Housing Opportunities for Persons with AIDS (HOPWA):

Distribution of Funding to the Southern States

Lesley Hamming, JD Candidate with Carolyn McAllaster, Clinical Professor of Law

Duke University School of Law Southern HIV/AIDS Strategy Initiative

I. Introduction

Homelessness is pervasive for people living with HIV/AIDS. Approximately half of HIV-

positive persons will need housing assistance during their illness.1 In addition, HIV rates in

homeless populations are three to ten times greater than for stably-housed populations.2

Government funding for housing through the Housing Opportunities for Persons with AIDS

(HOPWA) program helps to address these high rates of homelessness. As the region with

the highest rate of new HIV infections in the US, the south increasingly needs HOPWA

funding. In 2010, 51% of people newly infected with HIV lived in the south,3 even though

the south accounted for only 37% of the U.S. population.4

1 U.S. Dept. of Housing & Urban Development, Office of Community Planning & Development, Implementing the National HIV/AIDS Strategy 5 (Feb. 2011), available at www.whitehouse.gov/files/documents/nhas-implementation.pdf. 2 Daniel Kidder et al., Health Status, Health Care Use, Medication Use, and Medication Adherence Among Homeless and Housed People Living with HIV/AIDS, 97 AM. J. PUB. HEALTH 2238, 2238 (2007). 3 Centers for Disease Control and Prevention, HIV Surveillance Report (2012), available at www.cdc.gov/hiv/surveillance/resources/reports/2010report/index.htm. 4 US Census Bureau, Guide to State and Local Census Geography (2010), http://www.census.gov/geo/reference/guidestloc/select_data.html.

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This paper compares how HOPWA funds are distributed based on an entitlement

formula and competitive grants to the southern states and other regions. Several southern

states are particularly affected by HIV and have high rates of poverty, insufficient access to

medical care, and a cultural climate that likely contributes to the spread of HIV. These

states include Alabama, Georgia, Louisiana, Mississippi, Florida, North Carolina, South

Carolina, Tennessee, and Texas (the “targeted states”).

II. The Need for Stable Housing for Persons with HIV/AIDS

Congress passed the Housing Opportunities for Persons with AIDS (HOPWA)

program as one part of the Cranston-Gonzalez National Housing Act of 1990.5 The purpose

of HOPWA was to “provide States and localities with the resources and incentives to devise

long-term comprehensive strategies for meeting the housing needs of persons with

acquired immunodeficiency syndrome.”6 In his public statement upon signing the

Cranston-Gonzalez National Housing Act, President George Bush Sr. made no mention of

HOPWA, although he did applaud the Act’s objective of providing “decent, safe, and

affordable housing for all Americans.”7 Even though President Bush did not discuss the

AIDS epidemic in his public statement, the seriousness of the disease was evident. At that

time, over 100,000 people in the United States had already been diagnosed with AIDS; no

effective treatments had yet been developed; and Ryan White, one of the first hemophiliacs

diagnosed with AIDS, had recently died. 8

5 Pub. L. 101—625, Nov. 28, 1990, 104 Stat. 4079, §§ 851-863. 6 Id. at § 852. 7 George Bush, Nov. 28, 1990, 1990 U.S.C.C.A.N. 6231-1, 1990 WL 300989 (Leg.Hist.). 8 U.S. Dept. Health & Human Services, A Timeline of AIDS, AIDS.gov, http://aids.gov/hiv-aids-basics/hiv-aids-101/aids-timeline.

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HOPWA has proved to be an important program for persons living with HIV and

AIDS, providing housing for over 61,000 households across the country in FY 2012.9

Ninety-five percent of the individuals who received tenant-based rental assistance through

HOPWA achieved housing stability and seventy-four percent of the individuals who

received short-term and transitional housing through HOPWA achieved housing stability.10

Several studies have found an association between stable housing and improved

HIV/AIDS care and disease progression.11 Studies have also demonstrated that providing

stable housing to HIV-positive individuals is a cost-effective method of improving medical

care.12 In particular, the AIDS Foundation of Chicago, through the Chicago Housing for

Health Partnership (CHHP), conducted a randomized control trial comparing the number of

hospital, emergency room, and nursing home visits of (1) an intervention group of

homeless individuals who received supportive housing and (2) a control group of homeless

individuals who received the “usual care” provided by hospitals when discharging

homeless individuals, typically consisting of transportation to an overnight shelter and

