oversight

Housing: HUD's Program for Persons With AIDS

Published by the Government Accountability Office on 1997-03-24.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                 United States General Accounting Office

GAO              Report to the Subcommittee on VA, HUD
                 and Independent Agencies, Committee
                 on Appropriations, House of
                 Representatives

March 1997
                 HOUSING
                 HUD’s Program for
                 Persons With AIDS




GAO/RCED-97-62
                   United States
GAO                General Accounting Office
                   Washington, D.C. 20548

                   Resources, Community, and
                   Economic Development Division

                   B-276110

                   March 24, 1997

                   The Honorable Jerry Lewis
                   Chairman
                   The Honorable Louis Stokes
                   Ranking Minority Member
                   Subcommittee on VA, HUD and Independent Agencies
                   Committee on Appropriations
                   House of Representatives

                   The acquired immunodeficiency syndrome (AIDS) epidemic, well into its
                   second decade, has posed a serious health threat to the American public.
                   Through June 1996, over 545,000 cases of AIDS had been reported in the
                   United States, in addition to a large but undetermined number of people
                   who had not been diagnosed with AIDS but were infected with the human
                   immunodeficiency virus (HIV), which causes AIDS. Housing Opportunities
                   for Persons With AIDS (HOPWA), the only federal program targeted
                   specifically to meeting the housing needs of people with HIV/AIDS, was
                   established within the Department of Housing and Urban Development
                   (HUD) under the National Affordable Housing Act of 1990. From fiscal year
                   1992, when the HOPWA program began, through fiscal year 1996, the
                   Congress appropriated over $645 million for the program and an additional
                   $196 million for fiscal year 1997.

                   This report responds to your request that we review (1) what the rationale
                   is for having a housing program within HUD specifically for people with
                   AIDS, (2) what kinds of activities are being funded through the program,
                   (3) whom the program is serving, (4) how the program is coordinated with
                   the Department of Health and Human Services’ (HHS) Ryan White AIDS
                   assistance programs, and (5) how HUD headquarters oversees program
                   administration and monitoring. As requested, we are also providing
                   background information on how the program works.


                   The legislative history for the Housing Opportunities for Persons With AIDS
Results in Brief   program indicates that the Congress established the program within the
                   Department of Housing and Urban Development in 1990 because the
                   existing housing resources at the time were reportedly not meeting the
                   needs of people with AIDS, who often had difficulty obtaining suitable
                   housing because of the need for supportive services, discrimination, or
                   other problems. Department of Housing and Urban Development and
                   Department of Health and Human Services officials, along with several




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grantees and project sponsors we contacted, generally believe that these
problems still exist and that the Housing Opportunities for Persons With
AIDS program is still needed to counteract them. However, critics have
questioned the program because, for instance, they believe that it is not
appropriate to target assistance to persons with one disease and not
others or that any additional federal resources should be focused on
preventing AIDS.

Grantees can use funds for a broad range of housing assistance and
supportive services intended to prevent homelessness. The limited data
available from HUD indicate that about 71 percent of the funds that have
been expended has been used to provide housing assistance; about
16 percent has been used to provide supportive services independent of
housing assistance, such as health care, chemical dependency treatment,
and nutritional services; and the remaining 13 percent has been used for
housing information services, resource identification, and grantees’ and
project sponsors’ administrative costs. However, it should be recognized
that these data do not fully reflect the grantees’ use of program
appropriations. As of October 7, 1996, the grantees had expended
37 percent of the total funds appropriated since fiscal year 1992.
Furthermore, the grantees’ reports describing their use of program funds
that were available from the Department of Housing and Urban
Development’s Office of HIV/AIDS Housing as of October 7, 1996, covered
only 27 percent of the funds that the grantees had expended during that
time.

Under the Department’s regulations, the program generally provides
assistance to low-income individuals with HIV/AIDS and their families. Our
analysis of the limited data available from the Office of HIV/AIDS Housing
indicates that 70 percent of the program participants received housing
assistance, while about 30 percent received supportive services not
associated with housing assistance funded by the program. The
Department does not collect data on the characteristics of the program
participants who receive only supportive services. However, of those that
received housing assistance, about 67 percent were adult males, and about
70 percent had incomes below $500 per month. Over half of the
participants were living in rental housing prior to receiving housing
assistance under the program, while the rest came from various situations,
such as living with relatives or in shelters, substance abuse facilities, or
hospitals.




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Coordination between the Housing Opportunities for Persons With AIDS
program and Ryan White Titles I and II programs, which provide grants to
states and localities to fund a wide range of services to assist people with
HIV/AIDS, occurs primarily at the grantee level. According to officials in the
Departments of Housing and Urban Development and Health and Human
Services, coordination of the two programs at the national level is
basically informal. While the agencies have taken steps to increase
coordination in recent years, several grantees and project sponsors we
contacted believed that the two programs could be better coordinated.
Furthermore, we noted that while the formula used to distribute Ryan
White funds has been revised to reflect estimates of the current number of
people living with AIDS, the formula for the housing opportunities program
is still based on cumulative AIDS cases, which can lead to funding
inequities. Also, the requirements governing how the Ryan White grantees
are to coordinate with other parties when planning the use of grant funds
provide greater assurance that all affected parties will have a voice in
determining how the funds will be used than do the requirements for the
housing opportunities program.

Department of Housing and Urban Development field offices are primarily
responsible for the oversight and monitoring of grantees under the
program. The field offices can use a variety of tools to oversee grantees
and monitor their use of funds, including a review of the consolidated
plans and progress reports prepared by the grantees, as well as on-site
visits and consultation with community officials and other stakeholders.
The field offices also have considerable latitude and flexibility in how they
use these tools. Headquarters directs and monitors the field offices’
oversight of the grant programs.

Although we did not review the field offices’ monitoring of grants, in an
August 1996 telephone survey, field community planning and development
grant program directors expressed a general belief that headquarters has
not sufficiently emphasized completing essential monitoring and that
insufficient staff and travel funds have prevented sufficient on-site
inspection visits. Also, headquarters has not made effective use of the
available data on the performance of grantees because it has not used the
grantees’ annual progress reports to assess overall program
accomplishments nor ensured that these reports are received and
processed in a timely manner.




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             First identified in 1981, AIDS impairs the immune system and leaves
Background   affected individuals susceptible to certain cancers and infections. Through
             June 1996, over 545,000 people with AIDS had been reported to the Centers
             for Disease Control and Prevention (CDC); 343,000 of these had died.1 The
             CDC reported that in 1994, the most recent year of analysis, HIV infection
             was the most common cause of death among persons aged 25 to 44 years.2

             The Congress created the program of Housing Opportunities for Persons
             With AIDS in 1990 under the National Affordable Housing Act, authorizing
             grants for a broad range of housing activities and supportive services
             designed to prevent homelessness among people with HIV/AIDS. For fiscal
             year 1997, the Congress appropriated $196 million for the HOPWA program
             (including $25 million transferred from HUD’s Section 8 rental assistance
             program). HOPWA grantees may carry out eligible program activities
             themselves, through any of their administrative agencies, or by contract
             with a project sponsor. A project sponsor can be any nonprofit
             organization or governmental housing agency that receives funds under a
             contract with a grantee to carry out eligible HOPWA activities. The grantees
             and project sponsors may also contract with for-profit entities to provide
             services associated with their HOPWA activities.

             HUD awards 90 percent of the annual HOPWA appropriation by formula to
             eligible metropolitan statistical areas and states. On the basis of the
             statute, metropolitan areas with populations greater than 500,000 and
             more than 1,500 cumulative cases of AIDS3 are eligible for HOPWA formula
             grants; the most populous city in an eligible metropolitan area serves as
             that area’s HOPWA grantee. In addition, states with more than 1,500
             cumulative cases of AIDS in areas outside of eligible metropolitan areas

             1
              Of the cumulative number of people reported with AIDS through June 1996, about 85 percent were
             males. In addition to the number of AIDS cases reported, an undetermined number of individuals who
             have not been diagnosed with AIDS are infected with HIV, which causes AIDS. According to a recent
             CDC report, estimates of the prevalence of HIV infection in the United States in 1992 placed the
             number of people infected between 650,000 and 900,000.
             2
              Because of the prolonged period from the initial HIV infection to the onset of AIDS, recent trends in
             HIV-related   mortality reflect the trends in HIV transmission several years earlier. Despite recent
             increases in HIV-related mortality, the decreases in the percentages of HIV-related deaths resulting
             from particular HIV-related illnesses suggest some success in the treatment and prevention of these
             illnesses. According to CDC’s HIV/AIDS Surveillance Report, the estimated number of new diagnoses
             of severe HIV-related illnesses, called AIDS opportunistic infections (AIDS-OIs), are useful for tracking
             recent courses of the epidemic. CDC’s report of the data through June 1996 states that the recent
             trends in the number of AIDS-OIs illustrate an overall slowing in the rate of growth of the AIDS epidemic.
             According to the CDC report, while the estimated number of AIDS-OIs is still increasing slightly each
             year, it is likely that in the near future, the estimated number will stabilize or decline slightly. However,
             these overall trends at the national level are likely to mask diverse local subepidemics.
             3
              The count of cumulative AIDS cases represents the total number of cases reported to and confirmed
             by the CDC since AIDS reporting began in 1981.



