, et al., “Housing Status and HIV Risk Behaviors Among
Homeless and Housed Persons with HIV,” Journal of Acquired Immune Deficiency Syndromes, vol. 49, no. 4
(December 1, 2008), pp. 453-454.
8 Ibid., p. 452.
9 The second interim report was released on April 24, 1990. Its recommendations were reprinted in National
Commission on Acquired Immune Deficiency Syndrome, Annual Report to the President and Congress, August 1990,
10 Individuals living with HIV/AIDS have experienced housing discrimination even though they are protected as
persons with a “handicap” under the Fair Housing Act (FHA). 42 U.S.C. §§ 3601-3631. A number of court cases have
established that the definition of “handicap” protects persons who are HIV positive and persons with AIDS. See, for
example, Baxter v. City of Belleville, Ill., 720 F.Supp. 720, 729-730 (S.D.Ill.1989), and Support Ministries for Persons
With AIDS, Inc. v. Village of Waterford, N.Y., 808 F.Supp. 120, 129-133 (N.D.N.Y. 1992).
11 Hearing before the House Committee on Banking, Finance, and Urban Affairs, Subcommittee on Housing and
Community Development, “Housing Needs of Persons with Acquired Immune Deficiency Syndrome,” March 21,
1990, (hereafter Hearing on Housing Needs). See also, Statement of Representative James A. McDermott, 135 Cong.
eligibility for subsidized housing for persons living with the disease. A question raised during the
hearing but left unresolved was whether persons living with HIV or AIDS met the definition of
“handicap” in order to be eligible for the Section 202 Supportive Housing for the Elderly program 12
(which also provided housing for persons with disabilities). Another concern was that persons
living with HIV/AIDS often had difficulty obtaining subsidized housing through mainstream
HUD programs such as Public Housing and Section 8 due to the length of waiting lists; 13
individuals often died while waiting for available units.
In the 101st Congress, at least two bills were introduced that contained provisions to create a
housing program specifically for persons living with AIDS. These proposed programs were called
the AIDS Housing Opportunity Act (which was part of the Housing and Community
Development Act of 1990, H.R. 1180) and the AIDS Opportunity Housing Act (H.R. 3423). The
bills were similar, and both proposed to fund short-term and permanent housing together with
supportive services for individuals living with AIDS and related diseases. The text from one of
these bills, H.R. 1180, which included the AIDS Housing Opportunity Act, was incorporated into
the Cranston-Gonzalez National Affordable Housing Act (S. 566) when it was debated and passed
by the House on August 1, 1990. In conference with the Senate, the name of the housing program
was changed to Housing Opportunities for Persons with AIDS (HOPWA). In addition, the several
separate housing assistance programs that had been proposed in H.R. 1180 – one for short-term
housing, one for permanent housing supported through Section 8, and one for community
residences – were consolidated into one formula grant program in which recipient communities
could choose which activities to fund. The amended version of S. 566 was signed by the President
on November 28, 1990, and became P.L. 101-625, the Cranston Gonzalez National Affordable
The HOPWA program is administered by the Department of Housing and Urban Development
(HUD) and remains the only federal program solely dedicated to providing housing assistance to 14
persons living with HIV/AIDS and their families. The program addresses the need for
reasonably priced housing for thousands of low-income individuals (those with incomes at or
below 80% of the area median income). HOPWA was last reauthorized by the Housing and
Community Development Act of 1992 (P.L. 102-550). Although authorization for HOPWA
expired after FY1994, Congress continues to fund the program through annual appropriations.
Rec. 23641, October 5, 1989.
12 Hearing on Housing Needs, pp. 25-30. See footnote 11.
13 U.S. Congress, House Committee on Banking, Finance, and Urban Affairs, Housing and Community Development
Act of 1990, report to accompany H.R. 1180, 101st Cong., 2nd sess., June 21, 1990, H.Rept. 101-559.
14 The law is codified at 42 U.S.C. §§ 12901-12912, with regulations at 24 C.F.R. Parts 574.3-574.655.
HOPWA program funding is distributed both by formula allocations and competitive grants. HUD
awards 90% of appropriated funds by formula to states and eligible metropolitan statistical areas
(MSAs) that meet the minimum AIDS case requirements according to data reported to the Centers
for Disease Control and Prevention (CDC) in the previous year. (For the amounts distributed to
eligible states and MSAs in recent years, see Appendix.) HOPWA formula funds are available
through HUD’s Consolidated Plan initiative. Jurisdictions applying for funds from four HUD 15
formula grant programs, including HOPWA, submit a single consolidated plan to HUD. The
plan includes an assessment of community housing and development needs and a proposal that
addresses those needs, using both federal funds and community resources. Communities that
participate in the Consolidated Plan may receive HOPWA funds if they meet formula
requirements. Formula funds are allocated in two ways:
• First, 75% of the total available formula funds, sometimes referred to by HUD as
“base funding,” is distributed to
—the largest cities within metropolitan statistical areas (MSAs)16 with populations of at least
500,000 and with 1,500 or more cumulative reported cases of AIDS (which includes those
who have died); and
—to states with at least 1,500 cases of AIDS in the areas outside of that state’s eligible 17
• Second, 25% of total available formula funds – sometimes referred to by HUD as
“bonus funding” – is distributed on the basis of AIDS incidence during the past 18
three years. Only the largest cities within MSAs that have populations of at
least 500,000, with at least 1,500 reported cases of AIDS and that have a higher 19
than average per capita incidence of AIDS are eligible. States are not eligible
for bonus funding.
