AIDS Behav (2007) 11:S128–S139 DOI 10.1007/s10461-007-9250-7
ORIGINAL PAPER
Homelessness Prevention: The Effect of a Shallow Rent Subsidy Program on Housing Outcomes among People with HIV or AIDS Lisa K. Dasinger Æ Richard Speiglman
Received: 12 July 2006 / Accepted: 30 April 2007 / Published online: 19 June 2007 Ó Springer Science+Business Media, LLC 2007
Abstract This paper presents results of an evaluation of Project Independence (PI), a shallow rent subsidy program with services coordination support for very low income people with HIV or AIDS who live in Alameda County in the San Francisco Bay Area. By providing a small rental subsidy to eligible individuals and their families who are already stably housed, the philosophy of the program is to prevent homelessness before it starts. The housing outcomes of 185 PI clients were compared to those of 218 people who were not enrolled in the program but were presumed eligible for it, controlling for sociodemographic, HIV disease, and behavioral health characteristics. Using survival analysis techniques, non-program participants were found to be more likely to leave their rental housing at any given point in time compared to PI program participants. After one year of follow-up, while 99% of PI clients remained stably housed in their program-subsidized rental unit, only 32% of comparison group clients were still in rental housing. At two years, 96% of PI participants remained independently housed, compared to only 10% of non-participants. The success of the program suggests that Project Independence should be replicated and evaluated in other jurisdictions where a relatively high incidence and prevalence of HIV/AIDS is combined with a lack of affordable housing for low income households.
L. K. Dasinger (&) Division of Workers’ Compensation, Department of Industrial Relations, State of California, 1515 Clay Street, 18th floor, Oakland, CA 94612, USA e-mail:
[email protected] R. Speiglman Speiglman Norris Associates, Oakland, CA, USA
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Keywords Housing subsidy Homelessness HIV/AIDS Case management Survival analysis Hazard regression
Introduction Until recently, AIDS was considered a terminal disease from which most infected persons usually died within two years of diagnosis. With the development of new classes of antiretroviral medications and treatment regimens (HAART, or Highly Active Anti-Retroviral Therapy), improved clinical management, and earlier detection of the disease, HIV-infected and AIDS-diagnosed individuals now have a greater chance of experiencing better health outcomes and living longer than previously thought possible. However, even with these significant medical breakthroughs, the challenges facing people with HIV or AIDS are still numerous. One of the greatest of these is the challenge of maintaining a stable and affordable place to live. The ability to stay employed and maintain adequate health insurance can be seriously hampered for persons with HIV disease (Kass et al., 1994; Yelin, Greenblatt, Hollander, & McMaster, 1991). Loss of employment and health insurance can mean lack of financial resources to meet rent or mortgage payments, which may lead to homelessness, an inability to get or maintain proper medical care, and the subsequent worsening of the disease. Further, lack of stable housing, among persons living with HIV/AIDS as well as others, is associated with high rates of drug use and risky sex behavior (Aidala, Cross, Stall, Harre, & Sumartojo, 2005; Sethi et al., 2004), in turn increasing risks among the general population. There is also evidence of an association between change for the better in housing status and decline in risk-taking behavior
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(Aidala et al., 2005). A number of recent studies suggest that persons living with HIV/AIDS who are homeless or unstably housed are less likely to receive adequate medical care than those who are stably housed, putting them at risk for poorer health outcomes (Aidala, Davis, Abramson, & Lee, 2001; Aidala & Lekas, 1998; Aidala, Messeri, Abramson, & Lee, 2001; Smith et al., 2000). When they do obtain medical care, individuals with HIV/AIDS who are unstably housed or homeless find adherence to the HAART medication regimen particularly challenging (National Health Care for the Homeless Council, nd). Lack of housing has other effects on the costs of care and the system of care as a whole. Marginally housed and homeless individuals are more likely than stably-housed persons to use more expensive forms of care, such as emergency rooms (Arno et al., 1995) and inpatient hospitalization (Smith et al., 2000), and are less likely to use ambulatory care (Arno et al., 1995). Weissman et al. (1996) found that patients being treated for HIV/AIDS were more likely to be hospitalized if they were homeless. Bonuck and Arno (1997) also found that lack of housing was a significant factor affecting hospital discharge for persons with HIV/AIDS. Aidala and Lee (2000) examined factors predicting moving from an unstable to a stable housing situation, or maintaining a stable housing situation. Homeless persons were significantly more likely to get housing by their next interview if they received rental assistance or mental health services. Additionally, rental assistance and other housing services were the strongest predictors of maintaining housing. Substance use services, for persons with a drug history, contributed significantly to maintaining housing. In a multivariate analysis of the effects of services and housing assistance for unstably housed persons with HIV/ AIDS, services had some impact, but receipt of rental assistance was the strongest predictor of both obtaining housing and staying in housing once placed. In summary, ‘‘rental assistance was a necessary, but often not sufficient, condition for getting and maintaining housing among HIV/ AIDS-infected individuals’’ (Aidala, 2001). Recognizing the need to assist persons living with AIDS or HIV to either obtain housing or keep their current housing, AIDS and housing advocates nationwide have argued that special resources needed to be created for people living with AIDS that could be made available more quickly than traditional housing programs typically allow. To this end, a number of local jurisdictions have developed and implemented what are being called ‘‘shallow rent’’ subsidy programs. The term ‘‘shallow’’ is in contrast to the notion of a traditional ‘‘deep’’ subsidy – one that reduces the recipient’s housing expenses to a level that is deemed ‘‘affordable’’ by the federal government. In a deep subsidy program, such as the Section 8 Housing Choice Voucher