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qualify for formula funds. For fiscal year 1996, 27 states and 49
metropolitan areas had enough AIDS cases to qualify for formula grants.

The remaining 10 percent of HOPWA’s annual appropriation is set aside for
grants awarded on a competitive basis. The states and localities that do
not qualify for formula grants may apply for competitive grants for
projects that are part of long-term strategies for providing housing and
services. These grants are awarded on the basis of criteria such as the
applicant’s capacity to implement the proposed project; the area’s need for
the project; the appropriateness of housing and supportive services,
including how the activities will provide a continuum of housing and
services to meet the changing needs of people with AIDS; the extent of
leveraged public and private resources for the project; the extent of local
planning and coordination of housing programs for people with AIDS; and
the likelihood of the continuation of state and local efforts. In addition,
any state, locality, or nonprofit organization may apply for a competitive
grant to fund a Special Project of National Significance. These grants are
awarded on the basis of many of the same criteria as other competitive
grants, in addition to two other criteria: the innovative nature of the
proposal and its potential for replication in similar localities or nationally,
and the extent to which the proposal provides for the evaluation and
dissemination of information on the project’s success. HUD has awarded
competitive grant funds for fiscal years 1992 through 1996 to a total of 81
grantees.

Eligible states and cities apply for HOPWA formula funds through the
Consolidated Plans they submit to HUD. Under the Consolidated Plan
process, jurisdictions submit a single document that consolidates the
planning and application aspects of the four formula grant programs
administered by HUD’s Office of Community Planning and Development
(CPD).4 Applicants are to develop their Consolidated Plans through a
communitywide effort that assesses needs, creates a multiyear strategy,
and proposes an action plan for using federal funds and other community
resources in a coordinated and comprehensive manner.

HUD’s  regulations require jurisdictions applying for formula grants to adopt
a citizen participation plan that provides for and encourages citizens to


4
 In addition to HOPWA, CPD administers the Community Development Block Grant program, the
Emergency Shelter Grant program, and the HOME Investment Partnerships (HOME) program. The
block grant program provides annual grants, principally to state and local governments, to aid in the
development of viable communities. The emergency shelter program provides grants for safe and
sanitary housing, supportive services, and other assistance to the homeless. HOME provides funds to
produce affordable housing units.



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participate in developing the Consolidated Plan. The Consolidated Plan
process, which applies to all four Community Planning and Development
formula grant programs, also requires the grantees to consult with other
public and private agencies that provide assisted housing, health services,
and social services, including those that focus on specific populations
such as people with HIV/AIDS. The grantees’ Consolidated Plans are to
describe the agencies, groups, and others who participated in the planning
process; their consultations with social service agencies and other entities;
and their activities to enhance coordination between public and assisted
housing providers and private and governmental health, mental health, and
service agencies. In addition, regulations specific to the HOPWA program
require the grantees to cooperate and coordinate with state and local
government agencies responsible for services in the area for people with
HIV/AIDS and their families, and with other public and private organizations
that provide services for these people.

Before enacting HOPWA’s authorizing legislation, in 1990 the Congress
enacted the Ryan White Comprehensive AIDS Resources Emergency (CARE)
Act (P.L.101-381) to improve the availability and quality of
community-based health care and support services for individuals and
families with HIV/AIDS. The Health Resources and Services Administration
(HRSA), within the Department of Health and Human Services (HHS),
administers the Ryan White legislation. HRSA’s Bureau of Health Resources
Development administers titles I and II of the act, which provide grants to
those metropolitan areas disproportionately affected by the HIV epidemic
and to states. Title I provides both formula and competitive grants for
“emergency assistance” to localities to provide medical and support
services to those with HIV/AIDS and their families; title II provides formula
grants to states to improve the quality, availability, and organization of
health care and support services for people with HIV/AIDS and their families.
For fiscal year 1996, the Congress appropriated $762 million for the Ryan
White program; a total of over $652 million was appropriated for titles I
and II.




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                      The legislative history for the National Affordable Housing Act of 1990
The Congress          (P.L. 101-625), which established the HOPWA program, indicates that, at that
Established the       time, people with AIDS constituted a growing proportion of the homeless
HOPWA Program in      population. In its report on proposed legislation that ultimately became
                      Public Law 101-625, the Senate Committee on Banking, Housing, and
Response to Unmet     Urban Affairs reported that the Partnership for the Homeless had
Housing Needs         estimated that between 28,000 and 32,000 people with AIDS, and an
                      additional 10,000 to 11,000 of their dependents, were homeless throughout
Reported for People   the United States. According to the Committee’s report, housing,
With AIDS             especially housing with supportive services, was extremely limited for
                      people with AIDS; for example, the National Coalition for the Homeless had
                      reported that in Los Angeles, only 5 out of 42 shelters would accept
                      someone infected with HIV. The Committee stated that it viewed adequate
                      housing as the cornerstone of a comprehensive community-based network
                      of services for people with AIDS and that care in home- or
                      community-based settings was compassionate and more cost-effective
                      than hospitalizing people with AIDS who did not need acute care but could
                      not be discharged because they had nowhere to live.

                      The Congress reauthorized the HOPWA program under the Housing and
                      Community Development Act of 1992 (P.L. 102-550). In that same year, the
                      National Commission on AIDS had reported that an estimated 15 percent of
                      the homeless population was infected with HIV and that one-third to
                      one-half of all people with AIDS were either homeless or in imminent
                      danger of becoming so because of their illness, lack of income, and weak
                      support networks. The Commission added that the housing crisis for
                      people with AIDS was partially the result of an overall lack of adequate,
                      affordable housing for all citizens.

                      HUD has not conducted any comprehensive, nationwide studies to evaluate
                      the current housing needs of people with AIDS. However, AIDS Housing of
                      Washington, the recipient of a HOPWA competitive grant in fiscal year 1995
                      to provide technical assistance nationwide to communities and housing
                      providers for people with AIDS, has compiled data that provide some
                      indication of the housing needs. The organization surveyed 2,593 people
                      with AIDS during the course of its work in a mix of eight cities, counties,
                      and states.5 The results show that 36 percent of those surveyed in these
                      locations had been homeless since learning of their HIV infection or AIDS. In


                      5
                       AIDS Housing of Washington surveyed people with AIDS in Chicago, Illinois; Alameda County,
                      California; Contra Costa County, California; Riverside/San Bernardino Counties, California; Phoenix,
                      Arizona; and the states of Minnesota and Washington. The studies were conducted using convenience
                      sampling, and the results cannot be projected to the overall AIDS population.



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addition, officials in HHS’ HRSA identify housing assistance as a continuing
priority need for people with AIDS.

The Director of HUD’s Office of HIV/AIDS Housing told us that HUD strongly
believes that the HOPWA program is still needed. He noted that the
Congress has not only continued funding for the program but has
approved funding increases in fiscal years 1993, 1994, 1995, and 1997.
Furthermore, several grantees and project sponsors whom we contacted
believe that the need for the program has not only continued, but has
increased because of current developments in the AIDS epidemic. The
grantees and sponsors cited trends such as increasing infection among
African-American and Hispanic communities, women, families with
children, and injection drug users. In addition, they noted that the life
expectancy for a person with AIDS has increased since the initial years of
the epidemic and may continue to increase with the development of new
treatments. The Director of HUD’s Office of HIV/AIDS Housing and some
advocates maintain that these new treatments may enhance the
importance of adequate housing for people with AIDS because they require
a very strict regimen to be effective; without stable housing and support,
individuals could find it very difficult to adhere to the prescribed regimen
or to even access programs that make the new treatments available.