9 Phillip A. Pless, Program Support Specialist, US Department of Housing & Urban Development, Office of HIV/AIDS Housing, email December 13, 2012. 10 HIV/AIDS Housing, U.S. Department of Housing and Urban Development, http://portal.hud.gov:80/hudportal/HUD?src=/program_offices/comm_planning/aidshousing. 11 See, e.g., Daniel Kidder et al., Health Status, Health Care Use, Medication Use, and Medication Adherence in Homeless and Housed People Living with HIV/AIDS, 97(12) AM. J. PUB. HEALTH 2238 (2007) (finding that homeless individuals living with HIV had lower CD4 counts and were less likely to have taken HIV antiretroviral medications than housed individuals); Aidala et al., Housing Need, Housing Assistance, and Connection to Medical Care, 11(6) AIDS & BEHAVIOR S101 (2007) (finding a relationship between housing need and remaining outside of HIV medical care). 12 See, e.g., David Holtgrave et al., Cost-Utility Analysis of the Housing and Health Intervention for Homeless and Unstably Housed Persons Living with HIV, AIDS & BEHAVIOR (2012) (estimating that the cost-per-quality-adjusted-life-year saved by HIV-related housing services is $62,493).

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access to case management through a Ryan White program if HIV positive.13 Thirty-five

percent of the study participants had HIV.14 For participants in the study who had HIV, the

four-year CHHP study revealed that after one year:

55% of HIV-positive participants in the intervention group had intact

immunity compared to only 34% in the usual care group (intact immunity

defined as CD4>200 and viral load<100,000);

36% of HIV-positive participants in the intervention group had undetectable

viral loads compared to only 19% of usual care participants; and

median viral loads were 0.89 log lower in the intervention group than the

usual care group.15

In addition to these health benefits, the CHHP study revealed that the costs of

providing stable housing to persons living with HIV/AIDS was more than offset by the

reduced costs of hospital visits, nursing home services, prison services, and other social

services.16 Specifically, the study found that providing housing for HIV-positive individuals

resulted in financial savings of:

13 David Buchanan et al., The Health Impact of Supportive Housing for HIV-Positive Homeless Patients: A Randomized Controlled Trial, 99 AM. J. PUB. HEALTH S675 (2009); see also Laura S. Sadowski et al., Effect of a Housing and Case Management Program on Emergency Department Visits and Hospitalizations Among Chronically Ill Homeless Adults, 301(17) JOURNAL OF AMERICAN MEDICAL ASSOCIATION 1771, 1773 (May 6, 2009). 14 Id. 15 David Buchanan et al., The Health Impact of Supportive Housing for HIV-Positive Homeless Patients: A Randomized Controlled Trial, 99 AM. J. PUB. HEALTH S675, S675 (2009). 16 AIDS Foundation of Chicago, Studies on Supportive Housing Yield Results for Health of Homeless and Cost Savings, available at http://www.aidschicago.org/pdf/2012/chhp_data_sheet_2012.pdf.

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$1 million in public funds every year for every 100 chronically homeless

individuals living with HIV/AIDS who are placed in long-term supportive

housing; and

$600,000 in public funds every year for every 100 chronically homeless

individuals living with HIV/AIDS who are placed in short-term homeless

housing.17

Although HOPWA helps provide these health and financial benefits through

supportive housing to persons living with HIV/AIDS, HOPWA’s formula for distributing

funds does not accord with the current geographic distribution of the disease. In 2006, the

Government Accountability Office (GAO) criticized how HOPWA’s funding formula relies on

cumulative AIDS cases, which includes a significant number of deceased persons, for

distributing funds.18 The GAO report argued that a more equitable formula would rely on

current HIV case counts.19 The report concluded that if the formula took into account

current HIV case counts, the South and the Midwest would receive a greater proportion of

the HOPWA funds.20 The U.S. Department of Housing & Urban Development (HUD) is also

aware that the current HOPWA funding formula needs updating. HUD’s FY 2013 Budget

report “proposes to update the HOPWA program to better reflect the current

17 Id. 18 Government Accountability Office, HIV AIDS: Changes Needed to Improve the Distribution of Ryan White CARE Act and Housing Funds (February 2006), available at http://www.gao.gov/assets/250/249134.html. 19 Id. 20 Id.

