	Introduction

Acquired immunodeficiency syndrome (AIDS), a disease caused by the human immunodeficiency virus (HIV), weakens the immune system, leaving individuals with the disease susceptible to infections. From the early years of the epidemic, individuals who are infected with HIV/AIDS have faced impoverishment as they become unable to work, experience high medical costs, or lose private health insurance coverage. The incidence of HIV/AIDS has also grown among low-income individuals who were economically vulnerable even before onset of the disease. Creation of the Housing Opportunities for Persons with AIDS (HOPWA) Program

In 1988, Congress established the National Commission on AIDS as part of the Health Omnibus Extension Act ( P.L. The bills were similar, and both proposed to fund short-term and permanent housing, together with supportive services, for individuals living with AIDS and related diseases. 101-625 , the Cranston-Gonzalez National Affordable Housing Act. The HOPWA program is administered by the Department of Housing and Urban Development (HUD) and remains the only federal program solely dedicated to providing housing assistance to persons living with HIV/AIDS and their families. (For the amounts distributed to eligible states and MSAs in recent years, see Appendix .) Formula funds are allocated in two ways:
First, 75% of the total available formula funds, sometimes referred to by HUD as "base funding," is distributed —starting in FY2017, to the largest cities within metropolitan statistical areas (MSAs) with populations exceeding 500,000 and with more than 2,000 individuals living with HIV or AIDS (through FY2016, funds were distributed to MSAs with more than 1,500 cumulative AIDS cases), and —starting in FY2017, to states with more than 2,000 individuals living with HIV or AIDS in the areas outside of that state's eligible MSAs (through FY2016, funds were distributed to states with more than 1,500 cumulative AIDS cases). Prior to enactment of P.L. Competitive Grants

The remaining 10% of HOPWA funding is available through competitive grants. The HOPWA Program Formula

In 2016, Congress passed legislation to change the HOPWA formula as part of the Housing Opportunities Through Modernization Act (HOTMA, P.L. Through FY2016, 75% of funds were distributed using the cumulative number of AIDS cases as reported by the CDC, including those who had died, but not including those living with HIV. 114-201 , from FY2017 through FY2021, grantees are not to see their allocations decrease 5% or more, nor are allocations to increase 10% or more. The FY2009 budget stated that "[w]hereas the current formula distributes formula grant resources by the cumulative number of AIDS cases, the revised formula will account for the present number of people living with AIDS, as well as differences in housing costs in the qualifying areas." Its proposal includes the following:
using the number of persons living with HIV and AIDS to determine formula shares, and maintaining eligibility for all current grantees; ensuring that allocations not drop more than 10% per year nor increase more than 20% per year, with this phase-in to take place over three years; and replacing the incidence or "bonus" funding with a factor based on fair market rent and poverty. (See Table 1 .) Housing Funded Through the Ryan White HIV/AIDS Program

In addition to funds for housing provided through HUD, funds appropriated to the Department of Health and Human Services (HHS) Ryan White HIV/AIDS program may be used to provide short-term housing assistance to persons living with HIV/AIDS. The Relationship Between Stable Housing and Health Outcomes

HIV/AIDS status is associated with homelessness: persons who are homeless are more likely to be HIV positive than those who are housed (see " Housing Status of Persons Living with HIV/AIDS "). In addition, during the last decade, research has found that the health outcomes of homeless individuals living with HIV/AIDS may be improved with stable housing. Individuals in the comparison group received services, including assistance with finding housing, but did not receive HOPWA-funded housing. Specifically, compared to those in the usual care group, those in the treatment group showed 29% reduction in hospitalizations, a 29% reduction in the number of days spent in the hospital, and a 24% reduction in visits to the emergency room. Recent HOPWA Formula Allocations
Since the beginning of the acquired immunodeficiency syndrome (AIDS) epidemic in the early 1980s, many individuals living with the disease have had difficulty finding affordable, stable housing. In the earlier years of the epidemic, as individuals became ill, they found themselves unable to work, while at the same time facing health care expenses that left few resources to pay for housing. In more recent years, HIV and AIDS have become more prevalent among low income populations who struggled to afford housing even before being diagnosed with the disease. The financial vulnerability associated with AIDS, as well as the human immunodeficiency virus (HIV) that causes AIDS, results in a greater likelihood of homelessness among persons living with the disease. At the same time, those who are homeless may be more likely to engage in activities through which they could acquire or transmit HIV. Further, recent research has indicated that individuals living with HIV who live in stable housing have better health outcomes than those who are homeless or unstably housed, and that they spend fewer days in hospitals and emergency rooms.
Congress recognized the housing needs of persons living with HIV/AIDS when it approved the Housing Opportunities for Persons with AIDS (HOPWA) program in 1990 as part of the Cranston-Gonzalez National Affordable Housing Act (P.L. 101-625). The HOPWA program, administered by the Department of Housing and Urban Development (HUD), funds short-term and permanent housing, together with supportive services, for individuals living with HIV/AIDS and their families. In addition, a small portion of funds appropriated through the Ryan White HIV/AIDS program, administered by the Department of Health and Human Services (HHS), may be used to fund short-term housing for those living with HIV/AIDS.
In FY2016, Congress appropriated $335 million for HOPWA as part of the Consolidated Appropriations Act (P.L. 114-113). This was $5 million more than was appropriated in FY2015, and equaled the peak HOPWA funding level of $335 million in FY2010. Prior to FY2010, the most that had been appropriated for HOPWA was $310 million in FY2009. HUD awards 90% of appropriated funds based on a formula and the remaining 10% is distributed through a grant competition. Funds are used primarily for housing activities, although grant recipients must provide supportive services to those persons residing in HOPWA-funded housing. In FY2015, almost 55,000 households received housing assistance through HOPWA, a decrease compared to the previous years. See Table 1 for funding levels and households served since FY2001. The Appendix provides the formula grants distributed to eligible states and metropolitan statistical areas from FY2007 to FY2016.
For years the formula used to distribute the bulk of HOPWA funds was an issue considered by both the Administration and Congress. Since the inception of HOPWA, the formula relied on cumulative cases of AIDS to distribute formula funds, a number that included those who had died but did not include living cases of HIV. Legislation to change the formula to include people living with both HIV and AIDS, but exclude those who have died, was introduced in the 114th Congress, including in FY2017 appropriations language. On July 29, 2016, Congress changed the HOPWA formula as part of the Housing Opportunity Through Modernization Act of 2016 (P.L. 114-201). Going forward, the distribution of HOPWA formula funds will be based on people living with HIV or AIDS. In addition, HUD is to account for fair market rents and poverty in delivering a portion of funding, and a hold harmless provision ensures that, through FY2021, grantees will not see their allocations decrease by 5% or more nor increase by 10% or more from the previous year.