In contrast, some parties have questioned the HOPWA program. For
instance, a Senior Fellow at the Heritage Foundation told us that HUD has
not proven its ability to provide decent, safe, and sanitary housing at a
competitive price and, therefore, should not attempt to administer
programs like HOPWA that go beyond basic housing provision to offer
supportive services. This is particularly true, he said, when another
agency, HHS, already has expertise in supportive service programs.
Americans for a Sound AIDS/HIV Policy6 questions the HOPWA program on the
principle that AIDS should be addressed in the same way that other medical
problems are addressed at the national level; while federal assistance
should be available to people with AIDS, programs should not be targeted
only to the AIDS population but should be available to anyone with a
serious disease. In addition, during floor debate on HOPWA’s appropriation
for fiscal year 1997, the argument was made that any additional federal
resources to address the AIDS epidemic would be better spent on increased
efforts to prevent HIV infection and the disease’s progression from HIV to
AIDS, rather than on increasing the appropriation for housing. It was argued
that HIV/AIDS is largely a preventable disease and that no matter how much

6
 Americans for a Sound AIDS/HIV Policy is a Washington, D.C.-based organization that provides
education, prevention, and direct service programs related to HIV disease.



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                         money the nation spends on compassionate care in the later stages of AIDS,
                         it will never be enough; instead, the key to solving the AIDS crisis lies in
                         focusing federal efforts on preventing HIV infection and providing drugs
                         that could prevent HIV-infected individuals from developing AIDS.


                         Grantees can use HOPWA funds for a wide range of activities designed to
Limited Data Show        prevent homelessness, including housing, social services, and program
That Program Has         planning and development. Eligible activities include all forms of housing
Primarily Funded         assistance, such as the acquisition, rehabilitation, or new construction of
                         housing units; operating costs;7 rental assistance; technical assistance; and
Housing Assistance       short-term rental, mortgage, and utility payments to prevent homelessness.
                         As part of any assisted housing, the grantees must provide appropriate
                         supportive services, which could include health care, mental health
                         services, drug and alcohol abuse treatment and counseling, day care, or
                         nutritional services, among other things. The grantees can also use HOPWA
                         funds to provide services independent of any housing activity.

                         Grantees can also use HOPWA funds for

                     •   housing information services, such as counseling and referral services, to
                         assist an eligible participant to locate, acquire, finance, and maintain
                         housing;
                     •   resource identification to establish, coordinate, and develop housing
                         assistance resources for eligible participants, including conducting
                         preliminary research and determining the feasibility of specific
                         housing-related initiatives; and
                     •   administrative costs, which may not exceed 3 percent of the grant amount
                         for grantees and 7 percent for project sponsors.

                         For fiscal years 1992 through 1996, the Congress appropriated a total of
                         about $646 million for the HOPWA program. As of October 7, 1996, grantees
                         had spent nearly $239 million, or 37 percent, of these appropriated funds.
                         According to officials in HUD’s Office of HIV/AIDS Housing, the remaining
                         $407 million had not yet been expended by grantees for several reasons,
                         including that (1) HUD allows a 3-year period to fully expend a grant award;
                         (2) some grantees intentionally reserve funds until the final year of their
                         grant period to ensure that they can provide assistance for the full 3-year
                         period; (3) facility development can be slow because of complexities such
                         as environmental reviews and siting difficulties; and (4) some grantees

                         7
                          Operating costs for housing include expenses for maintenance, security, operation, insurance,
                         utilities, furnishings, equipment, and supplies.



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who had not developed an approach to assisting people with HIV/AIDS
before receiving the HOPWA grant waited to spend grant funds until they
had identified resources and developed an overall plan.

HUD’s  Office of HIV/AIDS Housing collects data on the use of program funds
through annual progress reports submitted by the grantees to their local
HUD field office. As of October 7, 1996, the HIV/AIDS Housing Office had
received annual progress reports representing about $65 million, or 27
percent, of the $239 million expended since the program’s inception.8 The
available data indicate that grantees used about 71 percent of the
expended funds to provide housing assistance9 and about 16 percent to
provide supportive services independent of HOPWA-funded housing
assistance. The remaining 13 percent was used to fund housing
information services, resource identification, and administrative costs (see
fig. 1). However, these data must be interpreted with caution because they
may not be representative of how the remaining 73 percent of expended
funds have been used.




8
 The Office of HIV/AIDS Housing had not received annual progress reports on the other 73 percent of
funds. Some of these reports were not due as of the October date, but others were overdue. This issue
is discussed later in our report.
9
Housing assistance expenditures can include funds for supportive services provided in conjunction
with assisted housing.



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Figure 1: HOPWA Expenditures
(Reflects Data From 1992 Through                                                       Supportive services
Oct. 7, 1996)
                                                                                       4.5%
                                                                                       Project sponsor administration
                                                                                       costs

                                                                                       3.5%
                                                                                       Housing information

                                                                                       2.4%
                                                                                       Resource identification

                                                                                       2.4%
                                                                                       Grantee administration costs




                                                        •
                                                    • •

                                                •

                                       • 16.1%


                                                               71.1% •                 Housing assistance




                                   Notes: Housing assistance expenditures can include supportive services provided in connection
                                   with assisted housing.

                                   The information represents 27 percent of the funds expended.

                                   Source: Grantees’ annual progress reports received by HUD’s Office of HIV/AIDS Housing as of
                                   October 7, 1996.




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                        The statute establishing the HOPWA program (P.L. 101-625) limited
Limited Data Show       eligibility to persons with HIV/AIDS or related diseases. The Congress
That Program Has        amended the act in 1992 (P.L. 102-550) to include the families of those with
Primarily Provided      HIV/AIDS, which HUD’s regulations define as a household of two or more
                        related persons, someone important to the care or well-being of a person
Housing Assistance to   with HIV/AIDS living with that person, or family members living with
Adult Males With        someone with HIV/AIDS in a HOPWA-assisted unit at the time of that
                        person’s death.10 HUD has generally limited program participation to
HIV/AIDS
                        low-income individuals and families.11

                        The limited data available from the grantees’ annual progress reports at
                        HUD’s HIV/AIDS Housing Office as of October 7, 1996, indicate that over
                        70 percent of the program participants received housing assistance, while
                        about 30 percent received supportive services not connected with any
                        housing assistance (see fig. 2). However, we again caution that these data
                        represent only 27 percent of the total funds expended as of the October
                        date and may not be representative of the population assisted with the
                        remaining 73 percent of funds expended since the program’s inception.




                        10
                         HOPWA-funded health services may be provided only to those with HIV/AIDS and not to the family
                        members of these individuals.
                        11
                          HUD instituted the low-income limitation after concluding that the HOPWA statute was somewhat
                        ambiguous on whether eligible persons must also be low-income. HUD noted that several provisions of
                        the HOPWA legislation restricted authorized activities to those that benefited persons with AIDS who
                        were homeless (or in danger of becoming so) or low-income persons with AIDS. Taking these
                        provisions into account, as well as the fact that limited funds were available for HOPWA, HUD decided
                        to limit the program to low-income individuals (those with incomes that do not exceed 80 percent of
                        the median income for the area) to help target the limited resources to those with the greatest need.
                        However, HOPWA funds may be used to provide housing information services to people with
                        HIV/AIDS and their family members regardless of income, and any person living in proximity to a
                        HOPWA-funded community residence may participate in that residence’s community outreach and
                        educational activities regarding AIDS.



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Figure 2: Number of Persons
Receiving Housing Assistance and                                                        Persons with HIV/AIDS receiving
Supportive Services (Reflects Data                                                      supportive services only
From 1992 Through Oct. 7, 1996)
                                                                                        4.7%
                                                                                        Family members receiving
                                                                                        supportive services only


                                                        •



                                          • 24.9%

                                                                   49.7% •              Persons with HIV/AIDS receiving
                                                                                        housing assistance


                                                20.7%
                                                   •




                                                                                        Family members receiving housing
                                                                                        assistance


                                     Note: The information represents 27 percent of the HOPWA funds expended.

                                     Source: Grantees’ annual progress reports received by HUD’s Office of HIV/AIDS Housing as of
                                     October 7, 1996.