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understanding of HIV/AIDS and ensure that funds are directed in a more equitable and

effective manner.”21

III. Overview of HOPWA Legislation

HOPWA is codified in Title 42, §§ 12901-12 of the United States Code. Section

12904 sets forth a list of activities for which grantees may use HOPWA grants, including

providing housing information and assistance, developing and operating shelter services,

providing rental assistance, rehabilitating single room occupancy dwellings, developing

community residences, and any other activity for people living with HIV/AIDS that the

Secretary of Housing & Urban Development (HUD) develops in cooperation with

awardees.22 The requirements for each of these activities are delineated in §§ 12906-

12910.23

Section 12903 instructs HUD on how to disperse the HOPWA grants.24 HUD must

first allocate 90% of the grant money for entitlement awards and 10% for competitive

grants (See Figure 1).25 As shown in Table 1, Congress has appropriated almost $300

million for entitlement awards and approximately $30 million for competitive grants each

year since fiscal year 2010. Based on President Obama’s proposed budget for FY 2013,26

HUD expects the HOPWA budget to decline slightly for the first time since the program’s

inception in the early 1990s.27

21 U.S. Department of Housing & Urban Development, FY 2013 Budget. 22 42 U.S.C. § 12904 (2012). 23 Id. at § 12906-10. 24 Id. at § 12903. 25 Id. 26 Partnership for Strong Communities, Obama’s FY13 Budget Increases Resources to Combat Homelessness, Cuts Other Housing Programs (Feb. 15, 2012), http://www.pschousing.org/news/pres-obama-releases-proposed-fy13-budget. 27 U.S. Department of Housing & Urban Development, FY 2013 Budget.

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Figure 1: HOPWA funding categories

Table 1: HOPWA Funding by Fiscal Year

Entitlement Awards28

Competitive Grants29

Total

FY 2013 (estimated)30

297,000,000 33,000,000 330,000,000

FY 2012 298,800,000 32,933,188 331,733,188 FY 2011 297,888,030 32,727,525 330,615,555 FY 2010 298,485,000 30,277,869 328,762,869 FY 2009 276,088,500 29,428,416 305,516,916 FY 2008 267,417,000 29,713,000 297,130,000

A. Entitlement Award Distribution

Ninety percent of HOPWA funding is for entitlement awards. Section 12903 sets

forth the formula for determining which localities are eligible for entitlement awards in

two parts.31 In the first part of the HOPWA formula, HUD must distribute 75% of the

entitlement award money to “(i) cities that are the most populous unit of general local

government in a metropolitan statistical area having a population greater than 500,000

28 U.S. Department of Housing & Urban Development, HOPWA Formula Allocations, http://portal.hud.gov/hudportal/HUD?src=/program_offices/comm_planning/aidshousing/programs/formula/grants. 29 U.S. Department of Housing & Urban Development, HOPWA Programs, http://hudhre.info/index.cfm?do=viewHopwaRptsSelect&opt_zero=Awards. 30 U.S. Department of Housing & Urban Development, FY 2013 Budget. 31 42 U.S.C. § 12903(c)(1) (2012).

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and more than 1,500 cases of acquired immunodeficiency syndrome; and (ii) States with

more than 1,500 cases of acquired immunodeficiency syndrome outside of metropolitan

statistical areas described in clause (i).”32 The Office of Management and Budget defines a

metropolitan statistical area (MSA) as a geographic area “associated with at least one

urbanized area that has a population of at least 50,000” and “comprises the central county

or counties containing the core, plus adjacent outlying counties having a high degree of

social and economic integration with the central county or counties as measured through

commuting.”33 As specified in the HOPWA legislation, only cities in MSAs with populations

greater than 500,000 and more than 1,500 AIDS cases are eligible for the portion of the

entitlement grant money specified in clause (i).34 Areas outside of an eligible MSA may

only receive funding if the area is a qualified state under clause (ii).35 In FY 2010, 83 cities

in eligible MSAs received entitlement funding under clause (i) and 40 States and Puerto

Rico received entitlement funding under (ii) (see Figure 2).36

In the second part of the HOPWA formula, HUD must distribute the remaining 25%

of the entitlement award money to cities that “are the most populous unit of general local

government” in an eligible MSA and that “have a higher than average per capita incidence

of acquired immunodeficiency syndrome.”37 Just like the first part of the formula, the

second part of the formula is based on AIDS cases rather than HIV/AIDS cases. To

determine which cities in eligible MSAs have a “higher than average per capita incidence” of

32 Id. 33 Office of Management & Budget, Federal Register, part IV, 2010 Standards for Delineating Metropolitan and Micropolitan Statistical Areas (June 28, 2010). 34 42 U.S.C. § 12903(c)(1)(A)(i) (2012). 35 Id. at § 12903(c)(1)(A)(ii). 36 David Vos, Housing for Persons with HIV/AIDS Targeting of Resources (Mar. 28, 2011). 37 § 12903(c)(1)(B).

