Since 1981, over 1.2 million  persons diagnosed with AIDS have been reported to the CDC and over  600,000 of them have died. 1). Also, in some cases local community-based  organizations receive both HOPWA and Ryan White Part A funding. Estimates of Housing Need for Persons with HIV Are Not Reliable, and the HOPWA Formula Does Not Effectively Target Funds

As the number of persons with HIV in the United States continues to  increase, research finds that stable housing is critical for effective medical  care and is associated with improved health outcomes for persons with  HIV. HUD Does Not Reliably Estimate the Extent of Housing Needs among Persons with HIV

HUD’s estimate of the number of persons with HIV who have a housing  need is not reliable. GAO’s work on assessing data reliability indicates that data should be  consistent—that is, data should be clear and well defined enough to yield  similar results in similar analyses. Because HUD does not require grantees to  use selected data sources in a consistent manner, the resulting  information is not comparable. Use of cumulative AIDS cases rather than living HIV cases has led to  MSAs with similar numbers of persons living with HIV receiving markedly  different amounts of HOPWA funding. However, it is not clear that HRSA’s housing status data  are current because HRSA does not require or encourage grantees to  maintain current data on clients’ housing status. Internal control standards for the federal government state that events  should be promptly recorded to maintain their relevance and value to  management in controlling operations and making decisions. Both HUD and HRSA collect data  from HOPWA and Ryan White HIV/AIDS program grantees, respectively,  including data on the activities funded and clients’ housing status (i.e.,  whether they have stable and permanent housing). Additionally, HRSA staff  provided technical assistance to Ryan White Part A grantees. Federal internal control standards state that monitoring should assess the  quality of performance over time and that activities need to be established  to monitor performance measures and indicators. By not analyzing trends in the unmet housing need  data grantees are required to report, HUD may be missing opportunities  to identify and address problems in grantee reporting. HRSA Collects Program Data but Does Not Monitor Housing Information

Although HRSA headquarters staff conduct routine monitoring of Ryan  White HIV/AIDS program grantees, they do not focus on housing  information. By not focusing attention on the housing data that grantees  are required to report, such as housing status, HRSA staff with  responsibility for program monitoring may be missing an opportunity to  improve their management of grantees’ performance. While HUD advises grantees to use one or more of seven  specific data sources, HUD does not require grantees to use these  sources in a consistent and therefore comparable manner, as suggested  by federal internal control standards and our work on data reliability. HUD  has taken steps toward developing a standard methodology but has not  established time frames for finalizing these efforts. Because HOPWA funds are awarded based on  cumulative AIDS cases, these funds are not being targeted as effectively  or equitably as they could be. Without taking steps to ensure that  grantee-reported housing status data are current, HRSA may not have  reliable information to use in reporting on the extent to which Ryan White  HIV/AIDS program clients are reaching the National HIV/AIDS Strategy  goals for attainment of permanent housing. Matter for Congressional Consideration

If Congress wishes HOPWA funding to more closely account for the  current impact of the HIV, it should consider revising the funding formula  used to determine grantee eligibility and grant amounts to reflect a  measure of persons living with HIV, including those with AIDS. Recommendations for Executive Action

We make the following four recommendations:
To improve information on the unmet housing needs of persons with  HIV and follow through on its efforts to develop a standard  methodology, we recommend that the Secretary of HUD direct the  Assistant Secretary for Community Planning and Development to  require grantees to use comparable methodologies to analyze HUD’s  recommended data sources on unmet housing need. Regarding  the second part of the statement with which HUD disagreed—that HUD  uses unmet housing need to assess the performance of the program—we  revised the report to state that HUD uses unmet housing need data for  reporting on the performance of the program, rather than assessing the  performance of the program. GAO staff who made key contributions to this report  are listed in appendix V.