Although HOPWA funds are allocated to the largest city within an MSA, these recipient cities are
required to allocate funds “in a manner that addresses the needs within the metropolitan statistical 20
area in which the city is located.” States that receive funds are to use them to benefit areas
outside of eligible MSAs. In FY2008, 87 MSAs (including the District of Columbia) received
funds, while 39 states and Puerto Rico received funds for use in the areas outside of recipient
15 The others are the Community Development Block Grant, the Emergency Shelter Grants, and HOME.
16 MSAs are defined as having at least one “urbanized” area of 50,000 or more and “adjacent territory that has a high
degree of social and economic integration with the core as measured by commuting ties.” See Office of Management
and the Budget Bulletin 09-01, Attachment, “Update of Statistical Area Definitions and Guidance on Their Uses,”
November 20, 2008, p. 2, http://www.whitehouse.gov/omb/bulletins/fy2009/09-01.pdf.
17 42 U.S.C. § 12903(c)(1)(A).
18 AIDS incidence is measured as the number of new AIDS cases during a given time period.
19 42 U.S.C. § 12903(c)(1)(B).
20 42 U.S.C. § 12903(f).
MSAs.21 Jurisdictions that receive HOPWA funds may administer housing and services programs
themselves or may allocate all or a portion of the funds to subgrantee private nonprofit
organizations. HOPWA formula funds remain available for obligation for two years.
As a result of language included in every HUD appropriations law since FY1999 (P.L. 105-276),
states do not lose formula funds if their reported AIDS cases drop below 1,500, as long as they
received funding in the previous fiscal year. States generally drop below 1,500 AIDS cases when
a large metropolitan area becomes separately eligible for formula funds. These states are allocated 22
a grant on the basis of the cumulative number of AIDS cases outside of their MSAs.
The remaining 10% of HOPWA funding is available through competitive grants. Funds are
distributed through a national competition to two groups of grantees: (1) states and local
governments that propose to provide short-term, transitional, or permanent supportive housing in
areas that are not eligible for formula allocations, and (2) government agencies or nonprofit 23
entities that propose “special projects of national significance.” A project of national
significance is one that uses an innovative service delivery model. In determining proposals that
qualify, HUD must consider the innovativeness of the proposal and its potential replicability in 24
other communities. Competitive grants may not be used to provide supportive services alone;
instead, services can only be provided in conjunction with housing activities, and funds for 25
services cannot exceed 35% of a project’s budget.
The competitive grants are awarded through HUD’s annual SuperNOFA (Notice of Funding
Availability), which is generally published in the Federal Register in the early spring. Since
FY2000 (P.L. 106-377), Congress has required HUD to renew expiring contracts for permanent
supportive housing prior to awarding funds to new projects. Beginning in FY2006, competitive
funds remain available for obligation for three years (from FY2002 through FY2005, competitive
funds had been available only for two years). The extension makes the rules for HOPWA’s
competitive program consistent with those of other competitive programs advertised in HUD’s
21 U.S. Department of Housing and Urban Development, Office of Community Planning and Development, Office of
HIV/AIDS Housing, list of FY2008 grantees, http://www.hud.gov/offices/cpd/about/budget/budget08/index.cfm.
22 States that have retained funding under this provision are Arizona, Delaware, Hawaii, Minnesota, Nevada,
Oklahoma, and Utah.
23 42 U.S.C. § 12903(c)(3).
25 See, for example, U.S. Department of Housing and Urban Development, “FY2008 Notice of Funding Availability
Housing Opportunities for Persons With AIDS,” 73 Federal Register p. 27266, May 12, 2008.
In the HOPWA program, individuals are eligible for housing if they are either HIV positive or if 26
they are diagnosed with AIDS. In general, clients must also be low income, meaning that their 27
income does not exceed 80% of the area median income. HUD reports area median incomes for 28
metropolitan areas and non-metropolitan counties on an annual basis. Housing and some
supportive services are available for family members of persons living with AIDS. When a person
living in HOPWA-supported housing dies, his or her family members are given a grace period 29
during which they may remain in the housing. This period may not exceed one year, however.
Individuals who are HIV positive or living with AIDS may also be eligible for other HUD-
assisted housing for persons with disabilities. However, infection itself may not be sufficient to
meet the definition of disability in these other programs. For example, in the case of housing
developed prior to the mid-1990s under the Section 202 Supportive Housing for the Elderly
program and those units developed under the Section 811 Supportive Housing for Persons with
Disabilities program, an individual who is HIV positive or has AIDS must also meet the statutory
definition of disability (in which HIV/AIDS status alone is not sufficient) to be eligible for 30
housing. The project-based Section 8 and Public Housing programs may also set aside units or
entire developments for persons with disabilities. The definition of disability for these programs
does “not exclude persons who have the disease of acquired immunodeficiency syndrome or any 31
conditions arising from the etiologic agent” for AIDS. However, the definition does not indicate
whether the status of being HIV positive or having AIDS is alone sufficient to be considered
HOPWA grantees may use funds for a wide range of housing, social services, program planning,
and development costs. Supportive services must be provided together with housing. Formula
grantees may also choose to provide supportive services not in conjunction with housing,
although the focus of the HOPWA program is housing activities. Allowable activities include the
26 The HOPWA statute defines an eligible person as one “with acquired immunodeficiency syndrome or a related
disease.” 42 U.S.C. § 12902(12). The regulations have further specified that “acquired immunodeficiency syndrome or
related diseases means the disease of acquired immunodeficiency syndrome or any conditions arising from the etiologic
agent for acquired immunodeficiency syndrome, including infection with the human immunodeficiency virus (HIV).”