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program or Shelter Plus Care, the household receiving the subsidy typically pays the landlord no more than 30% of its gross income, adjusted for certain factors such as number of dependents, physical disability, extraordinary child care or health care expenses, and the cost of utilities. The subsidy program then pays the difference between the tenant payment and the full rent. In this way the housing is made ‘‘affordable’’ to the participating household. A shallow subsidy program, in contrast, sets a defined payment which the program provides, and the subsidized household must pay everything additional to complete the full rent, generally with no cap. Essentially, in a shallow subsidy program the program pays the same subsidy level for every household of comparable size, while in a deep subsidy program the amount paid by the program may vary significantly depending on the actual household income of each subsidy holder. In the case where the amount of the shallow subsidy is enough to allow the participating household to pay 30% or less of its adjusted gross income for housing, it is effectively acting as a deep subsidy program for that household. In most shallow subsidy programs, however, the amount the program pays is not enough to bring most participating households’ portion of the rent down to the affordability standard. Given the fact that waiting lists for Section 8 in many communities are five or more years long, coupled with the fact that people living with HIV/AIDS are at greater risk for faster progression of the disease and mortality if not living in a stable housing situation, AIDS and housing advocates have argued that shallow rent subsidy programs may provide a viable alternative to deep rent subsidy programs for some individuals. In addition, it was argued that with limited resources, providing the minimumrequired subsidy to keep a larger number of persons with AIDS housed may be preferable to providing deeper subsidies to fewer people. In response to the above state of affairs and advocacy efforts, the federal Department of Housing and Urban Development (HUD) created the Housing Opportunities for Persons With AIDS (HOPWA) program in 1992. Among other types of housing assistance programs, HOPWA funds are being used by some communities to cover the cost of shallow rent subsidy programs on the condition that communities offer a range of programs, including deep subsidies for those with greater needs, and that the status of persons receiving shallow subsidies be regularly reviewed to ensure that they are being adequately supported. This report presents the results of an evaluation of Project Independence (PI), a shallow rent subsidy program with services coordination support for very low income people with HIV or AIDS and their families who live in Alameda County, California. The evaluation covers about the first four and a half years of the program, from March
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1997 to October 2001. Two characteristics of the County during that time—a high AIDS case rate and a paucity of affordable rental housing for low income families—underscored the need, first identified in 1995, for a housing subsidy program that would help low-income HIV/ AIDS-infected individuals at risk for homelessness remain stably and independently housed. The Oakland Eligible Metropolitan Area (EMA), which covers both Alameda County and nearby Contra Costa County, is among the fifty-one metropolitan areas in the nation that are disproportionately affected by HIV/AIDS and receive emergency relief funding through the Ryan White CARE Act to provide primary care and support services for people with HIV disease. According to the Alameda County Health Department, there were 1,854 people with AIDS and an estimated 6,400 with HIV disease living in the County at the end of 1997. During the study period, the AIDS case rate in Alameda County exceeded both the state rate and the national rate. In 1999, the County rate was 17.0 new cases per 100,000 population, compared to a state rate of 11.5 and a nationwide rate of 9.3. Oakland was the hardest hit area of the County, accounting for 51% to 65% of new AIDS cases each year between 1980 and 2000 (Alameda County Public Health Department, 2001). In addition to the relatively high AIDS case rate, Alameda County suffers from a shortage of affordable housing for low income households. Fair Market Rents (FMR) for a one bedroom apartment in the county increased 16% during the study period from $633 per month in 1997 to $734 per month in 2001 (U.S. Department of Housing and Urban Development). It is easy to see that the limited income of many people with HIV/AIDS, many of whom collect Supplemental Security Income (SSI) or Social Security Disability Income (SSDI), simply is not enough to cover the cost of a rental unit in Alameda County. In 2001, for example, the monthly SSI payment was $531. Assuming no other income, for a single person household in 2001, the Section 8 Housing Choice Voucher program would require the renter to pay 30% of that income, or $159, toward rent. For a one-bedroom apartment renting at $734 per month, Section 8 would therefore pay $421 toward the rent. In contrast, Project Independence pays a fixed amount ranging from $175 to $425 a month, depending on the size of the household and the number of bedrooms. For the same rental unit, PI would pay $225 per month, therefore leaving $509—virtually the entire monthly SSI/SSDI benefit—to be paid by the individual toward rent. At the time this study was begun, Project Independence was one of eleven shallow subsidy programs operating across the nation, of which all but one served people living with HIV/AIDS. Five of the programs are in the State of California. The oldest of these programs began in 1996, indicating that this is still a relatively new programmatic
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approach. Many of the programs serving persons living with HIV/AIDS rely on HOPWA funding, although other sources being utilized include Ryan White AIDS CARE Act funds, city general funds, and private funding. The number of households served varied considerably, ranging from 16 families in Monterey, California to 565 households in Chicago. Subsidy amounts ranged from a low of $45 a month to as high as $500 a month, with the majority falling in the $150 to $300/month range. There is variation in the amount of time each program provides subsidies. Some programs provide only short-term subsidies. Chicago’s subsidies lasted only three months, though they could be extended for up to six months. In contrast, Denver’s Shallow Rent Program subsidies lasted as long as participants continued to qualify, though they were to be re-certified every 21 weeks. Like recipients of deep subsidy rental assistance, Project Independence clients may remain enrolled in the program for as long as they remain eligible for it. Project Independence is just one component of the AIDS housing continuum in Alameda County. The program developed out of a year-long community-based needs assessment and planning process which included the participation of AIDS services providers, housing developers, government staff, and persons living with AIDS. The program was developed in response to the findings of a 600 person survey conducted in 1995 of people living with HIV in the County, which found that almost half were at risk of losing their rental housing if their incomes dropped by as little as $100 a month. By providing a small rental subsidy to eligible individuals and their families, the philosophy of the program is to prevent homelessness before it starts. The evaluation was designed to answer the following questions: (1) How long do people in the program stay independently housed?; (2) Do people in the program stay independently housed longer than people who are not in the program but are eligible for it?; and (3) Besides program participation, are there other factors which predict how long low income people with HIV/AIDS remain stably and independently housed?