Appendix I: Scope and Methodology

Our objectives were to discuss (1) the need for housing assistance for  persons with the human immunodeficiency virus (HIV) and the extent to  which federal assistance reaches communities in need; (2) the results  that have been achieved through federal programs that provide housing  assistance for persons with HIV and what is known about the strengths  and weaknesses of these programs; (3) the extent to which federal  programs that provide housing assistance and supportive services for  persons with HIV coordinate with one another; and (4) the extent of  federal oversight of programs that provide housing assistance to persons  with HIV. Also, we obtained and analyzed expenditure  data for both programs. Additionally, we interviewed both HUD  and HRSA officials on how they use performance data to monitor  HOPWA and Ryan White Part A grantees. Formula  grant funding criteria are based on each MSA’s share of cumulative  Acquired Immune Deficiency Syndrome (AIDS) cases.
Why GAO Did This Study

Over 1.2 million people in the United States are estimated to have HIV, and about 50,000 new infections occur each year. Research has shown that persons with HIV who lack stable housing are less likely to adhere to HIV care. HUD's HOPWA program and HRSA's Ryan White program provide grants to localities that can be used to fund housing and supportive services specifically for persons with HIV.
GAO was mandated to review housing assistance for persons with HIV. This report addresses (1) the need for housing assistance for persons with HIV and the extent to which assistance reaches communities in need, (2) results achieved through HOPWA and Ryan White, and (3) federal oversight of these programs. For both programs, GAO analyzed program data on persons served and outcomes achieved as of 2012, reviewed policies, interviewed agency officials, and visited a non-generalizable sample of four geographically diverse cities that received varying amounts of both HOPWA and Ryan White funding.

What GAO Found

The extent to which persons with human immunodeficiency virus (HIV) need housing assistance is not known, in part because the Department of Housing and Urban Development's (HUD) estimate of the housing needs of persons with HIV, including those with Acquired Immune Deficiency Syndrome (AIDS), is not reliable. HUD does not require Housing Opportunities for Persons with AIDS (HOPWA) grantees to use a consistent methodology to calculate unmet need. The agency has taken steps towards developing a standard methodology, but it has not established time frames for finalizing these efforts. GAO's work on assessing data reliability indicates that data should be consistent. Because HUD does not require grantees to use selected data sources in a consistent manner, the reported information on unmet housing needs of persons with HIV are not comparable across jurisdictions and are not useful and reliable. In addition, the statutory HOPWA funding formula is based on cumulative AIDS cases since 1981, including persons who have died, rather than on current numbers of persons living with HIV (including those with AIDS). This approach has led to areas with similar numbers of living HIV cases receiving different amounts of funding. Because HOPWA funds are awarded based on cumulative AIDS cases, these funds are not being targeted as effectively or equitably as they could be.
Agency data for HOPWA and the Health Resources and Services Administration's (HRSA) Ryan White program indicate most recipients of assistance obtained stable, permanent housing, but Ryan White housing data may have limitations. HRSA, within the Department of Health and Human Services, does not require Ryan White grantees to maintain current data on clients' housing status. However, it uses the data that grantees report to calculate the proportion of clients that have stable housing. HRSA is charged with tracking Ryan White clients' housing status as a part of the White House's National HIV/AIDS Strategy. Federal internal control standards state that events should be promptly recorded to maintain their relevance and value to management in controlling operations and making decisions. Because HRSA does not require grantees to maintain current data on clients' housing status, HRSA's data may be of limited usefulness in tracking the National HIV/AIDS Strategy goal of improving clients' housing status.
HUD and HRSA perform oversight activities but may be missing opportunities to use data to improve performance. HUD staff conduct risk-based monitoring of HOPWA grantees, and HRSA staff have improved monitoring of Ryan White grantees. HUD and HRSA both collect performance data from their grantees and take steps to ensure that the data are complete and submitted in a timely manner. HUD uses performance data to create summaries of program performance but does not have a specific process for comparing individual grantees' year-to-year data for unmet housing need. Federal internal control standards note the importance of such comparisons. By not analyzing these trends, HUD may not be identifying and addressing reporting problems. In addition, HRSA staff responsible for monitoring Ryan White grantees do not review grantee data on housing assistance provided. Federal internal control standards state that activities need to be established to monitor performance measures. By not focusing attention on housing data, HRSA staff with monitoring responsibility are not proactively using available resources to monitor individual grantees' contributions to the National HIV/AIDS Strategy goal of improving clients' housing status.

What GAO Recommends

If Congress wishes HOPWA funding to be more effectively targeted, it should consider revising the funding formula to reflect the number of living persons with HIV. GAO also recommends that (1) HUD require a consistent methodology for estimating unmet housing needs and (2) both HUD and HRSA improve the reliability and use of performance data to manage their programs. HRSA agreed with GAO's recommendations. HUD agreed with the first recommendation but disagreed with the second, stating that it already assesses trends in some program data. GAO clarified that HUD should identify reporting issues by analyzing trends in its unmet housing need data.