The Affordable Housing Crisis: Impact on People Living with HIV in CA

Access to stable affordable housing is critical to achieving optimal health outcomes for people living with HIV (PLWH), as well as a successful method of preventing new infections.ⁱ The Department of Housing and Urban Development (HUD) recognizes that access to stable housing is one of the most effective interventions for increasing retention in care, adherence to treatment, and viral load suppression rates for PLWH.^ii,iii Increased viral suppression in turn significantly reduces the risk of HIV transmission, as people living with HIV with suppressed viral loads have a negligible risk of transmitting HIV to their sexual partners.^iv President Obama’s National HIV/AIDS Strategy and the California Office of AIDS’ Laying a Foundation for Getting to Zero report include goals to increase access to affordable housing.^v,vi However, according to the California Office of AIDS’ Medical Monitoring Project, 12 percent of the estimated 139,000 PLWH living in California (16,680 people) were homeless or unstably housed in 2014.^vii

Federally-funded housing programs provide housing subsidies and supportive services; however, current funding levels do not meet the housing needs of most low-income PLWH in California. In addition, the Trump administration has proposed drastic cuts to HUD’s 2018 budget that would severely impact funding levels next year.^viii Steadily increasing rents coupled with out-of-date subsidy rates and low funding levels have contributed to a statewide affordable housing shortage and homelessness crisis that leaves many PLWH hard pressed to find stable affordable housing. This crisis must be addressed in order to improve health outcomes for PLWH and move California closer to ending the HIV epidemic. 

Housing subsidies and a number of supportive services for PLWH in California are funded through HUD’s Section 8 and HOPWA programs. Section 8 was authorized by Congress in 1974 and provides rental subsidies for eligible low-income families and individuals.^ix The HOPWA program was created in 1992 to provide housing assistance and related supportive services to low-income persons living with HIV/AIDS and their families.^x Although California allocates dollars to affordable housing programs, the state does not allocate any funding to HIV-specific housing services.^xvi However, local health jurisdictions that receive Ryan White funding from the Department of Health and Human Services (HHS) can use funds for housing referrals and short-term housing assistance.^xvii This is because Ryan White funds can be used for support services that “are needed for individuals with HIV/AIDS to achieve their medical outcomes”; housing assistance falls under this category.

While existing research on the HIV Continuum of Care shows that stable housing is an effective intervention for care, treatment, and prevention, and HUD provides funding for housing assistance and supportive services, several trends have emerged over the past 25 years that have made it significantly more difficult for PLWH to find stable affordable housing. These include: 1) a lack of availability of affordable units, 2) subsidies that have not increased as Fair Market Rent (FMR) has increased, rising housing costs, and inflation, and 3) reductions in HOPWA allocations and flat funding. In addition to these trends, barriers and challenges exist at the programmatic level that hinder access to affordable housing.

A literature review and key informant interviews with fifteen stakeholders from seven of the eleven California HOPWA formula grantees were conducted in order to identify key barriers to accessing stable affordable housing. Content analyses of barriers, gaps, and challenges discussed with these stakeholders elucidated several themes including lack of funding, lack of housing supply and availability, lack of supportive services, administrative challenges, problems with landlords, and lack of (or poor) data collection and sharing. While it is unlikely that the federal government will increase HOPWA and Section 8 allocations moving forward, smaller policy changes within California’s housing and health care systems can marginally increase access to stable affordable housing for PLWH. Based the themes identified we generated six policy recommendations:

1. Increase communication and collaboration between the state, local health jurisdictions, housing  authorities, non-profit organizations, and other community partners.
2. Update the Coordinated Entry System (CES) to prioritize PLWH.
3. Leverage other housing programs to better serve the needs of PLWH.
4. Increase community advocacy to boost visibility of PLWH within housing programs.
5. Support existing efforts to promote legislation that increases the affordable housing supply.
6. Conduct targeted research to support best practices for effective program delivery.

An array of medical, behavioral, and supportive services are integral for PLWH to become virally suppressed and manage other health outcomes, but stable housing is a critical intervention to improve health outcomes for PLWH and reduce new infections. However, housing is incredibly complex, and more targeted research and data collection is needed to understand how to improve access to housing for PLWH without increased funding levels or construction of more affordable housing units. Understanding how to better integrate housing services within the HIV Care Continuum and collaborate across housing and health care systems will accelerate efforts to stably house a greater number of PLWH. California’s housing crisis is unlikely to disappear soon, but housing authorities, local health jurisdictions, and community partners have an important role in tackling the affordable housing shortage for PLWH.