Description of Project Independence Overview Project Independence (PI) is a rental housing assistance program for very low income people living with HIV/AIDS in Alameda County, California. In existence since 1997, PI targets HIV positive individuals and their families who are already stably and independently housed in a rental unit in the County, but whose low income puts them at risk for homelessness.
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Subsidy Amounts Since its inception, at any given time the PI program has provided between 100 and 125 qualifying households with a monthly rental subsidy. The subsidy amount, unchanged during the program’s life, varies depending on household size, rent, and the income of the eligible household, but averages $225 per month. The maximum rental subsidy for PI is calculated using a simple matrix based on the number of bedrooms and household size, as shown in Table 1.1 Program Eligibility Criteria, Activities, and Requirements To be eligible for Project Independence, an applicant must have a diagnosis of HIV or AIDS, be 18 years of age or older (or be an emancipated minor), have an income at or below 50% of the area median income, have a lease on a rental unit within Alameda County, and be willing to engage in services as needed that promote independent living. At least 65% of households in the program are expected to have incomes below 25% of the area median income. Single individuals, adult couples, and families with children are all eligible for the program, although three-quarters of participants have been single adults. PI participants do not have to be disabled, have substance abuse issues, or have other problems to be eligible for the program, although having such presenting issues does not preclude enrollment in the program. Before receiving a subsidy, the rental unit must pass a federal housing quality standards (HQS) inspection, which determines that the unit meets minimum material and equipment conditions in order to ensure habitability, durability, health, and life safety. If an applicant’s unit does not pass the inspection, it can be repaired and re-inspected, or the applicant can choose to locate and move to another unit. In addition to the rental subsidy, participants are provided with limited case management services—termed ‘‘services coordination’’—provided by one of three nonprofit community-based ‘‘hub’’ agencies. Participants also have access to a range of community-based services for persons living with HIV/AIDS, including more intensive case management, primary medical care, food, mental health treatment, substance abuse treatment, peer counseling and other supportive services. These services do not differ from those available to other persons living with HIV/AIDS in Alameda County, but Project Independence
S131 Table 1 Project independence subsidy amounts Studio/0 bedroom 1 bedroom 2 bedroom 3 + bedroom 1 person $175
$225
2 people
$275
$325
3 people
$325
$375
$425
was designed to maximize the probability that participants will be made aware of the range of possible services and be assisted with gaining access to them. Contact with a services coordinator has been required on a quarterly basis, at minimum. Program Administration Project Independence is a collaboration of the County Housing and Community Development (HCD) Department and three non-profit ‘‘hub’’ agencies. Since the founding of Project Independence these three agencies have received Ryan White CARE Act funds, which are used to provide primary care and support services for people with HIV disease. The hub agencies accept program applications, issue the rental subsidy checks to landlords, and provide tenants with services coordination, including referrals to supportive services. HCD approves applications, coordinates the overall program, and, at the time of this evaluation, conducted HQS inspections. New applications are reviewed and processed on a first-come first-served basis as existing clients leave the program. Program Funding At the time this evaluation was conducted, Project Independence was funded by the Department of Housing and Urban Development (HUD) under the Housing Opportunities for Persons with AIDS (HOPWA) Special Project of National Significance (SPNS) competitive program. Project Independence was first funded in 1996 for a three-year period, and the first subsidies were provided in March, 1997. PI has been renewed for three additional three-year terms and is currently funded under a HOPWA Permanent Supportive Housing grant. For the first two of the three renewals the grant included funding to conduct a research study of the impact and effectiveness of the PI program; this study reports on the first of those. Method
1
The subsidy is actually the lesser of the maximum subsidy and the difference between the rent and 30% of the household’s adjusted gross income. In 80% of cases, the qualifying household receives the maximum. Only if the maximum subsidy causes the household to pay less than 30% of its adjusted income for rent and utilities is the subsidy lower.