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AIDS, the cities should be ranked according to the number of AIDS cases “reported to and

confirmed by the Director of the Centers for Disease Control of the Public Health Service as

of March 31 of the fiscal year immediately preceding the fiscal year for which the amounts

are appropriated and to be allocated.”38 The legislation also notes that a “single city may

receive assistance” under both the first and second part of the formula.39 Therefore, with

this formula, cities in eligible MSAs “with higher than average incidences” of AIDS receive

two entitlement grants whereas cities with below average incidences of AIDS and more

rural areas receive up to only one entitlement grant. In FY 2010, 29 cities in eligible MSAs

received funding from the second part of the formula for having higher than average

incidences of AIDS (see Table 2).40

38 Id. 39 Id. 40 David Vos, Power Point: Housing for Persons with HIV/AIDS Targeting of Resources (Mar. 28, 2011).

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Figure 2: Map showing 83 MSAs, 40 States, and Puerto Rico that received entitlement grants from the first part of the HOPWA funding formula (75% fund).

Table 2: 29 MSAs that received entitlement grants from the second part of the entitlement formula (25% portion) for having higher than average incidences of AIDS in FY 2010. ST FY2010 HOPWA

Grantee Name Funding from 25% of entitlement funds

CA Bakersfield $239,330 CA Los Angeles $757,226 CA San Francisco $3,229,925 DC District Of

Columbia $7,539,343

DE Wilmington $126,422 FL Jacksonville-

Duval County $1,086,760

FL Lakeland $110,444 FL Ft Lauderdale $4,781,342 FL Miami $6,140,354 FL West Palm

Beach $1,232,540

FL Orlando $1,302,801 FL Tampa $1,102,912 GA Atlanta $3,999,540

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LA Baton Rouge $1,330,258 LA New Orleans $1,383,130 MD Baltimore $5,304,468 MD Frederick $292,525 MI Detroit $60,353 MS Jackson $401,353 NC Wake County $210,326 NJ Newark $2,117,217 NJ Jersey City $1,231,259 NY New York City $21,875,106 PA Philadelphia $3,825,073 PR San Juan

Municipio $1,637,336

SC Columbia $785,198 TN Memphis $523,136 TX Dallas $88,198 TX Houston $1,907,377

TOTAL $74,621,251

Although HOPWA specified which cities and states are eligible for funds in its 75%

and 25% entitlement categories, the legislation did not specify how HUD was to divide the

funds among the eligible cities and states. HUD promulgated rules in 24 C.F.R. § 574.130 to

take care of this task.41 First, § 574.130(b)(1) provides that the 75% entitlement grants

should be distributed according to each MSA or State’s “proportionate share of cumulative

number of AIDS cases.”42 Second, § 574.130(b)(2) provides that HUD will allocate 25% of

the entitlement funds in proportion to a “high incidence factor.” The high incidence factor

is “computed by multiplying the population of the metropolitan statistical area by the

difference between its twelve-month-per-capita-[AIDS] incidence rate and the average rate

for all metropolitan statistical areas with more than 500,000 population.”43 Therefore,

HUD distributes the HOPWA funds based on cumulative AIDS cases for the 75% fund and

the prior fiscal year’s AIDS incidence rate for the 25% fund.

41 24 C.F.R. § 574.130 (2012). 42 Id. 43 Id.

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B. Competitive Grants

Ten percent of HOPWA funding is for competitive awards. In contrast to

entitlement grants, competitive grants are distributed without a formula. HUD accepts

applications for these proposed projects of national significance in response to Notices of

Funding Allowances (NOFAs).44 HUD grants competitive awards to two kinds of eligible

entities: (1) States or political subdivisions of States (such as towns) that do not otherwise

qualify for the entitlement awards and (2) States, political subdivisions of States, or

nonprofit organizations “to fund special projects of national significance.”45 To determine

which of the eligible States or political subdivisions of States under (1) should receive a

competitive grant, HUD considers factors such as the relative numbers of AIDS cases per

capita, the housing needs of those with AIDS in the community, the extent of local planning

and coordination of housing programs for people living with AIDS, and the likelihood that

the proposed programs will continue.46 To determine which of the eligible States, political

subdivisions, or nonprofit organizations under (2) should receive a competitive grant for

special projects of national significance, HUD considers “(i) the need to assess the

effectiveness of a particular model for providing supportive housing for eligible persons;

(ii) the innovative nature of the proposed activity; and (iii) the potential replicability of the

proposed activity in other similar localities or nationally.”47

44 See, e.g., Department of Housing and Urban Development, Docket No. FR-5500-N-13, Notice of Funding Availability (NOFA) for HUD’s Fiscal Year 2011: Housing Opportunities for Persons with AIDS (HOPWA). 45 § 12903(c)(3). 46 Id. 47 Id.