Access to stable affordable housing is critical to achieving optimal health outcomes for people living with HIV (PLWH), as well as a successful method of preventing transmission of the virus.¹ The Department of Housing and Urban Development (HUD) recognizes that access to stable housing is one of the most effective interventions for increasing retention in care, adherence to treatment, and viral load suppression rates for PLWH.^2,3 Increased viral suppression also significantly reduces the risk of HIV transmission, as people living with HIV with suppressed viral loads have a negligible risk of transmitting HIV to their sexual partners.⁴ President Obama’s National HIV/AIDS Strategy and the California Office of AIDS’ Laying a Foundation for Getting to Zero report include goals to increase access to affordable housing.^5,6 However, according to the California Office of AIDS’ Medical Monitoring Project, 12 percent of the estimated 139,000 PLWH living in California (16,680 people) were homeless or unstably housed in 2014.^<7/sup>

Federally-funded housing programs provide housing subsidies and supportive services; however, current funding levels do not meet the housing needs of most low-income PLWH in California. In addition, the Trump administration has proposed drastic cuts to HUD’s 2018 budget that would severely impact funding levels next year.⁸ Steadily increasing rents coupled with out-of-date subsidy rates and low funding levels have contributed to a statewide affordable housing shortage and homelessness crisis that leaves many PLWH hard pressed to find stable affordable housing. This crisis must be addressed in order to improve health outcomes for PLWH and move California closer to ending the HIV epidemic. 

This policy brief documents the funding sources for housing assistance and supportive service programs available to PLWH followed by an overview of the relationship between stable housing and positive health outcomes for this population. The brief then examines current fair market rent (FMR) rates compared with HUD’s Housing Opportunities for Persons with AIDS (HOPWA) and Section 8 subsidy rates and discusses key issues perpetuating the housing crisis for PLWH. To understand the current landscape, the Southern California HIV/AIDS Policy Research Center conducted a literature review and key informant interviews with HOPWA administrators and community partners in California to identify the main challenges and gaps in housing services for PLWH. The brief ends with a review of this qualitative evidence and a proposed set of policy recommendations to increase collaboration across the housing and health care sectors in order to combat the current housing crisis for PLWH.

Housing Resources for PLWH in California

Housing subsidies and a number of supportive services for PLWH in California are funded through HUD’s Section 8 and HOPWA programs. Section 8 was authorized by Congress in 1974 and provides rental subsidies for eligible low-income families and individuals.⁹ The HOPWA program was created in 1992 to provide housing assistance and related supportive services to low-income persons living with HIV/AIDS and their families.¹⁰ PLWH are eligible for HOPWA vouchers if their incomes fall at or below 80% of area median income (AMI), and for Section 8 vouchers if their incomes fall at or below 50% of AMI.¹¹ HOPWA programs and services include capital funds for construction and rehabilitation of permanent housing, move-in fees and vouchers for permanent supportive housing, emergency housing, rental subsidies for short-term and transitional housing, and supportive services, including counseling and referrals.

HOPWA grants are issued every year in the form of ‘formula’ and ‘competitive’ grants. Ninety per cent of HOPWA funds are granted to states and eligible metropolitan statistical areas (MSAs, usually cities) based on a formula that calculates the highest need in metropolitan areas. Prior to 2017, formula grants were based on cumulative AIDS cases, but in 2016 the HOPWA formula was modernized to determine allocations by “living with HIV” data.¹² The remaining 10 percent of HOPWA funds are distributed through competitive grants to states, local governments, and non-profit organizations.¹³ California received $34,945,333.00 in formula grants in 2016; Exhibit 1 below illustrates how funds were distributed across cities. The California Office of AIDS received $2,599,853.00 of that funding which was then distributed across local government agencies and non-profit community-based organizations based on HIV/AIDS cases to provide HOPWA services.¹⁴

Exhibit 1: HOPWA Formula Federally Funded Grantees in California, 2016

Although California allocates funding for affordable housing programs¹, the state does not allocate any funding to HIV-specific housing services.¹⁶ It is likely that many PLWH utilize other publicly funded homeless services, but HIV-status is not necessarily collected or tracked across other programs and their data systems. Therefore, there is no way of capturing PLWH’s use of those systems for analysis here. However, local health jurisdictions that receive Ryan White2 funding from the Department of Health and Human Services (HHS) can use funds for housing referrals and short-term housing assistance.¹⁷ This is because Ryan White² funds can be used for support services that “are needed for individuals with HIV/AIDS to achieve their medical outcomes”; housing assistance¹⁷ falls under this category.

The Intersection of Stable Housing and Health Outcomes for PLWH

An array of medical, behavioral, and supportive services are integral for PLWH to become virally suppressed and manage other health outcomes, but stable housing is a critical intervention to improve health outcomes for PLWH. In 2015, HUD published a brief detailing how stable housing improves health outcomes for PLWH and those at risk for HIV along the HIV Care and Prevention Continuum. Table 1 summarizes HUD’s findings.

