NEW HAMPSHIRE
AIDS HOUSING NEEDS AND
RESOURCE ASSESSMENT:
FINAL REPORT AND
ACTION PLAN
Prepared by
Jonathan Sherwood, PhD and
Anne Siegler,
AIDS Housing Corporation
Boston, MA
In collaboration with
Alison Paglia and
the NH HIV Community Planning Group
The research, development, and publication of this manual was funded by the Housing
Opportunities for People with AIDS (HOPWA) National Technical Assistance Program in
partnership with the U.S. Department of Housing and Urban Development’s Office of HIV/AIDS
Housing. The substance and findings of the work are dedicated to the public. The authors and
publisher are solely responsible for the accuracy of the statements and interpretations contained
in this publication. Such interpretations do not necessarily reflect the views of the Government.
AIDS Housing Corporation
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January, 2006
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TABLE OF CONTENTS
EXECUTIVE SUMMARY
3
INTRODUCTION
6
SECTION I: PERSONS LIVING WITH HIV/AIDS
IN NEW HAMPSHIRE: A PROFILE
9
SECTION II: OVERVIEW OF AIDS RELATED
RESOURCES: LOCAL AND NATIONAL
11
SECTION III: NEED FOR HOUSING RESOURCES
AMONG PERSONS WITH HIV/AIDS
IN NEW HAMPSHIRE
20
SECTION IV: BARRIERS TO HOUSING FOR
PERSONS WITH HIV/AIDS
IN NEW HAMPSHIRE
25
SECTION V: ASSESSMENT OF HOUSING
RESOURCES AND GAPS IN SERVICES
30
SECTION VI: CONCLUSIONS AND
RECOMMENDATIONS
38
SECTION VII: ACTION PLAN
41
APPENDICES:
A: HOPWA GRANT MANAGEMENT
B: HOPWA AND CARE ACT SERVICE AREAS
C: FOCUS GROUP AND SURVEY DATA TABLES
D: FOCUS GROUP MATERIALS
E: LIST OF KEY INFORMANTS
F: SURVEY MATERIALS
51
56
58
61
66
67
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EXECUTIVE SUMMARY
This report, commissioned by the State of New Hampshire’s CARE Planning Group and
funded by the Planning Group and by the U.S. Department of Housing and Urban
Development’s Housing Opportunities for Persons With AIDS (HOPWA) program, is an
assessment of the housing needs of people living with HIV/AIDS throughout the state of
New Hampshire. The report includes an overview of the housing related needs of people
living with HIV and AIDS in New Hampshire; the resources, both federal and local,
available to meet those needs; the barriers that some experience in trying to access the
available resources; an analysis of the adequacy of the state’s existing resource in
meeting the housing needs of persons with HIV/AIDS; and a plan for future action.
The number of HIV infections in New Hampshire continues to rise. At the end of 2004
there were a total of 978 people living with HIV/AIDS.1 Latest statistics suggest a 15%
increase in HIV/AIDS incidence statewide over the past three years. At the same time,
housing costs also continue to rise. Statewide, the median cost to rent a two-bedroom
apartment rose 4.9% in the past year, and has increased by more than a third over the past
five years.2 People with HIV are disproportionately affected by this housing squeeze; of
the sample of people living with HIV that completed our survey, nearly half lived below
the poverty line and more than 70% reported using emergency financial assistance to
make their rent.
The consequences of these coinciding trends are clear. Studies consistently show that
without stable housing, people with HIV are less able to access medical care and are less
likely to improve their health. Taking this as our backdrop, housing resources play an
integral role in the service planning and provision for people living with HIV.
Several programs in New Hampshire meet the housing needs of people living with
HIV/AIDS.
1
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Through a state HOPWA grant in Manchester, 117 individuals and their families
received rental assistance over the past year. Fifty-five received case
management services, and 216 received housing information services.
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A second state HOPWA grant based in Concord but funding services across the
state provided housing assistance to 145 persons, enabling them to maintain their
housing. Case management services assisted 112 persons, and housing
information services assisted 338 persons.
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A final HOPWA grant through Harbor Homes, Inc. provided direct rental
assistance to 49 people over the past year in the greater Nashua area. The grant
also provided for supportive services to an additional 19 people.
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Ryan White CARE Act Title I monies from the Boston Public Health
Commission also support housing activities in 3 counties in southern New
Hampshire.
HIV/AIDS Surveillance Report through December 31, 2004. NH DHHS. February 2005.
Emergency Shelter and Homeless Coordination Commission Annual Report, NH DHHS, 2004.
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2
The findings from this report show that while these programs provide an invaluable
resource for people living with HIV/AIDS in New Hampshire, there remain gaps of
unmet need. In some cases, there are simply not enough resources available. This report
finds that there is significant unmet need for long-term rental assistance, and partially
unmet need for housing information and advocacy as well as supplementary resources
that stabilize households. In other cases, resources exist but are inaccessible to some.
Barriers to housing resources found in this study include geographic isolation,
unsuitability of the housing resource, and ineligibility due to poor credit, criminal history,
or immigration status.
Looking forward, we offer four basic recommendations that draw on the findings of the
paper and suggest concrete ways of filling unmet need.
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We recommend that HOPWA grantees increase the amount of long-term rental
assistance in their HOPWA grants. All of the current HOPWA grants are below
the budget cap set by HUD, and this report suggests a significant unmet need for
long-term rental assistance. This increase can be done in HOPWA grant
renewals, perhaps in partnership with the New Hampshire Housing Finance
Agency.