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IV. Criticisms of Existing HOPWA Formula

The existing HOPWA entitlement formula for determining eligible localities in 42

U.S.C. 12903 and for distributing the funds among eligible localities in 24 C.F.R. § 574.130

does not distribute the funding in accord with the current state of the domestic epidemic.

First, the formula is based on the number of AIDS cases even though the number of

HIV/AIDS cases is more representative of the disease. Second, the formula is based on

cumulative AIDS cases, approximately half of which are deceased individuals, rather than

living HIV/AIDS cases. Third, the formula gives cities in eligible MSAs “with higher than

average incidences” of AIDS preferential treatment and disproportionate funding

compared to other cities and more rural areas.

First, a formula based on the number of AIDS cases does not logically parallel the

present distribution of the domestic epidemic. Today, the number of persons living with

HIV/AIDS is a more accurate measure of the epidemic than the number of AIDS cases. As

shown in Figure 3, at the time of HOPWA’s enactment in 1990, the rate of new AIDS

diagnoses and deaths was rapid.48 Since the advent of highly active antiretroviral therapy

(HAART) in 1995, however, the number of AIDS diagnoses and deaths has declined

markedly while the number of persons living with HIV infection or AIDS diagnoses has

been increasing at a steady rate.49 Given that HAART may allow an HIV-positive person to

stave off AIDS for decades, the formula for allocating entitlement awards should take into

account both HIV and AIDS cases rather than just AIDS cases.

48 Center for Disease Control & Prevention, Morbidity & Mortality Weekly Report 691 fig. (June 3, 2011). 49 Id.

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Figure 3: Estimated number of AIDS diagnoses and deaths, estimated number of persons living with AIDS diagnosis, and estimated number of persons living with diagnosed or undiagnosed HIV infection among persons aged > 13 years in the United States from 1981—2008.50

Second, a formula based on the cumulative number of AIDS cases does not logically

parallel the state of the epidemic because it includes a significant number of deceased

people. As shown in Figure 3, the number of AIDS diagnoses and deaths peaked

approximately twenty years ago in 1995, right before the introduction of HAART.51

Because of the high AIDS diagnosis rate in the early years of the epidemic, basing the

formula on cumulative cases skews the allocation of funding toward areas where the

disease originated in the United States and where high numbers of AIDS cases were

reported in the early years of the epidemic. David Vos, the Director of the Office of

HIV/AIDS Housing in HUD, stated that of the 1,071,940 cumulative AIDS cases included in

50 Center for Disease Control & Prevention, Morbidity & Mortality Weekly Report 691 fig. (June 3, 2011). 51 Id. at 691 Fig.

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the formula in fiscal year 2010, 591,615 were deceased individuals.52 Therefore, over half

of the people HUD considers when distributing the HOPWA funds to eligible localities are

deceased.

States and cities where the HIV/AIDS epidemic began later, after the introduction of

HAART, are expected to have a greater proportion of HIV cases compared to cumulative

AIDS cases than in locations where the epidemic originated. As shown in Figure 4, for FY

2011, states and cities in the Great Plains and southeast United States had higher ratios of

people living with HIV/AIDS to cumulative AIDS cases than in states where the disease

originated.53 HUD’s use of cumulative AIDS cases is interesting considering the enabling

statute, 42 U.S.C. § 12903, never uses the term “cumulative.” The requirement of

cumulative AIDS cases only appears in 24 C.F.R. § 574.130.

52 David Vos, Power point: Housing for Persons with HIV/AIDS Targeting of Resources (Mar. 28, 2011). 53 David Vos, U.S. Department of Housing & Urban Development, Housing as a Platform for Health (Dec. 7, 2011).

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Figure 4: Ratio of Count of Persons Living with HIV to Cumulative Count of Persons with AIDS among all States and MSAs receiving FY 2011 HOPWA funding.

Third, the formula gives cities in eligible MSAs “with higher than average

incidences” of AIDS a disproportionately large share of HOPWA funding compared to cities

with lower than average incidences and more rural areas. Specifically, 42 U.S.C. § 12903

provides that a single city may receive two kinds of entitlement grants. In the first part of

the formula, § 12903(c)(1)(A), a city may receive an entitlement grant when it is the “most

populous unit of general local government in a metropolitan statistical area having a

population greater than 500,000 and more than 1,500 cases of acquired immunodeficiency