Research Design Using a quasi-experimental retrospective longitudinal comparison group design, the study compares the housing
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outcomes of PI program participants to those of individuals in a comparison group who appear to meet the requirements of the program but are not enrolled in it. The outcome evaluated is the duration of time individuals in both groups remain in rental housing while continuing to meet the income requirements of the program, controlling for sociodemographic, HIV diagnosis, and behavioral health characteristics. The maximum length of follow-up for any individual was four years eight months, the time from program inception to final data collection for the evaluation. Measures An electronic database maintained by HCD provided demographic and program participation data for Project Independence participants, including age, gender, race/ ethnicity, stage of HIV disease at program entry, city of residence, household size, total monthly household income, income level ( £ 25% area median income (AMI) or 26– 50% AMI), size of rental unit (e.g., studio, 1-bedroom), total monthly rent, amount of rental subsidy, program entry and exit dates, and reason for exit, if applicable. Additional information on Project Independence clients was obtained from the Alameda County Public Health Department Office of AIDS Administration (OAA) database, which contains data on people who receive Ryan White-, HOPWA-, and/or county-funded HIV/AIDS-related direct services. This database was also used to obtain a comparison group for the study. The OAA database consists of data collected on ‘‘Client Intake Forms’’ that are submitted by each HIV/ AIDS service provider in the county to OAA once each fiscal year for each client who received services at that agency during the year. Entry of this document into the database creates a separate record for each client for each agency for each contract year in the database. In addition to providing demographic information comparable to that available from the HCD database, the OAA database contained the following variables that were used in this evaluation: primary language, HIV transmission categorie(s), month/year of first positive HIV test, household composition, presence of other presenting issues (substance abuse, mental health, STD, hepatitis, tuberculosis, homelessness), and current housing status. An anonymous client ID, which appears both in the HCD and the OAA databases, was used to identify records that pertained to Project Independence cases to obtain supplemental information about them, and to exclude them from the comparison group.
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The comparison group was drawn from the OAA dataset, which consisted of 19,003 intake records representing 5,565 unique client IDs. Intake dates ranged from January 1997 to July 2001. The comparison group was selected in the following way. First, the earliest intake record in the OAA database for which all of the following were true was used to select a group of individuals eligible for the comparison group: (1) intake date ‡3/1/97, the first month PI subsidies were issued; (2) intake occurred at one of the three hub agencies; (3) HIV positive or AIDS diagnosis; (4) ‡18 years of age; (5) household size £ 5, the largest household size of PI households; (6) total household income £ 50% AMI, adjusted for household size and intake date; and (7) living in rental housing or apartment/house. Cases were excluded if, on the same intake record, any of the following applied: (1) ‘‘living with relatives/friends,’’ suggesting the individual may have been doubled up with others rather than living independently; (2) client IDs partially matching those of PI clients’, to safeguard against including a PI client who had more than one client ID in use, due to typos and other factors. Cases without at least one later intake record where housing status and income were known were excluded. For remaining cases, the most recent intake record for which housing status and income were known, where no intervening records existed with unknown housing status and income, was chosen. This was so that a longitudinal measure of length of time in rental housing and the income eligibility of the individual for the program could be calculated for members of the comparison group. After application of the above criteria to the OAA database, only 238 client IDs, or 4.3% of all client IDs, remained for inclusion in the comparison group. Most clients were excluded from the comparison group because they were never in rental housing or their housing status was unknown. Fewer clients were excluded because they had only one intake record in the OAA database or had missing data on income or household composition, which made the determination of income level, and hence PI eligibility, impossible. It is important to note that eligibility of comparison group members for PI is unknown in four areas: whether the client held the lease on the rental unit, whether the rental unit met HUD housing quality standards, the rent amount and its relationship to HUD fair market rents and the client’s income, and the willingness of the client to participate in services needed for independent living. The comparison group may therefore have contained some individuals who would not have been eligible for the program.
Participants Data Analysis HCD provided a final dataset for this evaluation on October 26, 2001, by which time a total of 256 client-households had been served by the program since March 1, 1997.
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The analytic technique used for the evaluation is Cox proportional hazards regression, a time-to-event or survival
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analysis technique (Cox & Oakes, 1984). As its name implies, survival analysis was developed in the context of studying time to death, disease onset, or disease recurrence among clinical populations, typically in evaluating the effectiveness of a given treatment. Clinical trials typically measure the length of time from study entry to a disease endpoint—the ‘‘event’’—for a treatment and a control group. Time-to-event (survival) analysis allows inclusion of patients who fail to complete the trial or do not reach the study endpoint before the study ends (censored data) by making comparisons between the number of survivors in each group at multiple points in time. Survival analysis techniques are especially important since excluding patients who do not reach the endpoint from the analysis could introduce considerable bias because the length of survival for these patients prior to study exit is important information that contributes to the power and validity of the study. The main results of a Cox analysis are typically described in two ways. Time-to-event curves, also called cumulative survival curves, provide estimates of the proportion of individuals in each group still ‘‘surviving’’ at any given point in time after study entry through the study’s maximum follow-up period, where everyone’s ‘‘start time’’ is standardized to time ‘‘zero.’’ The ‘‘relative hazard,’’ also called the ‘‘hazard ratio,’’ is a number that indicates the instantaneous increase or decrease in risk of experiencing the study event at any given point in time relative to a baseline reference group, e.g., the treatment versus control group. The hazard ratio cannot be used to describe how much faster/sooner this event may occur, but only the instantaneous relative risk of it occurring for one group compared to another. Hazard ratios greater than one indicate an increased risk of the event occurring and ratios less than one a decreased risk. An assumption of proportional hazards regression is that the hazard ratio is constant over time. In the context of this evaluation, the outcome of interest is the time an individual remains independently housed in a rental unit after entrance into the study. The event of interest is therefore loss of independent, rental housing. For the Project Independence and the comparison group, loss of housing included living with relatives/friends, in a hotel/ motel, or in transitional housing, being homeless (in emergency shelter or on the streets), residing in a psychiatric, substance abuse treatment, hospital or other medical facility, residing in jail/prison, or ‘‘other’’ at last observation. For Project Independence clients, loss of housing also included moving into Section 8, Shelter Plus Care, or some other form of deep subsidized housing, being evicted or losing the lease, or living in ineligible housing. The study follows individuals from the time they either entered the program (PI participants) or the study (comparison
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group), when first observed to be housed in a rental unit and eligible for the program, until their housing status changed, or until follow-up data are no longer available. For those still independently housed in a rental unit at the time of last observation, the ‘‘true’’ survival time is only known to be a value greater than the time observed from study entry to the last observation. For these individuals, the time-to-event duration is unknown, and the final observation is said to be ‘‘censored.’’ We do not know how much longer the individual remained or will remain in their current housing situation after the final observation. Housing outcomes were also considered censored if (1) the individual became income ineligible for the Project Independence program at last observation, i.e., household income exceeded 50% AMI, (2) the individual left the County, or (3) the individual died. The latter two conditions were only known for PI clients. Individuals with censored housing outcomes contribute data to the computation of the survival curve up until the time right before their final observation date. All available variables were individually tested for their association with time remaining in rental housing using the Cox method. Variables with a significant association with housing outcome in bivariate survival analyses (P £ .10) or, as with age, which are commonly used as a control variable, were retained for the final analyses presented here. All analyses were conducted using SPSS version 11.0. The research was approved by the institutional review boards serving the Public Health Institute (Oakland, CA) and Speiglman Norris Associates (Oakland, CA).