24 C.F.R. § 574.3.
27 42 U.S.C. § 12908 and § 12909. The statutory provisions regarding short-term housing and community residences do
not require individuals to be low-income, although to be eligible for short-term housing a person must be homeless or
at risk of homelessness. See 42 U.S.C. § 12907 and § 12910.
28 U.S. Department of Housing and Urban Development, Office of Policy Development and Research, Fiscal Year
2008 HUD Income Limits Briefing Material, January 18, 2008, p. 1, http://www.huduser.org/datasets/il/il08/
IncomeLimitsBriefingMaterial.pdf. Tables showing area median incomes in recent years are available at
29 24 C.F.R. § 574.310(e).
30 For more information about housing for persons with disabilities and the definitions of disability under these
programs, see CRS Report RL34728, Section 811 and Other HUD Housing Programs for Persons with Disabilities, by
31 42 U.S.C. § 1437a(b)(3).
• The Development and Operation of Multi-Unit Community Residences, Including 32
the Provision of Supportive Services for Persons Who Live in the Residences.
Funds may be used for the construction, rehabilitation, and acquisition of
facilities, for payment of operating costs, and for technical assistance in
developing the community residence.
• Short-Term Rental, Mortgage, and Utility Assistance to Persons Living with 33
AIDS Who Are Homeless or at Risk of Homelessness. Funds may be used to
acquire and/or rehabilitate facilities that will be used to provide short-term
housing, as well as to make payments on behalf of tenants or homeowners, and to
provide supportive services. Funds may not be used to construct short-term 34
housing facilities. Residents may not stay in short-term housing facilities more
than 60 days in any 6-month period, and may not receive short-term rental,
mortgage and utility assistance for more than 21 weeks in any 52 week period.
These limits are subject to waiver by HUD, however, if a project sponsor is
making an attempt to provide permanent supportive housing for residents and has
been unable to do so. Funds may also be used to pay operating and administrative
• Project-Based or Tenant-Based Rental Assistance for Permanent Supportive 35
Housing, Including Shared Housing Arrangements. In general, tenants must pay 36
approximately 30% of their income toward rent. Grant recipients must ensure
that residents receive supportive services, and funds may also be used for
administrative costs in providing rental assistance.
• The New Construction or Acquisition and Rehabilitation of Property for Single-37
Room Occupancy Dwellings.
• Supportive Services, Which Include Health Assessments, Counseling for Those
with Addictions to Drugs and Alcohol, Nutritional Assistance, Assistance with
Daily Living, Day Care, and Assistance in Applying for Other Government 38
• Housing Information Such as Counseling and Referral Services.39 Assistance 40
may include fair housing counseling for those experiencing discrimination.
The majority of HOPWA funds are used to provide housing. According to HUD, 66% of HOPWA 41
funds support housing activities. Grantee performance reports indicate that clients who receive
32 42 U.S.C. § 12910.
33 42 U.S.C. § 12907.
34 HOWPA funds may only be used for construction of community residences and single-room occupancy dwellings.
See 24 C.F.R. § 574.300(b)(4).
35 42 U.S.C. § 12908.
36 See 24 C.F.R. § 574.310(d).
37 42 U.S.C. § 12909.
38 24 C.F.R. § 574.300(b)(7).
39 42 U.S.C. § 12906.
40 24 C.F.R. § 574.300(b)(1).
41 U.S. Department of Housing and Urban Development, HOPWA Update for 2008, Powerpoint Presentation, January
2008, slide 18, http://www.hud.gov/offices/cpd/aidshousing/library/2008perfreporting/2008hopwaupdate.ppt.
housing assistance through HOPWA are often at the lowest income levels; in its FY2008 Annual
Performance Plan, HUD estimated that 81% of households served have either extremely-low
incomes (at or below 30% of area median income) or very-low incomes (at or below 50% of area 42
The HOPWA method for allocating formula funds has been an ongoing issue because the
cumulative number of AIDS cases – including those who have died – is used to distribute funds.
A 2006 Government Accountability Office (GAO) report found that the cumulative measure
resulted in disproportionate funding per living AIDS case, depending on the jurisdiction. In 2004,
the amount of money grantees received per living AIDS case ranged from $387 per person to 43
$1,290. According to the report, if only living AIDS cases were counted in that year, 92 of 117 44
grantees would have received more formula funding, while 25 would have received less.