                                     The annual progress reports submitted by grantees collect information on
                                     the characteristics of program participants who receive housing assistance
                                     but do not collect data on participants who receive only supportive
                                     services. Our analysis of the annual progress report data available from
                                     HUD headquarters indicates that about 67 percent of those who received
                                     housing assistance were adult males; those aged 31 to 50 accounted for
                                     almost 46 percent of the people assisted (see fig. 3). The program
                                     participants generally had very low incomes: About 70 percent had
                                     incomes below $500 per month (see fig. 4). Over half of those who
                                     received housing assistance were living in rental housing prior to receiving
                                     the HOPWA assistance (see fig. 5). According to officials in HUD’s Office of
                                     HIV/AIDS Housing, those living in rental housing did not necessarily relocate




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                                       upon receiving HOPWA assistance; rather, they believe that the HOPWA
                                       housing assistance likely helped these participants remain in their current
                                       residences.


Figure 3: Percentage of Program
Participants by Gender and Age Group
(Reflects Data From 1992 Through
Oct. 7, 1996)                                                                               8.6%
                                                                                            Females 18 to 30

                                                                                            Females 31 to 50

                                                                                            1.3%
                                                                                            Females 51 and over


                                                                 •                          4.6%
                                                                                            Males 17 and under
                                                  • 14.1%
                                                                     17.9%
                                                                        •
                                                 •
                                                 •
                                                 •


                                                             45.9%
                                                                •




                                                                                            Males 18 to 30

                                                                                            Males 31 to 50

                                                                                            3.1%
                                                                                            Males 51 and over

                                                                                            4.5%
                                                                                            Females 17 and under


                                       Notes: The information represents only those participants receiving housing assistance.

                                       The information represents 27 percent of the HOPWA funds expended.

                                       Source: Grantees’ annual progress reports received by HUD’s Office of HIV/AIDS Housing as of
                                       October 7, 1996.




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Figure 4: Gross Monthly Family
Incomes of Program Participants                                                         $501 to $1,000
(Reflects Data From 1992 Through
Oct. 7, 1996)                                                                           2.8%
                                                                                        $1,001 to $1,500

                                                                                        0.8%
                                                                                        $1,501 and over


                                                      •


                                        • 26.1%                 29.4% •                 $0 to $250




                                                     40.9% •                            $251 to $500




                                   Notes: The information represents only those participants receiving housing assistance.

                                   The information represents 27 percent of the HOPWA funds expended.

                                   Source: Grantees’ annual progress reports received by HUD’s Office of HIV/AIDS Housing as of
                                   October 7, 1996.




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Figure 5: Previous Living Situations of
HOPWA Participants (Reflects Data
From 1992 Through Oct. 7, 1996)
                                                                                     7.3%
                                                                                     Homeless from the streets

                                                                                     3.8%
                                                                                     Homeless from emergency
                                                                                     shelters

                                                                                     3.5%
                                                                                     Participant-owned housing

                                                                                     3.3%
                                                                                     Homeless from transitional
                                                                                     housing

                                                                                     2.5%
                                                                                     Hospital or other medical facility

                                                                                     2.5%
                                                                                     Substance abuse treatment facility

                                                                                     1.5%
                                                                                     Jail/prison

                                                                                     3.2%
                                                                                     Other


                                                                  •
                                                            • •
                                                            •
                                                        •
                                                    •
                                                    •
                                                                      51.2% •        Rental housing


                                                    21.2%
                                                       •




                                                                                     Living with relatives/friends



                                                                                                       (Figure notes on next page)




                                          Page 16                               GAO/RCED-97-62 Housing for Persons With AIDS
                         B-276110




                         Notes: The information represents only those participants receiving housing assistance.

                         “Other” includes situations reported as “other” by grantees as well as those reported as domestic
                         violence situations and psychiatric facilities. The information represents 27 percent of the HOPWA
                         funds expended.

                         Source: Grantees’ annual progress reports received by HUD’s Office of HIV/AIDS Housing as of
                         October 7, 1996.



                         Neither the HOPWA nor the Consolidated Plan regulations specifically
Opportunities Exist to   require HOPWA grantees to coordinate with grantees under the Ryan White
Increase Consistency     CARE Act that provide services in the area. In contrast, the CARE Act

and Coordination         requires title I grantees, in planning the use of funds, to include grantees
                         under other federal HIV programs. Consistent with the intent stated by the
Between HOPWA and        Senate Labor and Human Resources Committee in its report on proposed
Ryan White Programs      Ryan White legislation in 1996, HHS has interpreted the category “grantees
                         under other Federal HIV programs” to include representatives of any HOPWA
                         grantees that provide services in the area. The two sources of grant funds
                         are similar to some extent, in that both HOPWA and Ryan White grants may
                         be used to provide supportive services for people with HIV/AIDS; both
                         may also be used to provide housing assistance, although Ryan White
                         grants may be used only for limited housing services, such as housing
                         referral services or emergency housing assistance, but not for
                         construction, renovation, or continuing rental assistance.

                         According to officials in HUD’s Office of HIV/AIDS Housing and in HHS’ Health
                         Resources and Services Administration (HRSA), coordination between
                         HOPWA and Ryan White funding occurs primarily at the grantee level, and
                         the effectiveness of this coordination is variable; some grantees coordinate
                         the two sources of funds very effectively, while other grantees do not
                         coordinate as well. Our discussions with several grantees and project
                         sponsors support this perception. Most of those we contacted were
                         satisfied with the coordination between HOPWA and Ryan White funds in
                         their area, but some believed that coordination needed improvement.
                         According to the AIDS Action Council, a Washington, D.C.-based advocacy
                         group for federal AIDS policy, it is important that the HOPWA and Ryan White
                         programs be coordinated, especially to the extent that grantees can use
                         the relatively scarce HOPWA funds to provide housing itself and coordinate
                         with the larger Ryan White program to provide services.

                         At the federal level, officials from the Office of HIV/AIDS Housing and HRSA
                         told us that coordination between the HOPWA and Ryan White programs is
                         basically informal but ongoing. For example, according to officials in the




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Office of HIV/AIDS Housing, they interact with HHS officials as part of the
interdepartmental efforts among several agencies to provide information
on and improve the understanding of AIDS and to help coordinate housing
issues associated with AIDS.

According to the Office of HIV/AIDS Housing, HUD’s communications with
HRSA have increased over the past couple of years. For example, for fiscal
year 1996 HUD and HHS entered into a joint initiative to each target a
portion of their fiscal year 1996 competitive grant funds under the HOPWA
and Ryan White programs, respectively, for projects to assist homeless
persons with multiple diagnoses of HIV/AIDS, chronic substance abuse
problems, and/or serious mental illness. This HIV Multiple-Diagnoses
Initiative is a collaborative effort between HUD and HHS to establish,
evaluate, and disseminate information on model programs to integrate
health care and other supportive services with housing assistance. An HRSA
official said that this joint initiative was very useful in increasing
communication and coordination between the two agencies and that HUD
and HHS should continue to examine ways to undertake more such joint
initiatives. The AIDS Action Council agrees that the joint initiative
represents a good step toward increased coordination but says that HUD
and HRSA should further explore ways to work more closely together
because both types of assistance are critical needs of the AIDS population.
Several grantees and project sponsors we contacted also agreed that the
HOPWA and Ryan White programs could be better coordinated.


One area in which the HOPWA and Ryan White programs differ is the basis
for determining funding eligibility and distribution. The HOPWA funding
formula distributes grant funds on the basis of an area’s cumulative
number of AIDS cases since reporting began in 1981. In considering
amendments to the HOPWA program in 1992 (P.L. 102-550), the Senate
Committee on Banking, Housing, and Urban Affairs reported that the
cumulative number of cases should serve as the eligibility criteria, adding
that this basis was consistent with the way that the Ryan White CARE Act
determined eligibility for its formula distribution of funds. However, in
1996 the Congress passed amendments to the Ryan White CARE Act,
changing the title I and title II funding formulas to reflect an area’s
estimated number of people currently living with AIDS rather than
cumulative cases. Prior to the amendments, eligibility was based on the
cumulative number of cases since AIDS reporting began in 1981, over
60 percent of whom have died. As we reported in 1995,12 because the CARE

12
 Ryan White CARE Act of 1990: Opportunities to Enhance Funding Equity (GAO/HEHS-96-26, Nov. 13,
1995).



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Act formulas included deceased persons, the areas that experienced the
first outbreak of AIDS were receiving substantially more per-case funding
than areas with a more recent growth in AIDS cases.