Results We first describe sociodemographic, income, HIV status, and behavioral health characteristics of PI participants and members of the comparison group. We then present the results of a multivariate survival analysis of the effect of program involvement (Project Independence vs. Comparison Group) on the length of time in independent rental housing while controlling for other key factors. Deidentified names are used for the hub agencies (A, B, and C) so as not to single out any particular hub agency as ‘‘better’’ or ‘‘worse’’ in terms of producing a positive housing outcome. Both the descriptive and multivariate analyses are limited to individuals with no missing values on all the variables of interest. This resulted in a sample size of 187 for the Project Independence group and 219 for the comparison group. Most (91%) of the 69 PI clients lost from the analysis had no data on other presenting issues in the OAA database during the time they were enrolled in PI. Since including these cases in the analysis and dropping the variables for other presenting issues did not change the
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significance and/or effect size of other variables in the analysis, the model with more variables and fewer cases is presented here. Table 2 shows that the PI group and the comparison group did not statistically differ in terms of age, presence of substance abuse issues, or hepatitis. Sociodemographically, members of the comparison group were more likely to be female (32.4% vs. 21.4%), black (72.6% vs. 59.9%), living with others (54.8% vs. 23.0%), have a household income at or below 25% of the area median income (90.0% vs. 64.7%), and be unemployed during their time in the study (87.7% vs. 76.5%). Regarding health characteristics, they were more likely to have AIDS (92.7% vs. 59.9%), and to have purportedly contracted HIV through intravenous drug use (34.7% vs. 18.7%), but less likely to have self-identified as having a mental health issue (21.9% vs. 39.6%). In addition, almost all comparison group clients’ baseline intake was conducted at hub agency A (94.1%) compared to 38% of PI clients. No comparison group client had an initial study intake at hub agency C. This distribution of comparison group clients among the hub agencies is not surprising, given the distribution of intakes among the three hub agencies represented in the OAA database. To the degree that each of the variables in Table 2 has an impact on length of time in independent rental housing, it is important to control for these variables in the multivariate analysis. Table 3 shows the results of the multivariate survival analysis. Since there were no statistically significant differences between White, Asian/Pacific Islander, and Native American clients on housing outcome in the bivariate analysis, and the sample size of the latter two categories was too small to treat them as separate groups, these were placed into a single category. The analysis also excludes clients with ‘‘other’’ gender, due to small sample size, resulting in 185 PI clients and 218 comparison group clients included in the final analysis. By far the most significant predictor of time remaining in independent rental housing, while controlling for other variables in the analysis, is program status. Members of the comparison group were 3.83 times more likely to lose their rental housing at any point in time after entrance into the study than Project Independence participants (P < .001). Smaller but significant effects were seen for the impact of hub agency, race/ethnicity, employment, mental health, and hepatitis on the risk of leaving rental housing. Age, gender, living alone, household income level, history of injection drug use, stage of HIV disease, and having a substance abuse issue, although significant in bivariate analyses, were not associated with the risk of losing rental housing in the multivariate analysis. The hub agency through which individuals entered the study was significantly associated with the risk of losing
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rental housing, independent of enrollment in PI. PI and comparison group individuals who enrolled through Hub Agency B had a decreased risk of 0.53 times that of Hub Agency A clients of losing their rental housing at any given point in time (P < .05). The risk of leaving rental housing among clients of Hub Agency C was 0.16 times the risk among Hub Agency A clients (P < .01). Possible reasons for these observed differences are the following: (1) clients served by each agency may have differed systematically in ways relating to housing outcome which were not measured in this study, e.g., more disadvantaged, harder to serve, or more precariously housed, (2) hub agencies may have differed in levels of case management, services coordination, other operating practices, and/or the provision of other services that affect a client’s ability to remain housed, and (3) in terms of PI clients, the hub agencies may have applied differential selection criteria when recommending clients for the program, biasing the results toward a more or less favorable outcome. Compared to White, Asian/Pacific Islander, and Native American clients, the risk of losing rental housing was 1.54 times greater for Black clients (P < .10) and 2.61 times greater for Hispanic clients (P < .01). Whether these differences are attributable to cultural differences in preferred living arrangements, discrimination, the kinds of services received, or other factors is unknown. Among members of the comparison group, Blacks and Hispanics who lost their rental housing were more likely to end up living with relatives and friends than Whites, Asian/Pacific Islanders and Native Americans (data not shown).2 Of Blacks who left rental housing, 36.3% indicated ‘‘lives with relatives/ friends’’ on the final client intake form used for the last observation in the analysis, and of Hispanics, 55.6% mentioned this living arrangement. Only 13.6% of Whites, Asian/Pacific Islanders, and Native Americans who left rental housing had this final housing outcome. Although from the perspective of the goals of Project Independence, doubling up with friends and relatives is a ‘‘negative’’ outcome, it may be preferred by some individuals—perhaps among certain racial/ethnic group lines—to living alone and/or independently. Clients who were not employed during their time of observation in the study had an increased risk of leaving rental housing that was 1.41 times that of individuals who had a part-time or full-time job at some point during participation in the study (P < .05). Employment may be associated with a number of factors which increase the ability of an individual to remain stably housed, for example, greater levels of self-sufficiency, health, and selfadvocacy that enable the client to secure needed services and supports to stay housed. 2
Comparable data on the PI participants are not available.