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We acknowledge that emergency rent and utilities assistance provides a vital role
in homelessness prevention, and recommend that it continues to be provided at
the current level. Given the extremely high utilization rates of this resource
across the state, however, it may be that some households that access this resource
regularly could be better served by permanent long-term rental assistance. We
encourage HOPWA grantees to reconsider these cases of ongoing utilization of
emergency rental assistance and reiterate the need for increased permanent
affordable housing resources, in order to relieve the chronic need for emergency
assistance.
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We recommend increased housing information and advocacy resources. In-depth
knowledge of housing resources and housing advocacy skills is essential for
connecting consumers to available resources. Recognizing the complicated nature
of navigating the worlds of subsidized housing and tenant-landlord legal issues,
we recommend the provision of periodic housing information and advocacy
trainings for case managers across the state.
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AIDS service organizations should actively participate in the local and state
Continua of Care in order to ensure the needs of people living with HIV are
included in the planning of homeless services.
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Stakeholders in the provision of AIDS services address the State of New
Hampshire and the legislature regarding the need for increased state funding and
coordination of services and resources.
Close attention should continue to be paid to the web of other resources that people living
with HIV/AIDS rely upon to achieve housing stability. These resources, such as food
pantries and fuel assistance, are unevenly distributed around the state at the expense of
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those living in rural areas. This attention will be important especially as the programs
that fund a large part of these resources, such as HOPWA and the Ryan White CARE Act
Title 1, are likely facing changes in the near future. Agencies that serve people with HIV
should be aware of these possible changes and consider how these and other resources are
used and distributed.
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January, 2006
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INTRODUCTION
Access to stable, affordable housing is an important factor in the ability to access medical
and social services. Indeed, various studies have suggested that the lack of a stable
housing situation is the primary obstacle for people with HIV/AIDS in accessing primary
health care. As a recent national HRSA study concluded, “Housing Is Health Care”. The
Voices of Experience 2003 study, prepared for the Boston Public Health Commission
Title I Planning Group, found that among people living with HIV/AIDS in New
Hampshire, “getting stable and affordable housing” was one of the top five needs. As
one focus group participant put it for this report, “if I don’t have housing, I can’t receive
any other services.” In trying to understand the service and medical needs of people
living with HIV/AIDS in New Hampshire, it is therefore important to understand housing
needs as well.
The purpose of this needs assessment on housing aims to explore four main questions:
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Is there currently a need for housing resources for people living with HIV/AIDS
in New Hampshire?
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What housing resources are available for people living with HIV/AIDS at
present?
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Are these resources accessible to people living with HIV/AIDS?
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What housing needs are not being met?
METHODOLOGY
Towards answering these questions, three forms of data collection were used in the needs
assessment: focus groups, key informant interviews, and a survey. In addition to
providing qualitative and/or quantitative data pertaining to the experiences of individuals
living with HIV/AIDS in the state, the focus groups and key informant interviews were
utilized to inform the content of the survey. The information obtained from the survey
provided quantitative data in order to better assess the prevention and care needs of
people living with HIV/AIDS in New Hampshire. Appendix D includes forms related to
the focus groups such as consent forms, focus group questions, and focus group
participant survey. Appendix E includes a list of key informants. Appendix F includes
survey materials such as recruitment materials, information sheet, and the survey.
Focus Groups
Six focus groups were held throughout the state. The participants were asked to complete
a brief survey developed by Alison Paglia with the assistance of the CPG Data,
Evaluation, and Assessment Committee and AHC. The participant survey was designed
to collect demographic information, such as gender and ethnicity, as well as information
related to HIV/AIDS such as mode of exposure, history of CD4/viral load count, etc.
Specific questions asked about factors that may limit access to care services, such as
substance use/abuse, incarceration history, income, housing status, and immigration
status. All of the focus groups lasted approximately three hours, with a 30 minute break
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for a meal. In addition to a meal, the participants received $50.00 in gift cards for local
vendors for their time. $35 was funded by the NH HIV/STD Prevention Section and the
NH CPG and $15 was provided by AHC.
In all cases the local ASO’s assisted in the recruitment of participants, therefore the
majority of the participants were clients of the ASO’s. The size of the focus groups
ranged from 3 to 11 participants. Below is a list of the ASO’s in NH that participated in
the Needs Assessment:
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AIDS Community Resource Network (ACORN) – Lebanon
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AIDS Response Seacoast (ARD) – Portsmouth
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AIDS Services for the Monadnock Region (ASMR) – Keene
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Greater Manchester AIDS Project – (GMAP) – Manchester
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Merrimack Valley AIDS Assistance Program (MVAP) – Concord
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Southern NH HIV/AIDS Task Force (SNHATF) – Nashua
With the exception of ACORN, all focus groups were held at the ASO’s. Due to space
constraints, the Lebanon area focus group took place at Dartmouth-Hitchcock Medical
Center (DHMC). Additionally, recruitment letters were sent to PLWHA that were
patients at DHMC and not clients of ACORN. No service providers or board members
were present at any of the focus groups.
Key Informant Interviews
Second, nine key informant interviews were carried out with providers across the state.
HIV service providers as well as homeless and housing providers were asked several
questions regarding housing resource availability and knowledge, challenges to housing
people with HIV, and recommendations for housing people with HIV. These interviews
were done by telephone with Anne Siegler or Jonathan Sherwood in the winter of 20042005.
Survey
Third, a broad survey was distributed to people living with HIV/AIDS across New
Hampshire with 125 respondents. Several questions on the survey were devoted to
housing history, housing stability, and factors that can affect housing.