Although the CARE Act formulas now reflect more current estimates of
people with AIDS, excluding deceased persons, the HOPWA formula is still
based on cumulative cases. Eight of the 11 grantees and project sponsors
we contacted either supported the idea of changing the HOPWA formula to
reflect a more current measure of need, similar to the recent changes
under the CARE Act, or were indifferent to such a change. Americans for a
Sound HIV/AIDS Policy, which believes that the current HOPWA formula
distributes funds inequitably, also supports the idea of changing the
program’s formula to reflect more current needs.13 In discussing possible
modifications of the HOPWA formula, officials in HUD’s HIV/AIDS Housing
Office pointed out that there are several differences between the Ryan
White CARE Act and HOPWA programs and that any changes to HOPWA’s
formula should be considered very carefully. According to officials in the
HIV/AIDS Housing Office, differences between the Ryan White CARE Act and
HOPWA programs that affect formula allocations include the number of AIDS
cases that triggers grant eligibility; HOPWA’s mechanism for distributing
additional funds to metropolitan areas with a higher-than-average per
capita incidence of AIDS; the CARE Act’s mechanism for awarding
supplemental funds to metropolitan areas; and funding eligibility for states
under the two programs. The officials said that any change has the
potential to shift funding between communities, create instability or
unpredictable results, and disrupt the support needed to continue
grantees’ current efforts. We recognize that differences between the two
programs may make it inappropriate to apply identical formulas to both
programs and that the effects of changes in the grantees’ funding levels
need to be carefully considered. Nonetheless, in our view, the general
principle of allocating grants on the basis of the estimated number of
people living with AIDS, excluding those who are deceased, ensures a more
equitable allocation of the available funds and is a principle that applies
equally to both programs.

Another difference between the HOPWA and Ryan White programs is the
requirements on planning the use of funds. Under title I of the CARE Act,
eligible metropolitan areas must use a community planning body to plan
for the use of title I funds. The requirements for the composition of these
planning bodies are very specific, identifying 12 different parties that must

13
  The other three grantees and project sponsors opposed a formula change for reasons such as
(1) satisfaction with the current formula and (2) concern that some areas would be “winners” but
others would be “losers” if the funding formula were changed.



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be involved in the planning process, including representatives of HOPWA
grantees that provide services in the area.14 On the other hand, the HOPWA
planning requirements are more general in setting forth who should be
included in the planning process. According to HUD, the Consolidated Plan
process involves citizens in developing a plan for providing housing
assistance and services to people with HIV/AIDS and serves as a vehicle for
coordinating HOPWA with other affordable housing efforts. However, on the
basis of our discussions with grantees, project sponsors, and other AIDS
organizations, it appears that HUD’s requirements may not ensure that
grantees involve and coordinate with all relevant parties in planning the
use of program funds.

Along these lines, a representative of AIDS Housing of Washington, the
recipient of a HOPWA grant to provide technical assistance to other AIDS
housing organizations, noted that although one of HOPWA’s most positive
aspects is its flexibility that allows jurisdictions a great deal of latitude in
implementing the program, this same flexibility and local latitude have
permitted some jurisdictions to administer the program less effectively
than they otherwise might. Similarly, the AIDS Action Council believes that
HUD’s requirements lack oversight and accountability mechanisms to
ensure that a jurisdiction’s HOPWA planning is actually meaningful and
involves the proper parties. The Council advocates mandating that the
HOPWA planning process be more inclusive, much as the Ryan White statute
requires inclusive representation on title I planning councils. Of the 11
grantees and project sponsors we contacted, 7 either agreed that HOPWA’s
requirements for planning the use of funds and coordinating with other
sources of AIDS assistance are not specific enough or said that, although
the general requirements have had no negative effects in their particular
area, adding more specific requirements could be helpful for the program
as a whole.15




14
 The Ryan White legislation requires that title I HIV health services planning councils include at least
one representative from each of 12 membership categories, including health care providers;
community-based organizations serving affected populations; social service providers; mental health
and substance abuse providers; local public health agencies; hospital planning agencies; affected
communities, including individuals with HIV/AIDS and historically underserved groups; non-elected
community leaders; state government; grantees under other titles of the CARE Act; and grantees
providing services in the area under other federal HIV programs, which HHS has interpreted to include
HOPWA.
15
 Three of the other four grantees and project sponsors said that the current requirements have been
specific enough, in their experience. The fourth was unfamiliar with HOPWA’s planning requirements
and could not give an opinion, because the grantee follows the more stringent title I requirements to
plan the use of HOPWA funds as well as CARE Act funds.



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                           Fiscal year 1997 is the first year of a new grants management system for
Oversight of Program       HOPWA and three other formula grant programs administered by HUD’s
Administration and         Office of Community Planning and Development. According to HUD, this
Monitoring                 new system is intended to address material weaknesses in overall program
                           management identified by us and HUD’s Inspector General and to respond
                           to the Government Performance and Results Act of 1993, which requires
                           agencies to develop and document performance standards and outcomes
                           for their programs. According to HUD, the new system seeks to strike a
                           balance between ensuring compliance with program requirements and
                           helping grantees achieve a high level of performance to serve their clients.
                           While in the past HUD saw its grant management responsibilities primarily
                           as helping communities understand requirements for programs and
                           monitoring to ensure they complied with the requirements, the new
                           process is intended to emphasize a more collaborative approach, including
                           up-front assistance, to help grantees achieve their objectives and to help
                           them identify and solve problems.

                           HUD’s  field offices have the primary responsibility for evaluating and
                           validating grantees’ performance through a process that HUD calls
                           performance-based program management. While the process uses
                           techniques and approaches already used by the field staff, the new system
                           is designed to work in conjunction with the Office of Community Planning
                           and Development’s (CPD) Consolidated Plan process, to put more emphasis
                           on continuous evaluation throughout a grantee’s program year and to take
                           better advantage of existing opportunities to raise performance issues and
                           document their resolution. HUD’s guidance outlines a number of
                           opportunities that field staff have to assess grantees’ performance, and the
                           guidance encourages field offices to exercise discretion and flexibility in
                           all aspects of their management of CPD grant programs. HUD’s guidance
                           lists the following opportunities that field staff have to assess
                           performance:16

                       •   Review and assessment of a grantee’s Consolidated Plan. As previously
                           discussed, grantees must submit these plans to apply for and receive CPD
                           grants. The plans are intended to establish a community-based strategy for
                           using CPD grants and other resources to address community needs.
                       •   Review of information and reports from CPD’s new Integrated
                           Disbursement and Information System (IDIS). This system is intended to

                           16
                            The HOPWA grantees are also subject to the Single Audit Act (31 U.S.C. 7501-7507). In general, this
                           act requires state or local governments that receive $300,000 or more a year in federal financial
                           assistance to be audited at least annually. The audit must be made by an independent auditor in
                           accordance with generally accepted government auditing standards. These audits provide HUD with
                           another source of information on grantees’ performance.



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                              provide information on critical grant performance indicators, such as
                              grant drawdowns, the number and characteristics of the people served,
                              and the program’s benefits. Once fully implemented, probably sometime
                              during fiscal year 1998, it will replace the requirement for the recipients of
                              HOPWA formula grants to submit annual progress reports. However, the
                              recipients of HOPWA competitive grants will continue to use annual
                              progress reports.
                          •   The annual community assessment. This is HUD’s annual assessment of
                              each grantee’s performance to determine whether the grantee has carried
                              out its planning and grant activities and has reported in accordance with
                              the statutory requirements.
                          •   On-site monitoring. HUD’s guidance states that on-site monitoring remains
                              a key vehicle for validating information and evaluating performance, but it
                              acknowledges that limited resources prevent CPD staff from conducting
                              on-site monitoring of each grantee on a routine basis.
                          •   Consultation. HUD’s guidance points out that consultation with local
                              officials and program participants helps CPD staff to evaluate the grantees’
                              performance, provides an opportunity for HUD to convey its observations
                              and conclusions, and provides an occasion to identify technical assistance
                              needs.

                              The Field Management Division, a part of CPD’s Office of Executive
                              Services at HUD headquarters, is responsible for overseeing CPD functions
                              at HUD’s field offices. Among other duties, this Division provides direction
                              to the field offices on how they should monitor the CPD grant programs and
                              how they should provide technical assistance to grantees. The Field
                              Management Division has seven field management officers who serve as
                              principal advisers to HUD’s Assistant Secretary for Community Planning
                              and Development on all matters related to the administration and
                              management of the CPD programs. Each of these field management officers
                              is responsible for monitoring performance in 5 to 7 of HUD’s 43 CPD field
                              offices.