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Table 2 Characteristics of Project Independence versus comparison group clients
Project Independence (N = 187)
Comparison Group (N = 219)
%
%
N
P
N
Age 18–30
9.6
18
7.8
17
31–50 51+
78.6 11.8
147 22
82.6 9.6
181 21
Female
21.4
40
32.4
71
Male
77.5
145
67.1
147
Other
1.1
2
0.5
1
Gender
*
Race/Ethnicity
*
White
27.8
52
19.6
43
Black
59.9
112
72.6
159
Hispanic
8
15
5.9
13
Asian/Pacific Islander
3.7
7
0.5
1
Native American
0.5
1
1.4
3
Lives Alone
***
Yes
77
144
45.2
99
No
23
43
54.8
120
90 10
197 22
Household Income £ 25% AMI 26%–50% AMI
*** 64.7 35.3
121 66
Yes
23.5
44
12.3
27
No
76.5
143
87.7
192
HIV+
40.1
75
7.3
16
AIDS
59.9
112
92.7
203
Yes
18.7
35
34.7
76
No
81.3
152
65.3
143
Employed PT or FT
**
HIV Status
***
Injection Drug User
***
Substance Abuse Issue Yes
25.7
48
22.4
49
No
74.3
139
77.6
170
39.6 60.4
74 113
21.9 78.1
48 171
Mental Health Issue Yes No
***
Hepatitis Yes
16
30
13.2
29
No
84
157
86.8
190
A
38
71
94.1
206
B
30.5
57
5.9
13
C
31.6
59
0
Hub Agency * P \ .05, ** P \ .01, *** P \ .001 (Pearson chisquare)
***
The risk of losing rental housing for individuals with a mental health issue was 0.59 times the risk for individuals without a mental health issue (P < .05). Similarly, presenting with hepatitis was associated with a decreased risk
0
of losing rental housing of 0.44 times (P < .01). One possible explanation of these findings is that these individuals, by virtue of self-disclosing a mental health or hepatitis issue, may be more likely to get help with these
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Table 3 Results of multivariate survival analysis of the effect of program participation and other variables on time in independent, rental housing Variable
Hazard Ratio
95% Confidence Interval
1 3.83***
2.79–5.25
Program-related variables Program status Project Independence Comparison Group Hub agency A
1
B
0.53*
0.29–0.97
C
0.16**
0.05–0.54
Sociodemographic variables Age 18 – 30
1
31 – 50
1.48
0.79 – 2.76
51+
1.21
0.56 – 2.61
Gender Female
1
Male
1.21
0.83 – 1.77
White, Asian, or Nat. Am. Black
1 1.54
0.97 – 2.44
Hispanic
2.61**
1.29 – 5.28
Race/Ethnicity
Client Lives Alone No
1
Yes
1.28
0.91 – 1.80
Household Income £ 25% MFI 26%–50% MFI
1 1.01
problems. The help received, in the form of additional case management or other services, may in turn facilitate staying stably housed, on its own or through its association with other services received. The group of people who did not present with a mental health or hepatitis issue may have included individuals who actually had these problems, but by lack of self-disclosure, did not receive needed help. Self-disclosure of a behavioral health issue may be associated with a greater level of self-advocacy. Figure 1 shows the estimated proportion of people remaining independently housed in a rental unit over time as a function of program status (Project Independence vs. comparison group), while controlling for all other factors in the multivariate analysis. The graph presents a striking picture of the positive impact of Project Independence on keeping individuals stably housed. After half a year of follow-up, 99% of Project Independence clients were still in rental housing compared to 65% of comparison group clients. After one year of follow-up, while 99% of Project Independence clients were still in their PI-subsidized unit, only 32% of comparison group clients were still in rental housing. At two years follow-up, the percentage of Project Independence clients estimated to be in rental housing remained high at 96%, while the percentage of comparison group clients still in rental housing had dropped to 10%. Unadjusted for other variables, the average time in rental housing for program participants was 1,416 ± 77 days, or 3.9 years. The corresponding figure for individuals in the comparison group was 372 ± 58 days, or 1.0 years
0.79 – 1.29
Employed PT or FT Yes
1
No
1.41*
1.0
1.03 – 1.92
HIV-related variables Injection drug user Yes Stage of HIV Disease
.8
1 1.25
AIDS Diagnosis
1
HIV+, not AIDS
1.21
0.86 – 1.81
0.71 – 2.06
Other Presenting Issues Substance Abuse No
1
Yes
1
C u m u l a t i v e S u r v i v al
No
.6
.4
Program Status Project Independence
0.62 – 1.60
Comparison Group
.2
Mental Health No
1
Yes
0.59*
0.36 – 0.95
Hepatitis No
1
Yes
0.44**
* P < .05, ** P < .01, *** P < .0001
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0.0 0
1
2
3
4
Time in rental housing (years) 0.24 – 0.80
Fig. 1 Survival function by program participation, adjusted for all other variables
AIDS Behav (2007) 11:S128–S139
Discussion The results of this evaluation provide strong support for the success of the Project Independence Program in meeting its objective of keeping low income people with HIV/AIDS and their families independently housed. The average time in rental housing for program participants, unadjusted for other variables, was 3.9 years, for the nearly five years since the program began in March 1997 to October 2001. When adjusted for sociodemographic, HIV disease, and behavioral health characteristics, members of a comparison group of individuals who met program eligibility criteria but were not enrolled in the program were 3.8 times more likely to leave their rental housing at any given point in time compared to Project Independence program participants. After one year of follow-up, an estimated 99% of Project Independence clients were still living in their rental unit, compared to only 32% of comparison group clients, adjusted for sociodemographic, HIV-related, and behavioral health factors. At 2 years follow-up, only 10% of comparison group clients were still housed in a rental unit, compared to 96% of Project Independence participants. The hub agency through which the client was enrolled into the study was also found to be associated with time remaining independently housed in a rental unit. Further investigation of the reasons accounting for the observed hub agency differences in housing outcomes is needed in order to maximize the success of all clients in maintaining