In each of the President’s budgets from FY2007 through FY2009, the Administration proposed to
change the way in which HOPWA funds are distributed. The FY2009 budget stated that
“[w]hereas the current formula distributes formula grant resources by the cumulative number of
AIDS cases, the revised formula will account for the present number of people living with AIDS,
as well as differences in housing costs in the qualifying areas.” The President’s FY2007 and
FY2008 budgets contained nearly identical language. HUD’s budget justifications for FY2009
elaborated somewhat on the Administration’s proposal to change the HOPWA distribution
formula. HUD’s explanation indicated that a new formula would use the number of persons living
with AIDS, and that eventually, when consistent data on the number of persons living with HIV
become available, that measure might also be used in determining the distribution of HOPWA 45
Discussions regarding the HOPWA formula and its use of cumulative AIDS cases to distribute
funds are not new. In 1997, GAO released a report regarding the performance of the HOPWA
program in which it recommended that HUD look at recent changes to the formula used by the
Ryan White CARE Act (now called the Ryan While HIV/AIDS program) to “determine what
legislative revisions are needed to make the HOPWA formula more reflective of current AIDS 46
cases ...” (At the time of the GAO report, Congress had recently changed the CARE Act 47
formula to use estimates of persons living with AIDS instead of cumulative AIDS cases.) In
42 U.S. Department of Housing and Urban Development, Annual Performance Plan FY2008, September 2007, p. 48,
43 U.S. Government Accountability Office, Changes Needed to Improve the Distribution of Ryan White CARE Act and
Housing Funds, GAO-06-332, February 2006, p. 23, http://www.gao.gov/new.items/d06332.pdf.
44 Ibid., p. 24.
45 U.S. Department of Housing and Urban Development FY2009 Congressional Budget Justifications, Housing
Opportunities for Persons with AIDS, p. Q-2, http://www.hud.gov/offices/cfo/reports/2009/cjs/cpd1.pdf.
46 U.S. Government Accountability Office, HUD’s Program for Persons with AIDS, GAO/RCED-97-62, March 1997,
p. 27, http://www.gao.gov/archive/1997/rc97062.pdf.
47 Ryan White CARE Act Amendments of 1996, P.L. 104-146. In 2006, when the Ryan White HIV/AIDS program was
reauthorized as part of the Ryan White HIV/AIDS Treatment Modernization Act of 2006 (P.L. 109-415), the formula
response to the GAO report, the House Appropriations Committee included the GAO language in
its report accompanying the FY1998 HUD Appropriations Act (P.L. 105-65) and directed HUD to 48
make recommendations to Congress about its findings regarding an update to the formula.
In response to the FY1998 Appropriations Act, HUD then issued a report to Congress in 1999 that 49
proposed changes that could be made to the HOPWA formula. The proposed formula in HUD’s
1999 report would have used an estimate of persons living with AIDS (instead of all cumulative
AIDS cases), together with housing costs, to distribute formula funds. It also would have included
a protection for existing grantees. Those recommendations were not adopted by Congress.
No legislation to change the HOPWA formula was introduced in the 110th Congress. In the 109th
Congress, two bills (S. 2339 and H.R. 5009) would have changed the way that HOPWA formula
funds are allocated by counting the number of “reported living cases of HIV disease” instead of
cumulative AIDS cases. Neither bill was enacted.
As a result of advances in medical science and in the care and treatment of persons living with 50
HIV and AIDS, individuals are living longer with the disease. As the number of those with
AIDS grows, so do the jurisdictions that qualify for formula-based HOPWA funds. Since 1999,
there has been a steady increase in the number of jurisdictions that meet the eligibility test to
receive formula-based HOPWA funds. Funding for the HOPWA program has increased in almost
every year since the program was created, eventually reaching $295 million in FY2004, before
declining to $282 million in FY2005. (See Table 1.) In FY2006 and FY2007, funding increased
by 1.52% over FY2005, to $286 million, but still remained below the FY2004 funding level. In
FY2008, Congress appropriated $300 million for HOPWA in the Consolidated Appropriations
Act (P.L. 110-161), an increase of almost 5% more than the FY2007 funding level, and the most
ever appropriated for the program.
The number of households receiving HOPWA housing assistance (including short-term housing
assistance, housing provided through community residences, or rental assistance in permanent
housing) has declined in every year but one from FY2003 through FY2008. (See Table 1.) In
FY2003, 78,467 households were served; in FY2004, this number dropped to 70,779. The
number of households served continued to fall in FY2005 (67,012 households), and in FY2006 5152
(67,000 households). Although the number increased in FY2007 to 67,850, the number of
began to incorporate living HIV cases in addition to living AIDS cases.
48 See U.S. Congress, House Committee on Appropriations, Subcommittee on VA, HUD, and Independent Agencies,
Departments of Veterans Affairs and Housing and Urban Development and Independent Agencies Appropriations Bill, thst
report to accompany H.R. 2158, 105 Cong., 1 sess., July 11, 1997, H.Rept. 105-175, pp. 33-34.
49 U.S. Department of Housing and Urban Development, 1999 Report on the Performance of the Housing
Opportunities for Persons with AIDS Program, October 6, 1999 (hereafter 1999 HUD Report).
50 According to CDC data, in 1993 there were 137,529 people reportedly living with AIDS in the 50 states, the District
of Columbia, and the territories. By 2006, there were 509,681 people reportedly living with HIV/AIDS in the same
areas. See Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report 1993, Vol. 5, Atlanta, GA,1994,
p. 26, table 3, http://www.cdc.gov/hiv/topics/surveillance/resources/reports/pdf/hivsur54.pdf, and HIV/AIDS
Surveillance Report 2006, Vol. 18, Atlanta, GA, 2008, pp. 24-25, table 12,
51 U.S. Department of Housing and Urban Development, FY2006 Performance and Accountability Report, November
households assisted still remained below earlier levels in FY2001 through FY2004. In FY2008, 53
the number of households served again declined to 62,210. These general reductions in
households served could be due to a number of factors, including the growth in jurisdictions
eligible for HOPWA grants, the amount of available funds, and housing costs.