Program Directors’ Have       Our recent work to update the status of HUD as a “high-risk” area17 found
Concerns About                several concerns about monitoring activities among the CPD program
Monitoring                    directors in HUD’s field offices. We asked the directors for their
                              perspectives on a wide range of corrective actions that HUD had taken over

                              17
                               We began a special effort in 1990 to review and report on the federal program areas we considered
                              high-risk because they were especially vulnerable to waste, fraud, abuse, and mismanagement. HUD,
                              as an agency, has been designated as one of our high-risk areas since January 1994. For our latest
                              update, see High-Risk Series: Department of Housing and Urban Development (GAO/HR-97-12,
                              Feb. 1997).



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                            the last 2 years. Forty-one percent of the CPD directors we surveyed said
                            that headquarters’ emphasis on completing essential monitoring was low,
                            and about 59 percent believed that headquarters’ emphasis should be
                            higher. While 91 percent of the CPD directors said that their staffs had
                            conducted on-site inspections during the preceding year, 66 percent
                            believed that the amount of on-site inspections should be increased. (The
                            majority of CPD directors were satisfied with the existing levels of other
                            types of monitoring, such as telephone inquiries and review of records and
                            documents submitted by grantees.) CPD directors cited the lack of staff and
                            travel funds as the biggest reasons why levels of monitoring activity were
                            lower than they should be.18


HUD Could Improve Its       In our current work, we found that HUD headquarters has not been using
Use of Information From     performance data that the grantees provide in annual progress reports as a
Grantees’ Annual Progress   basis for the Department’s reporting of HOPWA’s overall accomplishments.
                            Grantees must submit annual progress reports to HUD field offices within
Reports                     90 days after the end of their operating year. The data required in the
                            reports include (1) the number of persons with HIV/AIDS receiving housing
                            services, supportive services, and housing information services;
                            (2) descriptive information on those who received housing assistance,
                            such as age, gender, income, and previous living situation; (3) information
                            on the available HOPWA funds and breakouts of how much was spent in
                            various categories of assistance; and (4) the number and size of housing
                            units assisted. The field offices are instructed to review the reports as
                            soon as possible after receipt to determine if the grantee’s program is
                            achieving results, to identify actions HUD should take on the basis of the
                            grantee’s description of barriers and recommendations for change, to
                            detect inconsistencies between the reported information and what the
                            grantee proposed to do, and to identify areas in which the grantee could
                            benefit from technical assistance.

                            While, according to HUD, the annual progress report was designed
                            primarily to be a tool for the field offices’ oversight of grantees, the field
                            offices are also to send copies of these reports to HUD headquarters for
                            entry into a centralized database, which is intended to generate statistics
                            about the agency’s progress in assisting persons with HIV/AIDS and their
                            families to obtain appropriate housing assistance and supportive services.
                            However, to date, HUD has reported information on the HOPWA program’s
                            activities primarily from the grantees’ descriptions of planned activities, as


                            18
                             The complete results of the survey are reported in HUD: Field Directors’ Views on Recent
                            Management Initiatives (GAO/RCED-97-34, Feb. 12, 1997).



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                        contained in grant applications and Consolidated Plan reports, rather than
                        from the accomplishments reported in the annual progress reports. For
                        example, CPD’s 1996 annual report to the Congress includes an exhibit
                        showing the percentage of HOPWA formula grant funds that 1994 grantees
                        used for each eligible program activity. These data, however, reflect
                        planned (rather than actual) uses of funds, as described by the grantees in
                        their 1994 funding applications. Commenting on our analysis of the
                        grantees’ annual progress reports, officials in HUD’s Office of HIV/AIDS
                        Housing said they believed that the planned uses reflected the actual uses
                        of funds.

                        We also found that HUD headquarters has no system to track when the
                        annual progress reports are due and whether they are received and
                        processed in a timely manner. As a result, there is no ready way of
                        determining how many or which reports may be late. However, HUD
                        headquarters officials recently estimated that 36 of 110 HOPWA annual
                        progress reports (covering funds awarded in fiscal years 1992, 1993, and
                        1994) were past due as of October 7, 1996. Of the 36 overdue reports, 16
                        were for fiscal year 1992 grant recipients, 7 were for fiscal year 1993
                        recipients, and 13 were for fiscal year 1994 recipients. As previously
                        discussed, the annual progress reports that were available centrally at
                        headquarters as of that same date reflected only about 27 percent of the
                        HOPWA funds that HUD reported that the grantees had spent. While this
                        difference is partially explained by the time lag between when a grantee
                        spent the funds and when the next annual progress report was due, the
                        overdue reports were also a major factor.


HUD Is Implementing a   HUD’s  new Integrated Disbursement and Information System (IDIS) will, in
New Reporting System    the future, replace most current CPD’s grantee reporting requirements. IDIS
                        is an on-line computer system through which grantees draw down funds
                        against their grants and report accomplishments. HUD intends that the
                        system simplify and streamline grant management for the participants and
                        facilitate comparing and reporting to the Congress on the activities and
                        accomplishments of CPD’s four grant programs. Once a recipient of a
                        HOPWA formula grant is operational on IDIS, it no longer has to submit
                        annual progress reports. However, the recipients of HOPWA’s competitive
                        grants will continue to use annual progress reports.

                        IDISrequires the grantees to report much of the same accomplishment data
                        as required in the annual progress reports. However, HUD believes IDIS
                        offers the advantage of being able to provide more current information.



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              Rather than waiting until the end of the year to file an annual progress
              report, once the grantees are on IDIS, HUD officials said they will expect the
              grantees to update the HOPWA accomplishment information at least
              quarterly to keep it current. We noted, however, that HUD’s guidance to
              grantees does not clearly state this expectation, stating only that the
              information should be updated “periodically” or “as of the end of the
              program year.” Also, it is not yet clear how HUD plans to ensure that the
              grantees keep the accomplishment data current. According to a HUD
              official who is leading the development of the IDIS software, the system can
              tell when grantees enter data, but it does not as yet generate a report that
              would show whether or not grantees have met the expectation for
              quarterly updates.

              As of January 1997, HUD was in the process of training CPD grantees on the
              use of IDIS and bringing the grantees on-line as they are ready. Of the
              approximately 950 entities that will eventually be using IDIS, 135 were
              on-line as of that time, mostly small to moderately sized communities,
              according to HUD. HUD’s goal is to have all CPD grantees using the system by
              the end of fiscal year 1997 (Sept. 30, 1997), but officials acknowledge that
              there may be a few grantees that come on later in the next fiscal year,
              either because they lack the technical capacity to implement IDIS or
              because they are new grantees that have not yet established their HOPWA
              programs. HUD officials note that the HOPWA program is administered
              primarily by the larger cities and by state governments, which often must
              select a variety of sponsors and serve geographically different
              communities and therefore may take longer than other grantees to convert
              to IDIS. For these reasons, it is difficult to predict when all of the HOPWA
              formula grantees will be using IDIS. Because it may take some time for all
              HOPWA formula grantees to fully convert to IDIS, it will remain important
              that HUD headquarters be able to track the receipt and processing of their
              annual progress reports for as long as they are filed. Because the HOPWA
              competitive grantees will continue using the annual progress reports to
              provide performance information, a system for tracking the receipt of
              these reports will also be important.


              While the legislative amendments enacted in 1996 changed the Ryan White
Conclusions   programs’ formulas to allocate funds on the basis of the estimated number
              of people currently living with AIDS, the HOPWA formula continues to be
              based on the cumulative number of AIDS cases since 1981. As we noted in a
              November 1995 report on the Ryan White programs, such an allocation
              formula can result in funding inequities because it includes those who



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                  have died and no longer need services. While we recognize that because of
                  the differences between the HOPWA and Ryan White programs, it may not
                  be appropriate to use precisely the same formula for both, we believe the
                  principle of allocating funds on the basis of those currently living with AIDS
                  applies to HOPWA as well as to Ryan White grants.

                  HOPWA’s  requirements governing how grantees are to coordinate with other
                  parties when planning the use of grant funds are much less explicit than
                  the coordination requirements under the Ryan White title I program.
                  Whereas the Ryan White program’s requirements identify the specific
                  parties with whom grantees must coordinate, HOPWA’s regulations are
                  relatively general in this area, thus providing less assurance that grantees
                  involve and coordinate with all relevant parties. In our view, revising the
                  HOPWA requirements along the lines of those that exist under the Ryan
                  White title I program would provide greater assurance that all affected
                  parties have a voice in determining how the HOPWA funds are to be used.