Table 1: Impact of Housing on Health Outcomes along the HIV Care and Prevention Continuum

In addition to improved health outcomes, stable housing promotes such benefits as self sustainability, reduced visits to hospitals and emergency rooms, and reduced incarceration. From a provider and funder consideration, stable housing is very cost-effective, resulting in savings from reduced emergency and inpatient care visits, reduced time in emergency shelters, and reduced jail time. Analyses of these savings demonstrate that the overall savings from housing PLWH more than offsets the cost of housing assistance and supportive services.^19,20

A Housing Crisis: Trends in Housing Availability in California

While research shows that stable housing is an effective intervention for HIV care, treatment, and prevention, and HUD provides funding for housing assistance and supportive services, several trends have emerged over the past 25 years that have led to increased difficulties for PLWH to find housing. These include: 1) a lack of availability of affordable units, 2) subsidies that have not increased as Fair Market Rent (FMR) has increased, rising housing costs, and inflation, and 3) reductions in HOPWA allocations and flat funding.

Lack of Affordable Units

According to the California Housing Partnership Corporation, every county in California has a shortage of affordable housing for low-income renters. California has gained 900,000 renter households since 2005, but would need 1,541,386 more affordable units in order to meet the needs of renters with the lowest incomes.²¹ Worse, decreases in state and federal funding over the past nine years have reduced California’s investment in affordable housing construction and have eliminated funding for redevelopment by $1.7 billion annually.²² These factors contribute to the state’s large number of homeless individuals; according to HUD’s 2016 Continuum of Care data, California now has 118,142 homeless individuals, 66.4 percent of whom are unsheltered.²³

Fair Market Rent, Housing Costs, and Inflation

When the HOPWA program was introduced, HUD calculated the rental subsidy rate such that an individual would be required to contribute 30 percent of their monthly income to rent, and the subsidy would cover the rest up to the FMR. FMR is a gross rent estimate that includes shelter rent plus all tenant-paid utilities and is meant to be high enough to ensure the availability of a sufficient supply of rental housing but low enough to serve as many low-income families as possible.²⁴ However, over the years, HUD has not updated the subsidy level to meet rising rental levels. In California, the FMR for a one-bedroom apartment is $1,163, and $1,487 for two-bedroom apartment.²⁵ Yet FMR for seven of the eleven metropolitan areas within California that receive HOPWA grants are higher than this average, as depicted in Table 2, below. 

Table 2: California Fair Market Rent, Funding Year 2017

The California Housing Partnership Corporation reported that between 2000 and 2014, median rent in California increased 24 percent while median renter household income declined seven percent, when adjusted for inflation.²⁷ For example, in San Francisco in 2000, a one-bedroom apartment rented for $1,077 annually, while the Area Median Income (AMI) was approximately $55,000 for a household.^28,29 Thus, rent accounted for less than one quarter of income. In 2016, the FMR for a one bedroom apartment was $2,411 ($28,932 annually), but area median incomes were $88,829. Thus, rent for a one-bedroom apartment currently accounts for 32.6% of family incomes.

The National Low Income Housing Coalition estimates that a minimum wage worker earning $10 per hour in California in 2016 would have to work 89 hours a week to spend 30 percent or less of their income on a median price one-bedroom apartment. At the same time, a majority of PLWH in California live in jurisdictions that have median rental rates above the statewide FMR benchmark, demonstrating that HOPWA subsidies may not be sufficient to meet the need of PLWH in those areas. Table 3 compares wages, income, and work hours needed to afford a one-bedroom apartment in metropolitan areas of California that receive HOPWA formula grants.

Table 3: Wages, Income, and Work Hours to Afford a Median Price One-Bedroom Apartment in California, 2016

The lowest-income households in California spend a median of 68 percent of their income on rent.³¹ This financial burden is unreasonable for anyone, but particularly pernicious for PLWH who can experience barriers to finding and maintaining work. Even for low-income PLWH who have a stable source of income, it can be extremely difficult to find an apartment that rents for a FMR such that their income and the housing voucher would cover the total cost. In San Francisco, the monthly rent that someone spending 30% of AMI on housing could afford is $808. A person earning minimum wage would need to work 4.4 full-time jobs to afford a FMR two-bedroom apartment in San Francisco.

Note: *Housing Wage: Hourly wage a worker would need to make in order to afford rent and utilities without paying more than 30% of income on housing. Assumes a 40-hour work week, 52 weeks per year.

HOPWA Flat Funding

Although rental rates have continued to rise, Congress has held HOPWA funding flat since 2010, even though inflation and rising rents have resulted in fewer households receiving vouchers and an increased share of renters experiencing rent burden³² In fact, while HOPWA allocations rose modestly from 2001-2009 and increased significantly from 2006-2009, they peaked in 2010 and decreased from 2011 to 2013. 2016 was an exception in which the allocation increased by $5 million, but as Table 4 shows, 2016 funding was at similar levels to that in 2010. Nonetheless, due to increases in rent levels, 10 per cent fewer households received assistance in 2015 than in 2010 with the same amount of resources. Proposed budget cuts to HUD in 2017 do not bode well for HOPWA’s 2017 allocation. 