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syndrome.”54 In the second part of the formula, § 12903(c)(1)(B), a city may receive

another entitlement grant when it is the most populous unit of general local government in

a MSA having a population greater than 500,000 and more than 1,500 cases of AIDS and it

has “a higher than average per capita incidence of acquired immunodeficiency

syndrome.”55 The legislation makes clear that a “single city may receive assistance” under

both § 12903(c)(1)(A) and § 12903(c)(1)(B).56

Giving a single city two bites of the apple has resulted in some cities receiving a

disproportionately large share of the HOPWA funding. David Vos, Director of the Office of

HIV/AIDS Housing in HUD, has calculated that this formula resulted in giving $10,030 per

person living with HIV/AIDS in these doubly eligible cities and only $202 per person living

with HIV/AIDS for other eligible localities in FY 2010.57 Furthermore, the seven largest

MSAs received 72% of this double entitlement grant money,58 evidencing that urban areas

received a disproportionately large piece of the entitlement grant funding.

V. Existing HOPWA Legislation’s Impact on the Southern States

A. Entitlement Grants

If the formula 24 C.F.R. § 574.130(b)(1) for distributing the 75% portion of the

entitlement fund used the number of people living with HIV/AIDS rather than cumulative

AIDS cases, the South would receive a larger share of the entitlement fund. As shown in

Table 3, the south received 37.8% of the HOPWA funds allocated under 42 U.S.C. §

12903(c)(1)(A) in fiscal year 2010, but had 41.9% of PLWHA live in this region. The 4.1% 54 42 U.S.C. § 12903(c)(1)(A) (2012). 55 Id. at § 12903(c)(1)(B). 56 Id. 57 David Vos, Power Point: U.S. Department of Housing & Urban Development, Housing as a Platform for Health (Dec. 7, 2011). 58 Id.

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discrepancy between share of HOPWA entitlement funds and disease burden translates

into approximately a loss of $9.2 million for the region.

Table 3: Comparison of regions’ percent of cumulative AIDS cases to percent of living HIV/AIDS cases.

All targeted states have a higher proportion of people living with HIV/AIDS than

proportion of cumulative AIDS cases. Figure 5 shows how much each of the targeted states’

percent of § 12903(c)(1)(A) funding if the formula in 24 C.F.R. § 574.130(b)(1) changed

from cumulative AIDS cases to living HIV/AIDS cases. Florida and Texas would see little

change in their funding, but Alabama, Mississippi, and North Carolina could see increases of

over 30 percent. Amending the funding formula to use the number of people living with

HIV/AIDS rather than cumulative AIDS cases should result in all of the targeted states

receiving an increase in § 12903(c)(1)(A) HOPWA funding.

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Figure 5: Comparison of southern targeted states’ potential percent increase in HOPWA entitlement awards from § 12903(c)(1)(A) by changing the basis of the 24 C.F.R. § 574.130(b)(1) formula from cumulative AIDS cases to persons living with HIV/AIDS.

In addition to changing the formula in 24 C.F.R. § 574.130(b)(1) to PLWHA rather

than cumulative AIDS, § 12903(c)(1)(B) could be completely eliminated to remove the

bonus funds for cities that “have a higher than average per capita incidence of acquired

immunodeficiency syndrome.” The data in Table 3 and Figure 5 does not take into account

the bonus funds. Figure 6 compares the total entitlement funds received by each of the

targeted states in FY 2010, including funds from §§ 12903(c)(1)(A) & (B), to how the

entitlement funds could have been distributed based solely on the number of PLWHA in

each state. As shown in Figure 6, Alabama, Mississippi, North Carolina, South Carolina,

Tennessee, and Texas would receive increased funding whereas Florida, Georgia, and

Louisiana would receive less funding. The change in funding that would occur for all states

is displayed in Appendix A.

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Figure 6: Comparison of southern targeted states’ potential percent increase in HOPWA entitlement awards if eliminate § 12903(c)(1)(B) and distribute the HOPWA entitlement budget according to number of PLWHA.

Some of the proposals for updating the HOPWA formula from §§ 12903(c)(1)(A)

and (B) include incorporating into the formula:

data on persons living with HIV/AIDS rather than cumulative AIDS cases;

housing costs (such as fair market rents) and housing affordability, availability,

and quality;

poverty rates and area household incomes; and

other factors such as neighborhood market conditions, community amenities,

and service infrastructure.