                  Although the HOPWA grantees are required to make annual progress reports
                  to HUD, the agency has not used the information from these reports to
                  generate programwide analyses of HOPWA’s accomplishments. As a result,
                  HUD has relied primarily on planned, rather than actual, activities when
                  reporting to the Congress and other interested parties on the program’s
                  accomplishments. HUD headquarters also has not established a system to
                  track the receipt of these reports. For this reason, HUD headquarters has no
                  ready way of knowing whether it has received all the reports that are due
                  and, thus, that it has the most complete, up-to-date information available
                  about the grantees’ use of funds. Although the new IDIS should eventually
                  replace the annual progress reports for formula grantees, this system may
                  take some time to be fully implemented, and competitive grantees will
                  continue to use the annual progress reports rather than IDIS to report on
                  their performance. While IDIS offers the potential for providing more
                  current information on the HOPWA grantees’ actual accomplishments, thus
                  far HUD’s guidance on the new system does not clearly communicate to
                  grantees how frequently HUD expects them to update accomplishment
                  information, and it is unclear how HUD will ensure that grantees keep this
                  information current.


                  To help ensure that the HOPWA funds are allocated to grantees as equitably
Recommendations   as possible and that grantees involve all relevant parties in planning the
                  use of these funds, and to promote greater consistency and coordination
                  between the HOPWA and Ryan White programs, we recommend that the



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                     Secretary of HUD direct the Assistant Secretary for Community Planning
                     and Development to (1) examine the changes to the funding formulas
                     under titles I and II of the 1996 Ryan White CARE Act amendments,
                     determine what legislative revisions are needed to make the HOPWA
                     formula more reflective of current AIDS cases, and make appropriate
                     recommendations to the Congress and (2) specify the representatives that
                     the grantees must include in planning the use of the HOPWA funds, similar
                     to the CARE Act title I planning requirements.

                     To better assess HOPWA’s overall accomplishments and to ensure the
                     effective use of the annual progress reports required of the HOPWA
                     grantees, we recommend that the Secretary of HUD direct the Assistant
                     Secretary for Community Planning and Development to implement a
                     procedure, such as a tracking system, to ensure that all reports are
                     received and processed by HUD in a timely manner.

                     To ensure that IDIS, the new reporting system for the grantees, provides
                     current accomplishment information for the HOPWA grants, we recommend
                     that the Secretary of HUD direct the Assistant Secretary for Community
                     Planning and Development to clearly state in guidance to the grantees the
                     requirements for updating the information and establish a means of
                     ensuring that the grantees update the information as required.


                     We provided a draft copy of this report to HUD for its review and comment.
Agency Comments      While not disagreeing with the facts presented, HUD believed that the
and Our Evaluation   report presented information in a manner that understates grantees’
                     performance on the timely expenditure of funds and on reporting on their
                     accomplishments. The information we presented showed that grantees
                     had expended 37 percent of the total funds appropriated since fiscal year
                     1992 and that grantees’ reports describing their use of program funds that
                     were available from HUD’s Office of HIV/AIDS Housing as of October 7, 1996,
                     covered only 27 percent of the funds that grantees had expended during
                     that time. HUD’s comments point out that grantees had, for example, used
                     95 percent of fiscal year 1992 funds and 85 percent of fiscal year 1993
                     funds. The comments also assert that over $103.5 million of the HOPWA
                     funds were spent between January 24, 1996, and October 7, 1996, and that
                     only a small portion of these expenditures would have been required or
                     contained in the annual progress reports HUD provided us.

                     The information we presented on grantees’ use of program appropriations
                     was not intended to criticize the timeliness of grantees’ spending of funds,



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but rather to put into perspective the data reported on funded activities
and program participants. Our report points out that HUD allows grantees 3
years to spend program funds and that several factors may delay
expenditures. In connection with grantees’ reporting of expenditures, our
report recognizes that the low percentage of funds covered in the annual
progress reports was due, in part, to the fact that grantees’ reports
covering some expenditures were not yet due. However, we note that HUD
does not dispute the fact that a substantial number of reports were
overdue.

HUD  generally concurred with our recommendations. In commenting on
the recommendation that the Department examine changes needed to
make the HOPWA funding formula more reflective of current AIDS cases, HUD
stated that it will consider alternative formula constructions and make a
recommendation to the Congress. However, HUD noted that there are
several differences between the HOPWA statute and the CARE Act, especially
in their levels of funding, and that even small changes to HOPWA’s current
allocation formula could adversely affect ongoing programs by making a
number of current grantees ineligible for future funding. Our report
acknowledges that there are differences between the programs and,
accordingly, does not suggest that precisely the same formula should be
used for both. We also believe that the lower level of funding for the HOPWA
program heightens the importance of allocating those funds to the
communities with the greatest need, which we believe is better measured
by estimates of those still living with AIDS than by estimates of the
cumulative cases of AIDS. In response to our recommendation that the
Department specify the representatives that the grantees must include in
planning the use of HOPWA funds, HUD stated that such prescriptive
requirements would be inconsistent with its goal of involving a broad
cross-section of the community to discuss the whole of a community’s
housing needs. We disagree. Any such requirements should set forth only
the minimum standards that grantees must meet and would not minimize
the importance of involving as broad a cross-section of the community as
possible. Appendix I contains HUD’s complete comments and our
evaluation of them.


We conducted our review from August 1996 through February 1997 in
accordance with generally accepted government auditing standards. (See
app. II for a discussion of our scope and methodology.)




Page 28                            GAO/RCED-97-62 Housing for Persons With AIDS
B-276110




We are sending copies of this report to the appropriate congressional
committees; the Secretary of HUD; the Director, Office of Management and
Budget; and other interested parties. We will also make copies available to
others upon request.

Please call me on (202) 512-7631 if you or your staff have any questions.
Major contributors to this report are listed in appendix III.




Lawrence J. Dyckman
Associate Director, Housing and
  Community Development Issues




Page 29                            GAO/RCED-97-62 Housing for Persons With AIDS
Contents



Letter                                                                                             1


Appendix I                                                                                        32
                        GAO Comments                                                              37
Comments From the
Department of
Housing and Urban
Development
Appendix II                                                                                       39

Objectives, Scope,
and Methodology
Appendix III                                                                                      41

Major Contributors to
This Report
Figures                 Figure 1: HOPWA Expenditures                                              11
                        Figure 2: Number of Persons Receiving Housing Assistance and              13
                          Supportive Services
                        Figure 3: Percentage of Program Participants by Gender and Age            14
                          Group
                        Figure 4: Gross Monthly Family Incomes of Program Participants            15
                        Figure 5: Previous Living Situations of HOPWA Participants                16

                        Abbreviations

                        AIDS       acquired immunodeficiency syndrome
                        AIDS-OIs   AIDS opportunistic infections
                        CARE       Comprehensive AIDS Resources Emergency
                        CDC        U.S. Centers for Disease Control and Prevention
                        CPD        Office of Community Planning and Development
                        GAO        General Accounting Office
                        HHS        Department of Health and Human Services
                        HIV        human immunodeficiency virus
                        HOME       HOME Investment Partnerships program
                        HOPWA      Housing Opportunities for Persons With AIDS
                        HRSA       Health Resources and Services Administration
                        HUD        Department of Housing and Urban Development
                        IDIS       Integrated Disbursement and Information System


                        Page 30                          GAO/RCED-97-62 Housing for Persons With AIDS
Page 31   GAO/RCED-97-62 Housing for Persons With AIDS
Appendix I

Comments From the Department of Housing
and Urban Development

Note: GAO comments
supplementing those in the
report text appear at the
end of this appendix.




                             Page 32   GAO/RCED-97-62 Housing for Persons With AIDS
                 Appendix I
                 Comments From the Department of Housing
                 and Urban Development




See comment1.




See comment 2.


See comment 3.




                 Page 33                               GAO/RCED-97-62 Housing for Persons With AIDS
                 Appendix I
                 Comments From the Department of Housing
                 and Urban Development




See comment 4.




                 Page 34                               GAO/RCED-97-62 Housing for Persons With AIDS
                 Appendix I
                 Comments From the Department of Housing
                 and Urban Development




See comment 5.




                 Page 35                               GAO/RCED-97-62 Housing for Persons With AIDS
                 Appendix I
                 Comments From the Department of Housing
                 and Urban Development




See comment 6.




                 Page 36                               GAO/RCED-97-62 Housing for Persons With AIDS
               Appendix I
               Comments From the Department of Housing
               and Urban Development




               The following are GAO’s comments on the Department of Housing and
GAO Comments   Urban Development’s letter dated February 25, 1997.