The development of the surveys was informed by numerous sources. The expertise of
members of the New Hampshire Community Planning Group Care Services Committee
and the Data, Assessment, & Evaluation Committees, the findings of the key informant
interviews and consumer focus groups, and prior surveys utilized in New Hampshire and
other states and the Health Resources and Services Administrations Needs Assessment
Guide were used in the development of the survey instrument. The Data, Assessment,
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and Evaluation Committee, the STD/HIV Prevention Section, and the Materials Review
Committee reviewed and endorsed the final survey tool.
A recruitment letter was sent to all clients of the NH CARE Program and ASO HIV+
clients that are not part of the NH CARE Program. The letter informed the potential
participants of the purpose of the needs assessment, where the survey could be obtained,
and that participants would receive a $35 gift card incentive. Surveys were made
available at the aforementioned ASO’s that provide Care Services, at several doctors’
offices, and a survey could be mailed to clients if they called the HIV/STD Prevention
Sections toll free number The surveys were mailed anonymously to the state in postage
paid, pre-addressed envelopes. In order to ensure the privacy of the participants, the
incentive request cards were confidentially mailed to a separate Post Office Box. The
$35 gift card incentives were confidentially mailed to the address the participant
provided. Due to an unexpectedly low return rate a second letter was sent to NH CARE
clients and the deadline to return the completed surveys was extended. See Appendix F
for recruitment materials, incentive post cards, and the survey.
Literature Review
Last, available literature on housing and HIV/AIDS in New Hampshire was referenced,
such as information from the state Department of Health and Human Services, the New
Hampshire Housing Finance Agency, the US Department of Agriculture (on rural
housing issues), the Department of Housing and Urban Development, and local Continua
of Care.
This report is also available online through AHC’s website, www.ahc.org.
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January, 2006
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SECTION I: PERSONS LIVING WITH HIV/AIDS IN NEW HAMPSHIRE – A PROFILE
As of December 31, 2004, there were 978 total alive cases of HIV/AIDS in New
Hampshire (this data and all of the HIV/AIDS epidemiological data in this section is from
the New Hampshire Department of Health and Human Services, Division of Public
Health Services). Of these, 543 were persons living with AIDS and 435 were persons
living with HIV. In comparing the incidence of AIDS to that of
other states, at the end of 2003, only 7 states had fewer cases of
In comparing the
AIDS than New Hampshire.3 Since the state began tracking incidence of AIDS
cases of AIDS in January of 1983, an additional 454 persons to that of other
have died of AIDS in New Hampshire.
states, at the end
The greatest number of living AIDS cases is in Hillsborough and
Rockingham Counties, which combined have 62% of the total
cases statewide. (Data on the locations of HIV cases is not
available.) The next highest incidences are found in Merrimack
County, with 11%, and Strafford County, with 7%.
of 2003, only 7
states had fewer
cases of AIDS than
New Hampshire.
In looking at the epidemic by gender, the majority of people living with HIV/AIDS are
male. 75.6% of people living with HIV/AIDS are male, and 24.4% are female. This
number is very similar to the nationwide average, where 77% of those infected are male
and 22% are female. In New Hampshire, like the greater United States, the HIV
epidemic still disproportionately affects males. At this time, the state does not count
transgendered individuals.
The race and ethnicity of those living with HIV/AIDS in New Hampshire is as follows:
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White (not Hispanic)
Black (not Hispanic)
Hispanic (all races)
76.7%
11.9%
10.3%
Compared to the general population of New Hampshire, these numbers are significantly
skewed towards Blacks and Hispanics. 2000 Census data shows that Blacks make up
only 1% of the general population, while Hispanics make up 1.7%. While some of this
disparity could be accounted for if the population of Blacks and Hispanics has increased
proportionally between 2000 and the end of 2004, we can still conclude that the epidemic
disproportionately affects people of color in New Hampshire.
The profile of HIV/AIDS cases by age creates a fairly normal distribution, with the center
being between ages 30-39.
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Ages 0-19
Ages 20-29
2.3%
21.3%
3
“Estimated Number of Persons Living with AIDS at the End of 2003,” <http://www.statehealthfacts.org/>
(September 1, 2005).
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Ages 30-39
Ages 40-49
Over 49
48.7%
21.7%
6%
Last, we look at the modes of exposure among people living with HIV/AIDS in New
Hampshire. Among adults (pediatric cases are gathered separately):
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Men who have sex with men (MSM)
Injecting drug use (IDU)
MSM/IDU
Heterosexual contact
40.6%
19.2%
4.7%
12.5%
While the primary infected population of men who have sex with men echoes the
epidemic nationwide, there is a significant difference in the remaining statistics.
Nationwide, the second largest group people infected received the virus through
heterosexual sex. In New Hampshire, there are more people who received the virus
through injection drug use than through heterosexual sex. This number is important later
on, as we talk about housing programs that exclude people with histories of criminal
substance use.
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SECTION II: HIV/AIDS RELATED RESOURCES, NATIONAL AND LOCAL
There are a variety of housing-related resources in New Hampshire specifically for
people living with HIV disease. The following is a summary of the primary housingrelated services available for people with HIV and AIDS.
NATIONAL RESOURCES
Housing Opportunities for Persons With AIDS (HOPWA)
The HOPWA program is managed by the federal department of Housing and Urban
Development (HUD). There are three HOPWA programs in New Hampshire. HOPWA
is the primary funding source of AIDS housing resources in New Hampshire.