Table 1. HOPWA Funding and Eligible Jurisdictions, FY2001-FY2008
Number of Households
Qualifying Receiving Housing Funding
Fiscal Year Jurisdictions Assistancea (thousands of dollars)
2001 105 72,117 257,432
2002 108 74,964 277,423
2003 111 78,467 290,102
2004 117 70,779 294,751
2005 121 67,012 281,728
2006 122 67,000 286,110
2007 123 67,850 286,110
2008 127 62,210 300,100
Source: Table prepared by the Congressional Research Service based on data from the Department of Housing
and Urban Development budget justifications (number of qualifying jurisdictions and funding levels), and FY2004,
FY2006, FY2007, and FY2008 HUD Performance and Accountability Reports (number of households assisted).
For a breakdown of formula funding by jurisdiction, see Appendix.
a. Housing assistance includes short-term assistance with rent, mortgage or utilities, residence in short-term
housing facilities, housing provided through community residences and single room occupancy dwellings,
and rental assistance for permanent supportive housing.
In addition to funds for housing provided through HUD, funds appropriated to the Department of
Health and Human Services (HHS) Ryan White HIV/AIDS program may be used to provide
short-term housing assistance to persons living with HIV/AIDS. The Ryan White Comprehensive
AIDS Resources Emergency Act (P.L. 101-381) established the Ryan White program in 1990.
The program provides funds to states and metropolitan areas to help pay for health care and 54
support services for persons living with HIV/AIDS. The statute governing the use of Ryan
White funds does not specifically list housing as an eligible activity for which grantees may use
15, 2006, p. 136, http://www.hud.gov/offices/cfo/reports/2006/2006par.pdf.
52 U.S. Department of Housing and Urban Development, FY2007 Performance and Accountability Report, November
15, 2007, pp. 167-168, http://www.hud.gov/offices/cfo/reports/2007/2007par.pdf.
53 U.S. Department of Housing and Urban Development, FY2008 Performance & Accountability Report, November 17,
2008, p. 406, http://www.hud.gov/offices/cfo/reports/hudpar-fy2008.pdf.
54 For more information about the Ryan White program, see CRS Report RL33279, The Ryan White HIV/AIDS
Program, by Judith A. Johnson
funds. However, the statute provides that grantees may use Ryan White funds to provide support
services for persons living with HIV and AIDS. These services are defined as those “that are 55
needed for individuals with HIV/AIDS to achieve their medical outcomes ...” In 1999, the
HIV/AIDS Bureau of the Health Resources and Services Administration (HRSA) within HHS
released policy guidance regarding the type of housing that Ryan White grantees could provide 56
for their clients. According to the guidance, grantees may use funds for housing referral services
and for emergency or short-term housing. Ryan White funds must be the payer of last resort,
meaning that other sources of funds for housing must be exhausted before using Ryan White
Initially, the policy regarding use of Ryan White funds for housing did not require that specific
time limits be placed on short-term housing. In its report regarding the new guidance, HRSA
stated: “Although we are restricting the policy to transitional/temporary housing, we don’t define
‘transitional/temporary.’ Because we don’t know yet what the recent changes in medical treatment
of HIV/AIDS mean to the evolution of the epidemic, it is foolish to adopt any definition of ‘short- 57
term.’” However, when the Ryan White program was reauthorized in 2006, the new law limited
the amount of grants to states and urban areas that could be used for support services to no more 58
than 25% by requiring that at least 75% of funds be used for “core medical services.” Previously
the law did not limit the amount of funds that could be used for support services. In December
2006, in response to the “more restrictive funding limits established for support services in the
2006 reauthorization,” HHS issued a proposed policy notice to limit the amount of time that any
client could spend in Ryan White-funded transitional housing to 24 months in a lifetime, effective 59
retroactively. This would have meant that those individuals who had already exhausted the 24-
month time period would not be able to receive housing benefits. After receiving over 200
comments regarding the policy proposal, HHS eventually removed the provision requiring
retroactive application of the 24-month lifetime limit and released a final policy notice on 60
February 27, 2008. The policy took effect on March 27, 2008.
In 2007, HRSA reported that 476 Ryan White-funded service organizations provided housing 61
services for individuals living with HIV/AIDS. In 2006, an estimated 42,178 persons living with
AIDS received some sort of housing service. Note that this estimate includes duplicated services,
55 42 U.S.C. § 300ff-14(d)(1) and § 300ff-22(c)(1). At the time that HHS established its housing policy, the statute
stated that funds could be used “for the purpose of delivering or enhancing HIV-related outpatient and ambulatory
health and support services, including case management and comprehensive treatment services ... ” The statute was
amended to read as stated in the text of this report as part of the Ryan White HIV/AIDS Treatment Modernization Act
of 2006, P.L. 109-415.