               1. Our report is not intended to criticize the timeliness of grantees’
               spending but presents information on the program’s total appropriations
               and expenditures to put into perspective the data reported on funded
               activities and the program’s participants. Our report points out that there
               are several reasons why grantees have not fully expended program funds.

               2. HUD states that the information available is reflective of the use of
               program funds by all grantees because the data represent different
               grantees by geographic location, size, and type. However, HUD notes that it
               is not a statistical sample. As such, there is no way of knowing to what
               extent the available data accurately reflect the use of all program funds,
               and whether other grantees’ data could indicate different results.

               3. Our report recognizes that the low percentage of funds covered in the
               annual progress reports occurred, in part, because grantees’ reports
               covering some expenditures were not yet due. Nevertheless, HUD does not
               dispute the fact that a significant number of reports, dating back to fiscal
               year 1992, are overdue.

               4. Our report acknowledges the differences between the HOPWA and CARE
               Act programs and for this reason recommends that HUD consider the issue
               and identify appropriate changes to make the formula more reflective of
               current AIDS cases. We did not recommend that the HOPWA and CARE Act
               formulas be the same. We also note that the lower level of funding for the
               HOPWA program heightens the importance of allocating those funds to the
               communities with the greatest need, which is better measured by
               estimates of those still living with AIDS than by estimates of cumulative
               cases of AIDS.

               5. While agreeing with our recommendation, HUD’s response suggests that
               identifying specific representatives that grantees must include in planning
               the use of HOPWA funds would be inconsistent with the goal of involving a
               broad cross-section of the community to discuss the whole of a
               community’s housing needs. In our view, however, any such requirements
               would set forth only the minimum standards that grantees must meet;
               grantees clearly should be encouraged to go beyond these standards to
               involve as broad a cross-section of the community as possible.
               Additionally, our report does not recommend that HUD specify precisely
               the same participants as required by title I of the CARE Act, but only that



               Page 37                               GAO/RCED-97-62 Housing for Persons With AIDS
Appendix I
Comments From the Department of Housing
and Urban Development




the HOPWA planning requirements be made more specific, as they are under
the CARE Act. HUD’s requirements could include whichever parties it deems
relevant. Furthermore, while HUD states that the consolidated plan process
involves the larger housing community (public and private entities that
create, develop and/or manage housing resources within each
community), we note that HOPWA is the only program under the process
that addresses housing within the context of a specific health issue and
that, as such, it may benefit from specific requirements beyond those set
forth for all programs in general under the consolidated planning process.

6. We have clarified the report to indicate that the statements referring to
supportive services provided independent of housing assistance refer
specifically to the services provided independent of HOPWA-funded housing
assistance.




Page 38                               GAO/RCED-97-62 Housing for Persons With AIDS
Appendix II

Objectives, Scope, and Methodology


              As requested by the Subcommittee on VA, HUD and Independent Agencies,
              House Committee on Appropriations, we reviewed five aspects of the
              Department of Housing and Urban Development’s Housing Opportunities
              for Persons with AIDS (HOPWA) program: (1) what the rationale is for having
              a housing program within HUD specifically for people with AIDS, (2) the
              kinds of activities funded through the program, (3) whom the program is
              serving, (4) how the program is coordinated with the Department of
              Health and Human Services’ (HHS) Ryan White AIDS assistance programs,
              and (5) how HUD headquarters oversees the program’s administration and
              monitoring. As requested, we also obtained background information on
              how the program works.

              We obtained information on the rationale for having a housing program
              within HUD specifically for people with AIDS from HOPWA’s authorizing
              legislation (the National Affordable Housing Act of 1990 (P.L. 101-625), as
              amended) and its legislative history. To determine to what extent the
              factors used to originally support the need for the program still exist, we
              reviewed data on the housing needs of persons with AIDS compiled by AIDS
              Housing of Washington (the recipient of a 1995 HOPWA competitive grant to
              provide technical assistance to AIDS housing developers nationally) and by
              the National Commission on AIDS, and we obtained the views of a mix of
              parties that either support or question the continuation of the HOPWA
              program: (1) officials in the HUD headquarters Office of HIV/AIDS Housing;
              (2) staff from HHS’ Health Resources and Services Administration (HRSA);
              (3) officials from HUD’s field offices in Fort Worth, Texas, and Chicago,
              Illinois; (4) staff representing 11 HOPWA grantees and project sponsors;19
              (5) a representative from the AIDS Action Council; (6) an official from the
              Heritage Foundation; and (7) an official from Americans for a Sound
              AIDS/HIV Policy.


              To identify the activities funded by HOPWA and whom the program is
              serving, we analyzed a database compiled by HUD’s Office of HIV/AIDS
              Housing, which contains information from the annual progress reports
              submitted by the HOPWA grantees. We also obtained hard copies of the
              annual progress reports that had been received by the Office of HIV/AIDS


              19
                We selected these 11 grantees and project sponsors from a list of suggested AIDS housing
              representatives provided by HUD’s Office of HIV/AIDS Housing. We selected several who were
              members of the Board of Directors of the National AIDS Housing Coalition to provide a broader,
              national perspective, and others to provide a more local perspective. We also selected local grantees
              and project sponsors in Dallas and Fort Worth, Texas, and Chicago, Illinois, on the basis of their
              proximity to the GAO staff performing the work. The total number of the HOPWA grantees and project
              sponsors is difficult to quantify because grantees can change from year to year, and each grantee may
              have multiple project sponsors; however, about 93 jurisdictions received formula grants for fiscal
              years 1992 through 1996, in addition to 81 competitive grants awarded during that time.



              Page 39                                        GAO/RCED-97-62 Housing for Persons With AIDS
Appendix II
Objectives, Scope, and Methodology




Housing as of October 7, 1996. We verified the information that we used
from the database against these reports and made necessary corrections to
the database in order to perform our analysis. We did not verify the
accuracy of the information the grantees provided in the reports.

We obtained background information on how the HOPWA program works
and determined how funds are distributed by reviewing HUD’s regulations
and written procedures, focusing on the process by which eligible states
and metropolitan areas apply for funds and the process by which HUD
allocates funds for both formula and competitive grants. We also obtained
views on possible improvements to the process for allocating formula
grants from HUD’s Office of HIV/AIDS Housing, Americans for a Sound
AIDS/HIV Policy, and the 11 HOPWA grantees and project sponsors that we
contacted. We also used information from a previous report that we issued
on the funding allocation formulas for HHS’s Ryan White programs.20

To obtain information on how HOPWA is coordinated with HHS’ Ryan White
programs, we reviewed the coordination requirements in the authorizing
legislation and regulations for both programs. We also obtained
information on the level and effectiveness of coordination from HUD’s
Office of HIV/AIDS Housing, HRSA, the 11 HOPWA grantees and project
sponsors that we contacted, and the AIDS Action Council.

To obtain information on how HUD headquarters oversees the program’s
administration and monitoring, we reviewed the regulations and guidance
that prescribe the field offices’ responsibilities for evaluating grantees’
performance and headquarters’ responsibilities for monitoring and
overseeing the field offices’ functions. We did not review how the field
offices have carried out their responsibilities for monitoring grantees. We
did, however, draw information from a GAO telephone survey conducted in
August 1996 of those serving as directors of major programs in HUD’s 40
largest field offices (in terms of staffing). We asked officials responsible
for managing HOPWA and other Community Planning and Development
grant programs to assess the adequacy of the field offices’ monitoring of
grantees. We reviewed HUD’s regulations and guidance on headquarters’
and field offices’ responsibilities for tracking and using annual
performance reports that grantees submit to HUD. We also discussed HUD
headquarters’ and field offices’ responsibilities with HUD’s Office of HIV/AIDS
Housing and Field Management Office.



20
 Ryan White CARE Act of 1990: Opportunities to Enhance Funding Equity (GAO/HEHS-96-26, Nov. 13,
1995).



Page 40                                      GAO/RCED-97-62 Housing for Persons With AIDS
Appendix III

Major Contributors to This Report


                        Richard A. Hale
Housing and             Leigh K. Ward
Community               Andy C. Clinton
Development Issue       Woodliff L. (Skip) Jenkins, Jr.

Area
                        Luann M. Moy
Design, Methodology,
and Technical
Assistance Group
                        John T. McGrail
Office of the General
Counsel




(385649)                Page 41                           GAO/RCED-97-62 Housing for Persons With AIDS
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