The HOPWA Program was established in 1992 by HUD to address the specific needs of
people living with HIV/AIDS and their families. HOPWA makes grants to local
communities, states, and nonprofit organizations for projects that benefit low income
people medically diagnosed with HIV/AIDS and their families.
As stated in HUD’s Office of HIV/AIDS Housing 2003 report to Congress on the
HOPWA program,
HOPWA is the federal government’s primary targeted response to the pressing
housing needs of persons living with HIV/AIDS and their families. Since its
initiation in 1992, the HOPWA program has reached a large number of persons
living with HIV/AIDS and has assisted them in finding and accessing affordable
housing. HOPWA providers make use of the program to target assistance to
recipients to prevent their slide into homelessness and reduce the detrimental
health effects that are particularly devastating for persons with suppressed
immune systems.
HOPWA gives local communities the capability to devise the most appropriate
and effective housing strategies for community members with HIV/AIDS and
their families. HOPWA grantees develop comprehensive community-wide
strategies and form partnerships with area nonprofit organizations to provide
housing assistance and supportive services for eligible persons. Grantees provide
forums for public participation and consultation in the design, planning,
operations, and evaluation of the combined efforts. 4
The HOPWA program is specifically oriented towards achieving the following positive
outcomes for HIV+ persons:
ƒ
4
Increased housing stability
“Report to Congress on Program Expenditures for the Housing for Persons with AIDS (HOPWA)
Program”, August 2003, < http://www.hud.gov/offices/cpd/aidshousinglibrary/ reportcongressfinal.pdf>
(August 16, 2005) 1.
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Reduced risks of homelessness
Improved access to care, including medical care and social support
HOPWA funds may be used for a wide range of housing, social services, program
planning, and development costs. These include:
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the acquisition, rehabilitation, or new construction of certain housing units;
costs for facility operations;
rental assistance;
short-term payments to prevent homelessness;
supportive services, including mental health services, chemical dependency
treatment, nutritional services, case management, assistance with daily living, and
other supportive services; and
technical assistance.
Nationally, over half of HOPWA funds are spent directly on rental assistance; the
remainder funds services connected to housing assistance.5 In 2001, the HOPWA
program funded over 84,000 units of housing for persons living with HIV and AIDS.6 Of
the amount spent nationally on rental assistance, just over 50% was spent on emergency
(rather than long-term) rental assistance to eligible households.
Ninety percent of the HOPWA funds are distributed nationally through formula grants
based on cumulative numbers of AIDS cases in
relation to the general population. Currently, New
Hampshire is not a HOPWA formula area. The
“For my clients, especially those
coming straight from prison or
other 10% of the HOPWA funds are distributed
rehab, they come with only a
through HUD’s annual SuperNOFA process. The
bag in hand. To get a job, you
three New Hampshire grants are such competitive
need an address. To start to
grants. Each is a grant for three years and must be
get anywhere, you need an
periodically re-applied for in the competitive
address. The ability to access
process.
HOPWA dollars and get housing
first makes all the difference for
a person. HOPWA opens doors
for individuals.”
Provider in Keene, NH
5
In 2005, HUD allocated $281,728,000 for the
HOPWA program. The formula allocation was
$251,323,000; the competitive allocation was
$27,925,000. There were 122 formula grantees. In
2004, there were 22 competitive grantees.7 In 2005,
19 competitive awards have been made, with a
second competitive round currently open, including
the renewal of the State of New Hampshire’s
Ibid., pg. 6.
Ibid., pg. 7.
7
HOPWA 2005 Allocation, March 11, 2005, < http://www.hud.gov/offices/cpd/aidshousing/
budget/index.cfm> (August 16, 2005).
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6
statewide HOPWA grant.8
Integrating HOPWA with local planning processes, including the Consolidated Plan, tenyear plans to end homelessness, and Ryan White CARE Act needs assessments, helps
communities make progress toward HOPWA outcomes in many ways. Coordinating
comprehensive housing and services, improving access to mainstream services, and
leveraging funding from other sources ultimately helps to ensure housing stability, reduce
homelessness, and improve access to care and services.
Consolidated Plans identify community housing needs and set priorities and objectives
for the HOPWA, Community Development Block Grant (CDBG), HOME Investment
Partnerships (HOME), and Emergency Shelter Grant (ESG) programs. For areas that
receive formula HOPWA funds, Consolidated Plans must address HOPWA-eligible
activities and programs, people served by existing programs, existing gaps, and
community priorities for HOPWA funding. Communities reach consensus about
HOPWA priorities by assessing needs, reviewing current information, sharing
information with providers and consumers, and community-based planning sessions.
However, even in locales that do not receive formula HOPWA funds, such as New
Hampshire, it is important that consumers and providers of AIDS services participate in
the Consolidated Plan process, in order to insure that the affordable housing needs of
people living with HIV and AIDS is represented in overall planning.
The housing needs of people living with HIV and AIDS can also be addressed through
the so-called ‘McKinney-Vento’ homelessness programs, administered by the Office of
Special Needs Assistance Programs at HUD. The homeless programs are coordinated
though Continuum of Care planning processes, the Homeless Management Information
System (HMIS), and 10-year plans to end homelessness (the HOPWA competitive grants
are procured through the same ‘SuperNOFA’ process as the homelessness programs).
The Continuum of Care planning process identifies and coordinates strategies for
addressing homelessness in communities and sets priorities and funding among
McKinney-Vento Homeless Act programs, including SRO Mod Rehab, Shelter Plus
Care, and Supportive Housing Program (SHP). There are 3 Continua of Care in New
Hampshire, covering Nashua, Manchester and the Balance of State, respectively.