56 The use of funds for housing was established in HIV/AIDS Bureau Notice 99-02. The notice is reproduced in U.S.
Department of Health and Human Services, Health Resources and Services Administration, Housing is Health Care: A
Guide to Implementing the HIV/AIDS Bureau (HAB) Ryan White CARE Act Housing Policy, 2001, p. 3,
ftp://ftp.hrsa.gov/hab/housingmanualjune.pdf, (hereafter Housing is Health Care).
57 Housing is Health Care, p. 7. See footnote 56.
58 The program was reauthorized in the Ryan White HIV/AIDS Treatment Modernization Act of 2006 (P.L. 109-415).
See Section 105.
59 U.S. Department of Health and Human Services, “HIV/AIDS Bureau Policy Notice 99-02 Amendment #1,” 73
Federal Register 10261, February 26, 2008.
60 Ibid., pp. 10260-10261.
61 Information provided to CRS by HRSA on December 4, 2008.
so an individual who received both housing referral services and spent time in emergency housing 62
may be counted more than once.
As mentioned earlier in this report, HIV/AIDS status is associated with homelessness: those
persons who are homeless are more likely to be HIV positive than those who are housed. In
addition, recent research has found that the health outcomes of homeless individuals living with
HIV/AIDS may be improved with stable housing. For example, in a study of HIV positive
individuals living in New York City that was conducted over twelve years from 1994 to 2006,
those who were unstably housed – meaning that they were either living on the street, in a shelter,
in some form of transitional housing, or temporarily living in someone else’s home – were less
likely to access and retain medical care for their disease than those receiving some form of 63
In addition, preliminary findings from two recent studies have found favorable health outcomes
for HIV positive individuals who are stably housed. In one of these studies, called the Housing
and Health Study, HUD, together with the CDC, provided HIV positive individuals who were
homeless or at severe risk of homelessness with HOPWA-funded rental housing. (The study
considered individuals to be at severe risk of homelessness if they frequently moved from one
temporary housing situation to another.) Those individuals in the comparison group received
services, including assistance with finding housing, but did not receive HOPWA-funded 64
housing. Despite the differences in rental assistance provided between the treatment and 65
comparison groups, both groups had a statistically significant increase in stable housing.
Although 4% of all participants were stably housed when the study began, 82% of HOPWA-
assisted renters and 52% of individuals in the comparison group retained housing 18 months after
the start of the study. Perhaps due to the fact that the comparison group also had some success in
achieving and maintaining housing, both groups saw some improvements in health outcomes.
Findings from the study show that individuals in both groups had fewer emergency room visits,
fewer hospitalizations, reduced opportunistic infections (those infections that occur due to
weakened immune systems), reduced participation in sex trade, and reductions in depression.
62 U.S. Department of Health and Human Services, Health Resources and Services Administration, Ryan White
HIV/AIDS Program Annual Data Summary, 2006, p. P11.
63 Angela A. Aidala, Gunjeong Lee, and David M. Abramson, et al., “Housing Need, Housing Assistance, and
Connection to HIV Medical Care,” Aids and Behavior, vol. 11, no. 6 (November 2007, supplement), pp. 109-112.
64 The methodology of the study is described in Daniel P. Kidder, Richard J. Wolitski, and Scott Royal, et al., “Access
to Housing as a Structural Intervention for Homeless and Unstably Housing People Living with HIV: Rationale,
Methods, and Implementation of the Housing and Health Study,” AIDS and Behavior, vol. 11, no. 6 (November 2007,
supplement), pp. 149-161.
65 Preliminary findings from the Housing and Health Study were presented at the National Housing and HIV/AIDS
Research Summit III, March 6, 2008. Findings are summarized in The National AIDS Housing Coalition, Examining
the Evidence: The Impact of Housing on HIV Prevention and Care, Policy Paper from the Third Housing and
HIV/AIDS Research Summit, 2008, pp. 6-7, http://www.nationalaidshousing.org/PDF/FinalSummit.pdf (hereafter
Examining the Evidence).
A second study, called the Chicago Housing for Health Partnership study, identified homeless
individuals with chronic illnesses, including HIV, for participation. Among those identified to
participate in the study, 36% were HIV positive. The treatment group received housing funded
through either HOPWA or HUD’s Supportive Housing Program for homeless individuals, while
the comparison, or usual care group, received available supportive services but no separate
assistance with rent. The group receiving housing assistance had higher rates of intact immunity
compared to the comparison group and were more likely to have undetectable viral loads 12 66
months after the study began. In addition, the treatment group spent fewer days in emergency
rooms, nursing homes, and hospitals during the 18 month period the researchers followed
66 Like the preliminary findings from the Housing and Health Study, the preliminary findings from the Chicago
Housing for Health Partnership Study were presented at the National Housing and HIV/AIDS Research Summit III.
The findings are summarized in Examining the Evidence, pp. 5-6. See footnote 65.