0.00

5,000,000.00

10,000,000.00

15,000,000.00

20,000,000.00

25,000,000.00

30,000,000.00

35,000,000.00

40,000,000.00

45,000,000.00

AL FL GA LA MS NC SC TN TX

Total HOPWA Entitlement Funding inFY 2010

Total HOPWA Funding if formulachanged to be based on PLWHA in FY2008

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B. Competitive Awards

Even though the competitive awards (10% to total HOPWA funding) are distributed

based on evaluating applications and not on a formula, one can examine the competitive

award grants over the last several years to look at the amount of competitive awards the

southern region has won compared to other regions. The distribution of competitive

grants can also be compared to each region’s proportion of PLWHA. Based on data from

the Kaiser Family Foundation, the percent of PLWHA by Census Bureau region as of

December 200859 is as follows:

Targeted States (AL, GA, LA, MS, FL, NC, SC, TN, TX) = 31.73%

Southern States (AL, AR, DE, DC, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX,

VA, WV) = 41.9%;

Northeast States (ME, NH, VT, MA, CT, RI, NJ, PA, NY) = 25.58%;

Midwest States (ND, SD, NE, KS, MN, IA, MO, WI, IL, IN, OH, MI) = 11.4%;

Western States (WA, OR, ID, MT, WY, CA, NV, UT, CO, AZ, NM, AK, HI) = 18.9%

Puerto Rico + Guam = 2.14%

For an equitable distribution of the competitive funds, one would expect that the

distribution of competitive HOPWA funding would largely mirror the distribution of

PLWHA across the U.S. As shown in Table 4, however, the Census Bureau southern region

received only approximately 21% of the competitive grant funding over the last four years

even though the Census Bureau southern region has 42% of PLWHA. Similarly, the

southern targeted states received only approximately 12.7% of the competitive grant

59 Kaiser Family Foundation, People Living with HIV/AIDS as of December 2008, http://www.statehealthfacts.org/comparemaptable.jsp?ind=1016&cat=11.

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funding over the last four years even though the Census Bureau southern region has 31.7%

of PLWHA. In contrast, the Census Bureau Northeast, Midwest, and West all received

higher proportions of the competitive HOPWA grants than their proportions of PLWHA

(see Figure 7). Table 5 provides a breakdown of the number of competitive awards given

per Census Bureau region and Table 6 provides a breakdown of the total amount of

competitive grants given to each Census Bureau region by fiscal year. Figure 8 shows the

dollar amount of competitive award received by each Census Bureau region averaged over

fiscal years 2009-2012 divided by each Census Bureau region’s number of PLWHA. The

south, especially the targeted states, has received less competitive grant money per PLWHA

over the last several years than other regions.

Table 4: Percent competitive award $ by Census Bureau region, FY 2009-2012

Targeted States (AL, GA, LA, MS, FL, NC, SC, TN, TX)

Southern States (AL, AR, DE, DC, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV)

Northeast States (ME, NH, VT, MA, CT, RI, NJ, PA, NY)

Midwest States (ND, SD, NE, KS, MN, IA, MO, WI, IL, IN, OH, MI)

Western States (WA, OR, ID, MT, WY, CA, NV, UT, CO, AZ, NM, AK, HI)

Total for census bureau regions

FY 2012 2.27 6.54 34.55 27.28 31.63 100.00

FY 2011 21.17 34.54 28.98 5.91 30.57 100.00

FY 2010 21.72 36.76 27.95 6.08 29.21 100.00

FY 2009 5.63 5.63 35.49 29.67 29.21 100.00

Average 12.70 20.87 31.74 17.23 30.15 100

23

Figure 7: Comparison of each Census Bureau region’s percent competitive award from Table 4 to each Census Bureau region’s percent PLWHA.

Table 5: Number of competitive awards allocated to each Census Bureau region of the United States by fiscal year.60

Targeted States (AL, GA, LA, MS, FL, NC, SC, TN, TX)

Southern States (AL, AR, DE, DC, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV)

Northeast States (ME, NH, VT, MA, CT, RI, NJ, PA, NY)

Midwest States (ND, SD, NE, KS, MN, IA, MO, WI, IL, IN, OH, MI)

Western States (WA, OR, ID, MT, WY, CA, NV, UT, CO, AZ, NM, AK, HI)

Total for Census Bureau regions

FY 2012 1 2 11 7 8 28

FY 2011 6 9 8 2 9 28

FY 2010 7 12 7 2 8 29

FY 2009 2 2 10 7 7 26

60 U.S. Department of Housing & Urban Development, Homelessness Resource Exchange, HOPWA Programs, Grantees, and Reports, http://hudhre.info/index.cfm?do=viewHopwaRptsSelect&opt_zero=Awards&yr=2010&quarterNum=&rptLevel=byAllStates&stateOrGrantee=all&grantee=Competitive.