Information regarding the Continua of Care in New Hampshire can be found at
http://www.hud.gov/offices/cpd/homeless/programs/cont/coc/nh/index.cfm.
The Homeless Management Information System (HMIS) supports data gathering and
reporting and is required for HOPWA-funded projects that target homeless people. HMIS
can facilitate coordination between agencies by streamlining client intake, coordinating
case management, and enhancing benefit screening, thereby providing clients more
streamlined services. HMIS provides grantees with data needed to complete the Annual
Progress Report and is intended to simplify reporting for local providers and improve the
8
HUD News Release, August 19, 2005, <http://www.hud.gov/news/release.cfm?content=pr05-108.cfm>
(September 1, 2005).
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quality of information. By helping communities make informed decisions, HMIS
facilitates the development of effective strategies to address homelessness.
There is no centralized HMIS system that gathers homelessness data nationally. Rather,
the various Continua of Care across the country can develop or contract for their own
data collection systems, based on HUD standards. In New Hampshire, the 3 HUD
Continua of Care are working together to report homelessness data through a single point.
The State’s Office of Homelessness and Housing Services in the Department of Health
and Human Services contracts with the Community Services Council of New Hampshire
to collect and manage data from the 3 Continua of Care. The Council works with local
providers using ServicePoint, a web-based database application, to compile information
regarding the homeless in New Hampshire. As they do not target homeless individuals,
the HOPWA grantees and sponsors in New Hampshire are not yet participating in the
HMIS system.
Ryan White CARE Act
The CARE Act was passed by Congress in 1990, reauthorized in 1996 and again in 2000
for a five-year period. The CARE Act is due to be re-authorized again this year. The
CARE Act funds primary care and support services for individuals living with HIV
disease who lack health insurance and financial resources for their care. The FY 2004
appropriation was $2.04 billion. While ambulatory health care and support services are
the primary focus of the legislation, training, technical assistance, and demonstration
projects are also funded. The Act has various ‘titles’ that fund different activities
nationally. New Hampshire directly or indirectly receives funding through the first 4
Titles. Titles I and II fund housing and case management services.
Title I of the Ryan White CARE Act provides emergency assistance to Eligible
Metropolitan Areas (EMA’s) that are most severely affected by the HIV/AIDS epidemic.
Title II provides grants to all 50 states, the District of Columbia, Puerto Rico, Guam, the
U.S. Virgin Islands, and to eligible U.S. Pacific Territories and Associated Jurisdictions
to provide health care and support services for people living with HIV/AIDS. Title II
funds may be used for a variety of services including home and community based
services, continuation of health insurance coverage, and direct health and support
services. Title II also funds the AIDS Drug Assistance Program (ADAP). More
information about the CARE Act can be found at http://hab.hrsa.gov/programs.htm.
Information regarding the CARE Act in New Hampshire can also be found at the Kaiser
Family Foundation’s website, http://www.statehealthfacts.org.
Ryan White planning councils and consortia oversee planning and assessment of service
delivery and include representatives from health and social service providers, AIDS
service organizations, public health officials, and people living with HIV/AIDS. As
people living with HIV/AIDS often need both housing and services, and access to
services supports housing stability, it is important to coordinate services, funding, and
planning between HOPWA and Ryan White programs. For New Hampshire, there are 2
relevant planning councils. For Title I funds that cover Rockingham, Hillsborough and
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Strafford counties in New Hampshire, the Boston AIDS Consortium manages CARE Act
Planning for the Boston Public Health Commission; for more info visit
http://www.bacboston.org/plan.html. Title II funds in New Hampshire are administered
by the State; planning is handled by the HIV Community Planning Group. For more
information regarding the Planning Group in New Hampshire, contact Heather Hauck at
the Department of Health and Human Services, (603) 271-4502.
Finally, opportunities for partnership and integration also exist with other types of
agencies. For example, HOPWA grantees and project sponsors have expanded the
availability of subsidized and affordable housing by working with public housing
authorities and local and regional affordable housing developers, as well as partnering
with mental health and substance use providers, and working with criminal justice
systems to reduce homelessness occurring after discharge from institutions. Outreach to
grassroots, faith-based, and community nonprofit groups have also created opportunities
to expand AIDS housing and supportive services.
LOCAL RESOURCES
HOPWA
The State of New Hampshire Office of Homeless and Housing Services is the recipient
for two of the HOPWA grants in New Hampshire. The first grant, which was awarded in
1998 and renewed in 2002, provides case management, long-term and emergency
housing assistance, and housing information and referral across the state. Services are
provided locally by various AIDS service organizations, including ACORN (Lebanon),
AIDS Response Seacoast (Portsmouth) and AIDS Services for the Monadnock Region
(Keene). The program is managed by the Merrimack Valley Assistance Program
(MVAP). This program does not cover the Manchester and Nashua areas. This grant has
also provided for resource identification and technical assistance support from Harbor
Homes of Nashua, including the development of a broad
web-based resource for AIDS service providers
In the past program
(http://www.nhhopwaresources.org/). The three-year grant year, [the statewide]
awarded in 2002 was for $908,000. The State submitted a HOPWA
grant
renewal application for this grant for the 2005 SuperNOFA provided short-term
emergency
rental
process, which was awarded in August, 2005 for $824,120.