Table A-1.HOPWA Formula Allocations, FY2004-FY2008
MSA, State, or Territory FY2004 FY2005 FY2006 FY2007 FY2008
Alabama State Program 1,139,000 1,117,000 1,145,000 1,163,000 1,241,000
Birmingham 520,000 497,000 511,000 516,000 538,000
Arkansas State Program 752,000 723,000 707,000 720,000 766,000
Arizona State Program 164,000 164,000 173,000 180,000 191,000
Phoenix 1,434,000 1,391,000 1,433,000 1,456,000 1,541,000
Tucson 402,000 390,000 389,000 390,000 411,000
California State Program 3,042,000 2,869,000 2,929,000 2,926,000 2,746,000
Bakersfield — — — — 323,000
Los Angeles 10,476,000 11,848,000 10,310,000 10,393,000 10,437,000
Oakland 2,006,000 1,879,000 1,905,000 1,896,000 1,952,000
Riverside 1,772,000 1,683,000 1,684,000 1,689,000 1,751,000
Sacramento 844,000 795,000 786,000 784,000 818,000
San Diego 2,683,000 2,527,000 2,549,000 2,551,000 2,646,000
San Francisco 8,562,000 8,466,000 8,070,000 8,189,000 8,193,000
San Jose 792,000 736,000 738,000 739,000 767,000
Santa Anna 1,436,000 1,342,000 1,359,000 1,345,000 1,402,000
Colorado State Program 366,000 354,000 364,000 363,000 379,000
Denver 1,424,000 1,342,000 1,359,000 1,361,000 1,414,000
Connecticut State Program 251,000 242,000 253,000 252,000 263,000
Bridgeport 779,000 717,000 737,000 739,000 771,000
Hartford 1,023,000 1,285,000 1,108,000 1,098,000 1,140,000
New Haven 1,232,000 1,624,000 1,178,000 1,075,000 946,000
Washington, DC 11,802,000 10,535,000 11,370,000 11,118,000 11,541,000
Delaware State Program 164,000 162,000 166,000 167,000 179,000
Wilmingtona 798,000 703,000 679,000 552,000 604,000
Florida State Program 4,063,000 3,581,000 3,312,000 3,316,000 3,191,000
Cape Coralb — — 336,000 332,000 350,000
Fort Lauderdale 6,240,000 6,106,000 6,637,000 6,878,000 7,351,000
Jacksonville 1,564,000 1,624,000 1,587,000 1,630,000 1,988,000
Lakelandb — 378,000 445,000 418,000 509,000
Miami 10,715,000 10,351,000 11,189,000 11,689,000 12,370,000
Orlando 3,189,000 2,871,000 2,906,000 2,895,000 3,234,000
Palm Bay — — — — 311,000
Sarasota 397,000 548,000 390,000 391,000 409,000
MSA, State, or Territory FY2004 FY2005 FY2006 FY2007 FY2008
Tampa 2,389,000 3,049,000 2,542,000 2,772,000 3,193,000
West Palm Beach 3,836,000 3,426,000 3,595,000 3,235,000 3,271,000
Georgia State Program 1,515,000 1,527,000 1,576,000 1,621,000 1,744,000
Atlanta 4,899,000 6,592,000 5,290,000 6,801,000 7,034,000
Augusta 373,000 418,000 376,000 394,000 385,000
Hawaii State Program 181,000 169,000 162,000 160,000 164,000
Honolulu 452,000 428,000 429,000 419,000 433,000
Iowa State Program 347,000 329,000 330,000 336,000 354,000
Illinois State Program 864,000 827,000 875,000 875,000 916,000
Chicago 8,338,000 5,379,000 5,561,000 5,572,000 5,819,000
Indiana State Program 836,000 806,000 818,000 822,000 863,000
Indianapolis 759,000 738,000 751,000 752,000 782,000
Kansas State Program 363,000 349,000 331,000 332,000 346,000
Kentucky State Program 423,000 407,000 410,000 408,000 431,000
Louisville 462,000 443,000 447,000 453,000 476,000
Louisiana State Program 940,000 932,000 951,000 975,000 1,034,000
Baton Rouge 1,813,000 1,659,000 1,572,000 1,409,000 1,433,000
New Orleans 2,992,000 3,398,000 2,997,000 2,914,000 2,769,000
Massachusetts State Program 525,000 178,000 168,000 166,000 173,000
Boston 1,829,000 1,721,000 1,719,000 1,690,000 1,747,000
Lowell 659,000 623,000 627,000 622,000 644,000
Lynn — 316,000 317,000 312,000 326,000
Springfield 461,000 433,000 424,000 418,000 426,000
Worcester 369,000 348,000 354,000 349,000 368,000
Maryland State Program 345,000 335,000 348,000 345,000 357,000
Baltimore 7,936,000 7,754,000 7,649,000 8,038,000 8,195,000
Frederickc 535,000 518,000 524,000 539,000 575,000
Michigan State Program 911,000 862,000 877,000 893,000 941,000
Detroit 1,979,000 1,554,000 1,597,000 1,640,000 1,979,000
Warren 405,000 392,000 397,000 409,000 437,000
Minnesota State Program 110,000 105,000 112,000 114,000 119,000
Minneapolis 839,000 797,000 829,000 833,000 873,000
Missouri State Program 496,000 475,000 455,000 450,000 473,000
Kansas City 978,000 924,000 918,000 918,000 955,000
St. Louis 1,217,000 1,158,000 1,150,000 1,140,000 1,227,000
Mississippi State Program 756,000 749,000 778,000 783,000 833,000
Jackson 724,000 998,000 868,000 899,000 885,000
MSA, State, or Territory FY2004 FY2005 FY2006 FY2007 FY2008