Table 4: HOPWA Funding Allocations, 2001-2017, in millions

Discussion of Key Challenges

In order to identify key barriers to accessing affordable housing, we conducted an extensive literature review as well as key informant interviews with fifteen stakeholders from seven of the eleven California HOPWA formula grantees. We contacted twelve administrators and ten community partners through a snowball sample. We first sent personalized emails to housing authority staff and community partners with whom we frequently interact. Then, we sent emails explaining the report’s purpose and requesting interviews with respondents from housing authorities who we did not know. When interviewees declined but offered different contacts or referred us to additional contacts, we sent outreach emails to these secondary contacts. A review of the available literature and content analyses of barriers, gaps, and challenges discussed with these stakeholders elucidated several themes, presented in Table 5.

Table 5: Key Barriers, Challenges, and Gaps

We generated six policy recommendations from our evaluation of the current landscape and challenges identified from the literature and key informant interviews. It is important to consider that with uncertainties in the current political environment, including the proposed $7.4 billion cut to the HUD budget, it is unlikely that the federal government will increase HOPWA and Section 8 funding allocations moving forward. California also has many complex barriers to overcome to increase the affordable housing supply. However, smaller policy changes within California’s housing and health care systems can marginally increase access to stable affordable housing for PLWH in California. Listed below are our policy recommendations, including strategies and activities for each.

1. Increased communication, collaboration, and system standardization between the state, local health jurisdictions, housing authorities, non-profit organizations and other community partners.
   • Establishment of data sharing among and within housing authorities and between housing authorities and public health departments to track clients in both systems.
   • Standardization of housing services within Metropolitan Statistical Areas.
   • Creation of a centralized, publicly accessible portal for waitlist times, vacancy rates, number of beds available in a Metropolitan Area, resource guides, etc.
2. Updating the Coordinated Entry System (CES).
   • Give HIV/AIDS a higher score on the VI-SPDAT, the scoring system used to prioritize chronically homeless individuals into housing.
   • Reduce documentation restrictions and increase flexibility within the chronically homeless definition for PLWH – for example, ‘couchsurfing’ for a few days would no longer deem a client ineligible for housing assistance.
3. Leveraging Other Programs.
   • Train housing authorities and non-profit organizations to develop an HIV acuity system to determine whether a client can more quickly obtain housing or supportive services based on eligibility unrelated to HIV status (veteran status, mental health diagnoses, survivor of domestic violence and/or sex work, etc).
   • Work with agencies who can provide services like safe medication storage or free cell phones for unstably housed clients to keep them in touch with housing navigators and case workers.
4. Increased Community Advocacy.
   • Urge community partners to monitor federal, state, and local “Getting to Zero” efforts and advocate for the inclusion of goals around access to stable affordable housing.
   • Raise the visibility of HIV as a public health crisis and the need to stably house PLWH in order to reduce transmissions.
   • Educate legislators, housing and health care officials, and community partners about the effect of stable housing on health outcomes.
5. Support for legislation aimed at increasing the affordable housing supply.
   • Adopt local legislation like Los Angeles’ Measures HHH and H to fund affordable housing construction and supportive services.³
   • Monitor California’s promise to invest $2 billion to reduce homelessness in the state.
   • Advocate for State Assembly and Senate bills that remove certain development and zoning restrictions, boost funding for construction of affordable housing units, increase tax breaks for renters, increase rent control, and establish a richer supportive services portfolio.^35,4
6. Targeted Research.
   • Conduct an analysis about best practices for increasing landlord participation. For example, making landlords accept government vouchers if the voucher covers the FMR.
   • Conduct an in-depth review of the administrative aspect of housing services to identify best practices for streamlining services, collaboration and standardization.

This policy brief provides a broad overview of the affordable housing crisis for PLWH and policy recommendations to better meet the need for housing among PLWH amid rising rents and declining federal funding. It reviews the funding streams for housing assistance and supportive services and highlights trends in housing affordability in California. Housing is incredibly complex, and more targeted research and data collection is needed to understand how to improve access to housing for PLWH without increased funding levels or construction of more affordable housing units. Access to stable, affordable housing is a critical component to ending the HIV epidemic. Understanding how to better integrate housing services within the HIV Care Continuum and collaborate across housing and health care systems will accelerate efforts to stably house a greater number of PLWH. California’s housing crisis is unlikely to disappear soon, but housing authorities, local health jurisdictions, and community partners have an important role in tackling the affordable housing shortage for PLWH.