In the past program year, this HOPWA grant has provided
short-term emergency rental assistance to 145 persons and
their family members. Case management funded through this
HOPWA grant provided referrals and supportive services to
112 clients. Housing Information Services served 338
persons.
assistance to 145
persons and their
family members.
The second HOPWA grant held by the State was awarded in 1999 and renewed in 2003.
This grant also provides case management, long-term and emergency housing assistance,
and access to housing, in this case in the greater Manchester area. The program is
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 15 of 80
managed by the Merrimack Valley Assistance Program. MVAP works with local
landlords and property management companies to stabilize the housing situations of
participants. The three-year grant awarded in 2003 was for $607,545. This grant will be
up for renewal in 2006.
This grant over the last contract year provided short-term rental assistance to 117 persons.
A total of 55 individuals and their family members were assisted by case management,
and 216 individuals received Housing Information Services.
Harbor Homes of Nashua is the grantee for the third HOPWA grant in New Hampshire.
This grant was initially awarded in 1998, and renewed in 2001 and 2004. Covering
Hillsborough County, with the exception of the City of Manchester, the program provides
participants with case management, counseling support and emergency rent and utilities
assistance. The program is managed by Southern New Hampshire AIDS Task Force
(SNHATF). The 2004 three-year renewal grant was for $525,457.
Harbor Homes, during the last contract year, provided emergency short-term rental
assistance to 49 individuals and 64 additional members of their families. Supportive
services were provided for 19 people.
More information about all three grants can be found on the New Hampshire page of the
HOPWA program website,
http://www.hud.gov/offices/cpd/aidshousing/local/nh/index.cfm
More information about the State’s Office of Homeless and Housing Services can be
found at http://www.dhhs.nh.gov.
More information about Harbor Homes can be found at http://www.harborhomes.org/.
Ryan White CARE Act Title I
The second important source of housing-related resources for people with HIV disease in
New Hampshire is Ryan White CARE Act Title I funding.
Three counties in New Hampshire—Hillsborough, Rockingham and Strafford—receive
Title I monies through the Boston EMA grantee, the Boston Public Health Commission
(BPHC). The three southern New Hampshire counties are part of the Boston EMA, a 10
county region. BPHC funds a variety of care-related services in New Hampshire.
Housing is among the eligible Title I activities and is one of the priorities for the Boston
EMA Planning Council. For the 2005 fiscal year, BPHC granted $93,301 to the Southern
New Hampshire AIDS Task Force to provide emergency rent and utilities assistance to
people with HIV and AIDS in southern New Hampshire and the Seacoast area. SNHATF
works with other AIDS service providers to disperse these funds to eligible participants.
In the 2004 fiscal year, 120 unique clients received 142 units of rental assistance and 98
units of utility assistance through this grant.
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January, 2006
Page 16 of 80
More information about BPHC’s AIDS program and Title I funding can be found at
http://www.bphc.org/programs/.
For more information about SNHATF, see http://www.aidstaskforcenh.org/.
Other Resources
The New Hampshire Housing Finance Agency (NHHFA) administers a state-wide
Section 8 Housing Choice Voucher Program. NHHFA, like other public housing
authorities, can establish various priorities or preferences for applicants to their housing.
Among NHHFA’s priorities are two that may include people living with HIV and AIDS.
First, the HFA prioritizes people who are homeless or at imminent risk of homelessness,
according to a specific definition. As discussed in the first section of this report, HIV
disease often has a strong association with poverty and housing instability. HIV+ people
who meet the HFA’s definition of homeless are eligible for priority status. Second, the
HFA prioritizes households where a member has a ‘terminal illness’, which HFA defines
as an illness where ‘death will result within 24 months as verified by a physician.’ More
information can be found at http://www.nhhfa.org/rent_section8app.htm.
The NHHFA also funds and supports privately owned subsidized rental housing across
the state. A directory of this housing can be found at http://www.nhhfa.org/frd_dah.htm.
There are other local public housing authorities in New Hampshire, as well. Each has its
own mix of subsidized resources, such as Section 8 and Public Housing. A list of local
housing authorities can be found at http://www.nhhfa.org/frd_lha.htm.
Housing programs that use HUD McKinney-Vento program funds that target the
homeless sometime include people with HIV and AIDS among their target populations.
Harbor Homes of Nashua, for example has over 70 units that include homeless people
and people with HIV/AIDS or other disabilities as target participants. There is no
centralized listing of such programs but information can be obtained from the three HUD
‘Continuum of Care’ representatives in New Hampshire, listed on HUD’s New
Hampshire web page, http://www.hud.gov/offices/cpd/homeless/programs/
cont/coc/nh/index.cfm.
The State of New Hampshire funds a “Housing Security Guarantee Program” (HSGP)
through the Bureau of Behavioral Health. This program assists eligible households with
loans for security deposits. Household income must be at or below 50% of the Median
Family Income to be eligible. In FY 2004, HSGP provided security deposits for 818
families across New Hampshire.9 The State also funds the “Rental Guarantee Program”
(RGP). Using federal “Temporary Assistance for Need Families” (TANF) funds, RGP
offers an incentive to landlords to rent to homeless families or pregnant women. RGP
pays for up to 3 months of rent as an incentive for landlords. Both of these programs are
handled locally through Community Action Program agencies. For more information
9
New Hampshire Department of Health and Human Services, Bureau of Behavioral Health, Office of
Homeless and Housing Services. Homeless in New Hampshire: Emergency Shelter and Homeless
Coordination Commission Annual Report July 2003 – June 2004, 19.