North Carolina Program 2,082,000 2,010,000 2,097,000 2,154,000 2,272,000
Charlotte 571,000 565,000 597,000 626,000 671,000
Wake County 352,000 337,000 366,000 382,000 434,000
Nebraska State Program — — — — 306,000
New Jersey State Programa 1,106,000 1,050,000 1,064,000 1,056,000 1,079,000
Camden 657,000 628,000 620,000 610,000 642,000
Jersey City — 2,240,000 2,545,000 2,443,000 2,534,087
Newark 5,182,000 5,014,000 5,246,000 4,924,000 5,167,000
Paterson — 1,265,000 1,282,000 1,250,000 1,286,736
Woodbridge 1,462,000 1,366,000 1,375,000 1,351,000 1,390,000
New Mexico State Program 533,000 503,000 514,000 514,000 532,000
Nevada State Program 238,000 219,000 219,000 219,000 228,000
Las Vegas 916,000 886,000 882,000 897,000 952,000
New York State Program 1,776,000 1,702,000 1,797,000 1,809,000 1,897,000
Albany 429,000 415,000 436,000 439,000 462,000
Buffalo 472,000 456,000 480,000 480,000 507,000
Islip 1,660,000 1,565,000 1,617,000 1,608,000 1,675,000
New York City 60,355,000 47,056,000 56,610,000 54,723,000 56,811,177
Poughkeepsie 604,000 577,000 679,000 812,000 947,000
Rochester 597,000 575,000 599,000 605,000 640,000
Ohio State Program 1,041,000 1,024,000 1,037,000 1,051,000 1,108,000
Cincinnati 550,000 517,000 518,000 530,000 562,000
Cleveland 854,000 822,000 826,000 840,000 870,000
Columbus 584,000 584,000 596,000 608,000 641,000
Oklahoma State Program 518,000 494,000 498,000 506,000 226,000
Oklahoma City 466,000 441,000 435,000 437,000 459,000
Tulsa — — — — 307,000
Oregon State Program — 321,000 319,000 317,000 335,000
Portland 1,006,000 949,000 947,000 943,000 988,000
Pennsylvania State Program 1,540,000 1,511,000 1,548,000 1,527,000 1,670,000
Philadelphia 7,632,000 7,336,000 7,083,000 6,650,000 7,052,000
Pittsburgh 626,000 620,000 623,000 619,000 649,000
Puerto Rico State Program 1,748,000 1,636,000 1,633,000 1,616,000 1,679,000
San Juan 7,140,000 5,324,000 5,874,000 5,632,000 6,144,000
Providence 807,000 764,000 776,000 773,000 801,000
South Carolina State 1,387,000 1,356,000 1,387,000 1,403,000 1,491,000
MSA, State, or Territory FY2004 FY2005 FY2006 FY2007 FY2008
Charleston 418,000 390,000 397,000 401,000 419,000
Columbia 1,270,000 1,160,000 1,041,000 1,034,000 1,138,000
Tennessee State Program 739,000 718,000 747,000 756,000 796,000
Memphis 2,134,000 1,462,000 1,882,000 1,879,000 2,115,000
Nashville 737,000 840,000 737,000 757,000 795,000
Texas State Program 2,736,000 2,634,000 2,691,000 2,733,000 2,841,000
Austin 988,000 931,000 940,000 947,000 987,000
Dallas 3,192,000 3,867,000 3,141,000 3,134,000 3,332,000
Fort Worth 835,000 805,000 813,000 819,000 863,000
Houston 5,068,000 9,669,000 6,039,000 6,579,000 6,038,000
San Antonio 1,027,000 960,000 971,000 972,000 1,025,000
Utah State Program 120,000 111,000 112,000 111,000 115,000
Salt Lake City 386,000 354,000 353,000 346,000 357,000
Virginia State Program 640,000 612,000 618,000 615,000 634,000
Richmond 692,000 658,000 665,000 660,000 690,000
Virginia Beach 1,022,000 958,000 941,000 937,000 968,000
Washington State Program 652,000 619,000 620,000 622,000 651,000
Seattle 1,688,000 1,611,000 1,615,000 1,604,000 1,663,000
Wisconsin State Program 405,000 383,000 389,000 391,000 407,000
Milwaukee 512,000 487,000 497,000 492,000 515,000
—Subtotal formula grants 263,039,000 251,323,000 256,162,000 256,162,000 267,417,000d
—Subtotal competitive grants 29,227,000 27,925,000 28,463,000 28,463,000 29,713,000
—Subtotal technical asst. 2,485,000 2,480,000 1,485,000 1,485,000 1,485,000
Total HOPWA 294,751,000 281,728,000 286,110,000 286,110,000 300,100,000
Source: U.S. Department of Housing and Urban Development, Office of Community Planning and Development
Program Formula Allocations, available at http://www.hud.gov/offices/cpd/about/budget/budget08/index.cfm, and
FY2006-FY2009 Congressional Budget Justifications.
a. According to directions in the HUD Appropriations Act, funds awarded to the Wilmington MSA are
transferred to the State of New Jersey to administer the HOPWA program for the one New Jersey county
that is in the Wilmington MSA (Salem county).
b. The State of Florida administers the grants for the Cape Coral and Lakeland MSAs.
c. The State of Maryland administers the grant for the Bethesda-Frederick-Gaithersburg MSA.
d. Subtotals and totals for FY2008 are estimates.
Analyst in Housing