their housing. Although the independent influence of receipt of services coordination support, case management, or any other kind of service, on housing outcome could not be studied due to lack of readily available data, evidence from another study provides some support for the added beneficial effect of services. In the study by Aidala and Lee (2000) of 600 people with HIV/AIDS living in New York City, social services were found to have some impact on the maintenance of a stable housing situation, although receipt of a rental subsidy had a bigger impact. Further studies are needed to determine the degree to which additional client characteristics and the uptake of the services coordination component of the program, as well as utilization of other kinds of services, affect housing outcomes. In a later evaluation of the Project Independence program, which studied housing outcomes among PI clients only over a longer time frame (from March 1997 to December 2005), the effect of hub agency was no longer significant (Speiglman & Dasinger, 2006). This study found that clients who enrolled in the program later were more likely to remain successfully housed for a longer period of time than those who had enrolled earlier. Interviews with hub agency and other program staff suggest that program implementation or start-up issues, and a more open application process, with less attention to or under-
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standing of who would best be served by the program, may partly account for the hub agency differences seen in the program’s earlier years. A third potential factor mentioned by key informants is that treatment of the disease was not as good in earlier as in subsequent years. In addition to program-related factors, a number of other client characteristics significantly predicted length of time in rental housing, namely, race/ethnicity, employment, and presenting with a mental health or hepatitis issue. Hispanics were 2.6 times more likely to leave rental housing at any given point in time and Blacks were the 1.5 times more likely compared to Whites, Asian/Pacific Islanders and Native Americans. Many factors, whether a product of client attitudes, expectations, and behaviors, attitudes and behavior of landlords, or other, ‘‘environmental’’ conditions, could have contributed to observed differences by race/ethnicity. However, it is noteworthy that findings from other examinations of what is termed ‘‘housing dynamics’’ differ from ours. Generally, Black and Hispanic recipients of housing assistance are less likely than others to leave the housing subsidies. In a sense, they ‘‘conserve’’ the available housing resources. Using a hazard model from late 1980’s Survey of Income and Program Participation (SIPP) data to estimate tenure in housing programs, Hungerford (1996) found that, compared to others, Blacks were significantly less likely to depart subsidized public housing (P < .10) and, though not significantly so, also less likely to leave subsidized rental housing. More recently, relying on stratified, random samples of recipients of assistance in the 1995–2000 period from the Department of Housing and Urban Development through the Multifamily Tenant Characteristics System and Tenant Rental Assistance Certification System databases, Ambrose (2005) found stronger results: African-American households have a much lower probability of leaving both public housing and tenant-based assisted housing programs, compared with White households. Hispanics, compared with non-Hispanics, are significantly less likely to depart assisted housing. They are also less likely to leave public housing (P < .10). Finally, Olsen, Davis, and Carrillo (2005) report similar findings in their study of HUD data for the 1995 to 2002 period. The interpretation is that Blacks and Hispanics, like other groups with relatively fewer social options, exhibit greater tendencies to retain subsidies. Although we have no data to directly interpret our contrary race/ethnicity finding, we believe research on this matter is critically important. Very low income people living with HIV or AIDS receiving housing assistance through the Project Independence program arguably face even more challenges than other populations of individuals who receive housing assistance. In that context, compared to the situation for Whites, an array of biographical and
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societal conditions may have a greater limiting influence on Black and Hispanic clients’ ability to access the kinds of services and/or supports necessary to maintaining stable—and subsidized—housing. Having a part- or full-time job was associated with a decreased risk of losing rental housing, as was having a disclosed mental health or hepatitis issue. These variables may each be associated with a higher level of self advocacy and/or self-sufficiency, which in turn are associated with obtaining the kinds of services and supports that are necessary to maintaining stable housing. The main limitation of the study is that the comparability of the comparison group and the Project Independence group is not entirely known. Among members of the comparison group, no information was available about rent amounts, quality and size of the unit, or whether the client’s name was actually on the lease. Nor was it known whether comparison group members were committed to engaging in activities that would facilitate living independently. Comparison group members may have been paying a larger share of their household income toward rent, in comparison to Project Independence participants both before and after receiving the rental subsidy, which would put them at more of an economic disadvantage. Although an attempt was made to limit the comparison group to clients who were living independently by excluding individuals whose initial eligible intake indicated ‘‘living with relatives/friends,’’ this was no guarantee that the client was actually on a rental lease agreement and living independently. Members of the Project