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January, 2006
about these programs, visit http://www.dhhs.nh.gov/DHHS/HOMELESSHOUSING/
default.htm.
Finally, the Legal Advice and Referral Center (LARC) provides a variety of housing
related assistance services aimed at homelessness prevention. LARC publishes a number
of informative brochures related to housing on topics such as lock-outs, evictions and
security deposits.
More information about LARC can be found at http://www.larcnh.org/Home/PublicWeb.
Social Capital
Social capital is less straightforward as a housing resource but no less important in terms
of actually enabling low-income HIV+ people to get into and maintain decent housing.
Robert Putnam defines ‘social capital’ as "the networks, norms and trust that facilitate
coordination and cooperation for mutual benefit."10 Based on our interviews across the
state, active participation by AIDS service organizations in local groups working on
housing and homelessness issues offered clear benefits to the clients of ASO’s. Such
participation, of course, requires both time and capacity on the part of the ASO’s and the
existence of such groups or networks in their community.
A
good
example of…a
network
that
successfully
‘banks’ social
capital
and
puts
it
to
effective use is
the
Nashua
Continuum of
Care.
A good example of such a network that successfully ‘banks’ social
capital and puts it to effective use is the Nashua Continuum of Care.
As mentioned above, HUD directs its McKinney-Vento monies that
target the homeless through local ‘Continuum of Care’
organizations. In New Hampshire, there are three Continua of Care,
for the cities of Nashua and Manchester, as well as the ‘balance of
State’ for the rest of New Hampshire. The Continua of Care are
federally mandated collaborations; community organizations that
work with the homeless and who receive HUD funds to do so must
annually submit one joint application to HUD for funding.
Continuum of Care collaborations vary widely based upon local
political and non-profit organization and culture.
The Nashua Continuum of Care (CoC), led by Harbor Homes, is
particularly active as a collaborative. Through regular meetings, it involves not only the
agencies that receive McKinney-Vento HUD funds locally but a wide variety of
community organizations that target low-income and special needs populations. The
Nashua CoC has developed a 10 year plan to end homelessness in the Greater Nashua
area. This plan details need and spells out specific action steps for stakeholders across
the community. Organizations that participate in the plan and in the CoC sign on to a
‘Good Neighbor’ agreement that commits them to the goals and actions of the plan.
More information about the Nashua CoC’s activities can be found on its website,
http://www.nashua-coc.org/.
10
Robert D Putnam, “Bowling Alone: America’s Declining Social Capital,” Journal of Democracy 6
(1995), 67.
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Page 18 of 80
January, 2006
For the purposes of this report, there are two primary benefits from this active
collaborative for housing people with HIV and AIDS. The primary benefit identified by
three of the key informants that we interviewed was the facilitation of housing placement
for clients that resulted from regular and close interaction with housing providers through
the CoC. The case manager that we interviewed from the Southern New Hampshire
AIDS Task Force noted that with housing providers, city welfare officers and housing
authority staff present at the meetings, participants could problem solve ‘on the spot.’
The other benefit is the exchange of information regarding resources. Community
referrals are much more effective when direct contacts between providers have been
made. At the Nashua meetings, participants regularly share information regarding new
general or specialized resources and changes to existing programs. Participants even
share apartment leads.
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 19 of 80
SECTION III: NEED FOR HOUSING RESOURCES AMONG PERSONS WITH
HIV/AIDS IN NEW HAMPSHIRE
This section explores the question “Is there a need for housing resources for people living
with HIV/AIDS in New Hampshire and, if so, of what kind?” First we examined the
available data on incomes of people living with HIV in New Hampshire. Then we
compared these findings with average rental costs around the state in order to establish
some general statements regarding housing affordability. Next, we looked at markers of
housing stability, such as homelessness, evictions, and use of emergency rental assistance
among people with HIV drawn from a survey of 125 HIV+ people in New Hampshire.
Last, in order to place these findings in a broader context, we asked people living with
HIV as well as the providers that serve them what the effects of housing stability and
instability are on health and the ability access healthcare and other services.
Income and Rent Comparisons
When a person tests positive for HIV in the state of New Hampshire, it is required that
this positive test is reported to the state, along with some basic demographic information
such as gender and race. Income is not reported, however, which makes an exhaustive
look at the incomes of people living with HIV impossible. Instead, we have data on the
incomes of people with HIV who access the state’s CARE Program services, which is
about 33% of the total population of those living with HIV in New Hampshire. Of these
people,
ƒ
41.2% (169/410) were earning at or below the federal poverty level
ƒ
33.4 % (137/410) earned between 101-200% of the federal poverty level11
The federal poverty definition is established by the United States Department of Health
and Human Services. This definition, often referred to as the ‘poverty line’, is the same
across the country. For a household of one person, the poverty level is an annual income
of $9,310, or $775.83 per month. Thus, 1-person households with incomes below the
poverty line are making less than $775.83 a month.
Additionally, a survey of 125 HIV+ NH residents asked participants about their monthly
incomes. Of these participants, most of whom reported 1- or 2-person households,
ƒ
34.4% (43/125) were earning $1000/month or less
ƒ
23.2 % (29/125) earned between $1001 and $1500 a month.
Of those surveyed, a third to a half of those with incomes under $1000 a month reported
that the sources of their income are Supplemental Security Income (SSI) and/or Social
Security Disability Insurance (SSDI) from the Social Security Administration. Though
the Department of Health and Human Services, which manages the CARE Program, does
not track income sources, presumably many of the people who receive CARE Program
services with incomes below the federal poverty line receive SSI or SSDI as well.