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

40.00

45.00

TargetedStates

SouthernStates

NortheastStates

MidwestStates

WesternStates

Average % competitive award,FY 2009-2012

% PLWHA in 2008

24

Table 6: Total Competitive Grants Awarded by Census Bureau Region and FY

Targeted States (AL, GA, LA, MS, FL, NC, SC, TN, TX)

Southern States (AL, AR, DE, DC, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV)

Northeast States (ME, NH, VT, MA, CT, RI, NJ, PA, NY)

Midwest States (ND, SD, NE, KS, MN, IA, MO, WI, IL, IN, OH, MI)

Western States (WA, OR, ID, MT, WY, CA, NV, UT, CO, AZ, NM, AK, HI)

FY 2012 $746,853 $2,152,803 $11,378,119 $8,984,462 $10,417,804

FY 2011 $6,636,782 $10,830,282 $9,087,402 $1,852,291 $9,584,150

FY 2010 $6,577,577 $11,131,460 $8,462,398 $1,840,791 $8,843,220

FY 2009 $1,658,228 $1,658,228 $10,443,514 $8,731,829 $8,594,845

Figure 8: Average dollar amount of competitive award received by each Census Bureau region during FY 2009-2012 divided by the each Census Bureau region’s number of PLWHA.

$0

$10

$20

$30

$40

$50

$60

TargetedStates

SouthernStates

NortheastStates

MidwestStates

WesternStates

Average Competitive Award/PLWHA

25

This research reveals that the southern states, especially the targeted southern

states, are receiving a disproportionately smaller share of the HOPWA competitive awards

compared to their share of PLWHA. The reasons for this disproportionately small share of

the HOPWA competitive awards are not clear. First, it is possible that the evaluation

process for competitive grant applications is disfavoring southern states. Second, it is

possible that fewer organizations in the southern states are applying for competitive

awards. Third, it is possible that the organizations in the southern states that are applying

are not submitting quality applications. More investigation into the number of applications

received from each region, as well as more details about the evaluation process for the

applications, would help elucidate the reasons for the southern region’s lower distribution

of HOPWA competitive grants.

VI. Conclusion

Preliminary research shows that the southern states would receive a greater

proportion of the HOPWA entitlement funding under § 12903(c)(1)(A) if the formula were

amended to take into account persons living with HIV/AIDS rather than cumulative AIDS

cases. For some southern states, the change is significant. North Carolina, for example,

would see an increase of close to 50% in its HOPWA funding with this change. Preliminary

research also shows that southern states have historically received fewer competitive

awards than their share of PLWHA would indicate. It is not clear whether this discrepancy

is due to fewer southern entities applying for these grants, southern entities submitting

applications of poorer quality, or a HUD evaluation process that favors other regions.

26

Appendix A: Effect on HOPWA Entitlement Distribution from eliminating § 12903(c)(1)(B) and distributing funds based on Number of PLWHA.

ST

Total HOPWA Entitlement Funds distributed in FY 2010 based on cumulative AIDS cases and including 12903(c)(1)(B)

Potential distribution of funds if formula changed to PLWHA and 12903(c)(1)(B) were eliminated

AL 1997344 $3,581,932

AK 0 $221,859

AR 849352 $1,638,267

AZ 2441964 $4,017,092

CA 36572427 $38,245,396

CO 1998180 $3,663,418

CT 3307813 $3,721,964

DC 14118841 $5,507,794

DE 974252 $1,070,951

FL 40034574 $32,068,257

GA 11679624 $11,022,436

0 $31,156

HI 655131 $771,372

ID 0 $254,727

IA 400137 $559,784

IL 7441798 $11,126,518

IN 1849903 $2,835,554

KS 384683 $918,251

KY 1048793 $1,560,890

LA 6814793 $5,775,532

MA 4031862 $5,651,592

ME 0 $338,267

MT 0 $122,228

MD 11422788 $11,689,041

MI 3499110 $4,680,615

MN 1114995 $2,088,490

MO 2997269 $3,815,775

MS 1918992 $2,829,049

ND $59,573

NC 4200628 $7,914,009

NE 344586 $526,231

NH 0 $377,298

NJ 14361213 $11,685,618

NM 593314 $809,718

NV 1353491 $2,296,655

NY 61192823 $42,318,979

OH 3589330 $5,671,450

27

OK 1100377 $1,606,768

OR 1462922 $1,665,314

PA 11449814 $11,303,869

PR 8255261 $6,349,011

RI 9129464 $832,657

SD 0 $131,130

SC 3752393 $4,889,122

TN 3516019 $5,050,381

TX 17896011 $21,575,818

UT 514164 $760,416

VT 0 $119,831

VI 0 $195,154

VA 2557661 $6,768,763

WA 2549726 $3,510,033

WI 1030207 $1,666,341

WY 0 $76,692

WV 336232 $515,960