Independence group may also have been in stable housing before entering the program longer than comparison group clients when they were entered into the study. Interestingly, most (94%) comparison group members were clients of the hub agency which showed the poorest housing outcomes. The housing outcomes for clients at that hub agency may have been confounded with other client and/or hub agency characteristics that were not measured in this study, but which were associated with poorer housing outcomes. Another study limitation is the relative lack of precision in the measurement of time in rental housing for comparison group clients versus Project Independence clients. Unlike the PI clients, whose continued participation in the program was dependent upon hub agencies’ verification of the client’s housing situation throughout program participation, the housing situation of comparison group clients was only known at the moment of intake at the communitybased agencies at which they received services. It was therefore not possible to know exactly when a comparison group member’s housing status changed. The program departures of PI clients who left the county were treated as non-failure outcomes, assuming that the clients’ moves represented greater self-sufficiency. In fact, we have no
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data on the situations in which former clients found themselves. It is probable that some departures were to less independent and less stable settings. These measurement errors produce both under- and overestimates of time in rental housing among both groups. Despite the limitations of the study, the large difference in housing outcomes observed between the Project Independence group and the comparison group strongly support the conclusion that Project Independence is successful at helping low income HIV/AIDS-affected households remain independently and stably housed. The importance of a Project Independence-type subsidy also rests in the fact that it can be made available relatively quickly to a large number of individuals. In comparison, a deep rental subsidy such as Section 8 requires a much larger sum of money to help the same number of people. Nevertheless, the Project Independence evaluation did not benefit from a randomized, controlled design. Given the ethical challenges and other difficulties in fielding such rigorous studies, we believe it would be appropriate to replicate—and evaluate—the Project Independence program in other areas of the state and country experiencing a relatively high incidence and prevalence of HIV/AIDS combined with a lack of affordable housing for low income households. We note that the model of a shallow rental subsidy plus services coordination may prove relevant for other populations. Demonstration programs which include an evaluative component might apply the Project Independence model to any number of client groups. We would encourage prospective studies, with more comprehensive data collection across a number of factors, including some follow-up of clients departing the program. Project Independence and other housing programs can be evaluated not only in terms of effects on stable housing and the prevention of homelessness but also in terms of their effects on maintaining or improving health and avoiding unnecessary high cost health care such as hospitalization. Elsewhere, housing has been found to predict lower HIV risk and less risk of transmission of HIV as well as improved health outcomes. Another approach, which has been considered but not yet implemented in Alameda County, would involve studies that examine clients’ versus controls’ access to and utilization of health-related and other services and measure the cost-effectiveness of Project Independence. Each of these topics is addressed in a recent policy paper from the National AIDS Housing Coalition (2007), which considers housing a ‘‘promising structural intervention to prevent and treat HIV’’ (p. 5). Whether considering housing outcomes, HIV transmission, the promotion of positive health outcomes, appropriate use of outpatient, emergency, and inpatient services, or cost effectiveness, shallow rent subsidy programs with associated supportive services should be examined in comparison
AIDS Behav (2007) 11:S128–S139
to other housing models: deep subsidy programs, housingfirst programs, and programs with more, and less, supportive services. Where causal effectiveness in preserving housing and health—of HIV seropositive people as well as others—as a result of these programs can be demonstrated, additional support will be generated and more individuals at risk of losing housing will be assisted so that they can keep their homes and protect their own and the community’s health. Acknowledgments This paper is based on an evaluation of Project Independence that was completed by the authors in 2002 with funding from the Alameda County Community Development Agency, Housing and Community Development Department (HCD), through a Housing Opportunities for Persons with AIDS Program (HOPWA) Special Project of National Significance (SPNS) competitive grant from the Department of Housing and Urban Development (HUD) to HCD. HCD subcontracted with the Public Health Institute to perform this initial evaluation (Contract# SPNS99-04). Additional funding for this paper was provided by a HOPWA Program Permanent Supportive Housing Renewal grant from HUD to HCD and a subcontract with Speiglman Norris Associates for a follow-up evaluation of Project Independence (Contract # C-2005-207). We would like to thank the following current or former HCD and Alameda County Office of AIDS Administration officials who assisted with the evaluations: Katharine Gale, Linda Gardner, Laura Hansen, Tom Mosmiller, Sandra Pastermack, Hazel Weiss, and Riley Wilkerson. Over the course of this study several of the Alameda County officials served as invaluable sounding posts and, along with the editor and two anonymous reviewers, very helpful critics.
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