11
Heather Hauck, MSW. Email to Anne Siegler, March 29, 2005.
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 20 of 80
SSI provides income benefits to people who have been determined disabled but do not
have a substantial work history. SSDI is paid to those who become disabled and have
‘paid in’ sufficient amounts through previous employment. Benefits vary from state to
state; they are a combination of basic rates paid by Social Security and state
contributions. People who receive SSDI benefits often receive higher benefits than those
on SSI, though these incomes can still be very low and well under 50% of median
income.
In New Hampshire, as of January 2005, monthly SSI benefits are:
ƒ
$570 for an individual
ƒ
$869 for a couple12
Next, to get a general sense of housing affordability for people living with HIV/AIDS, we
look at current rent levels across New Hampshire and compare those with the income
data we have discussed above. Fair Market Rent (FMR) levels are established by HUD
annually for localities across the country and are loosely defined as what a person could
reasonably expect to pay for an apartment in a particular community.
2005 Fair Market Rents in New Hampshire13
Metropolitan Areas
City
Manchester
Nashua
Portsmouth
0 BR
$632
$706
$634
1 BR
$773
$834
$745
2 BR
$934
$1038
$930
3 BR
$1116
$1392
$1239
4 BR
$1150
$1510
$1407
Non-Metropolitan Areas
County
0 BR
Belknap
$455
Carroll
$505
Cheshire
$559
Coos
$328
Grafton
$496
Hillsborough
$582
Merrimack
$500
Rockingham
$582
Strafford
$539
Sullivan
$422
1 BR
$560
$533
$597
$429
$546
$591
$593
$712
$621
$511
2 BR
$699
$703
$748
$504
$692
$776
$765
$893
$777
$651
3 BR
$923
$956
$902
$707
$931
$1131
$939
$1180
$1031
$882
4 BR
$1186
$1174
$1098
$794
$981
$1363
$1218
$1215
$1265
$953
12
Social Security Online, October 19, 2004. <http://ssa-custhelp.ssa.gov/cgibin/ssa.cfg/php/enduser/std_adp.php?&p_lva=&p_faqid=85> (June 15, 2005).
13
HUD User, Schedule B: Fair Market Rents for Existing Housing 2005 Final Revised Data.
<http://www.huduser.org/Datasets/FMR/FMR2005R/map/nh_FY2005_FMR.pdf> (August 22, 2005).
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 21 of 80
Considering these current rental costs, and considering that the Department of Housing
and Urban Development (HUD) recommends that households pay no more than 30% of
their income towards rent, in no place in New Hampshire is even a 0-bedroom apartment
affordable for a single individual depending on SSI. In the most affordable region, Coos
County, the cost to rent a 0-bedroom apartment is 58% of a single individual’s disability
check. In the least affordable place, the city of Nashua, the cost to rent a 0-bedroom
apartment is 124% of the monthly SSI payment for a single individual. The recently
released Priced Out in 2004: The Housing Crisis for Persons With Disabilities indicates
that some communities in Southern New Hampshire have among the worst SSI benefit to
Fair Market Rent ratios in the entire United States. 14
Noting that “(d)isability incomes have not kept up with
housing costs”, recently published summary of key points
from public meetings held for the State’s 2006-2010
Consolidated Plan affirms the need for scattered site rental
assistance options for persons living with disabilities.15
Specifically regarding very low income (≤30% of Median
Family Income) persons with HIV/AIDS, the current State
Consolidated Plan for 2001-2005 ranks the need for housing
assistance as high.16
In no place in New
Hampshire is even a 0bedroom
apartment
affordable for a single
individual living on
SSI.
Survey data supports this, finding that roughly half of respondents rely on regular, longterm assistance in order to make rental payments. (48% of respondents state they use
long-term rental assistance, and 51% of respondents living in rental property report it is
subsidized in some way, such as local public housing projects or the Section 8 Housing
Voucher program.)
Markers of Housing Instability among Persons Living with HIV/AIDS
Given the unaffordable nature of housing for people living with HIV/AIDS in New
Hampshire as demonstrated above, it is not surprising that markers of housing instability
are prevalent throughout the population. Survey data shows that
ƒ
ƒ
14
34% (43/125) of respondents moved in the last two years.
11% (14/123) of respondents experienced homelessness in the last two years.
For one bedroom units in Southern New Hampshire communities that are part of Boston’s metropolitan
area, the Fair Market Rent is 182.2% of the New Hampshire SSI benefit, making these communities the 3rd
least affordable areas in the country for persons with disabilities. A. O’Hara, E. Cooper, Priced Out in
2004: the Housing Crisis for People with Disabilities, Table 1, “Ten Highest Cost Local Housing Areas-1
bedroom units”, (Boston: Technical Assistance Collaborative, August 2005), 9.
15
New Hampshire Housing Finance Agency, “Consolidated Plan 2006-2010: Key Points from Public Input
Meetings,” August 11, 2005, < http://www.nhhfa.org/conplan04/HCDPCdocs/conplanpublicinput.pdf>
(August 19, 2005).
16
New Hampshire Housing Finance Agency, “New Hampshire Consolidated Plan 2001-2005,”
<http://www.nhhfa.org/conplan/homeless_housingneeds.pdf> (August 18, 2005), 16.
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Page 22 of 80
January, 2006
There is a strong correlation between moving and homelessness, suggesting that a move
does not generally indicate movement towards more permanent, stable housing, but
rather indicates instability. Furthermore, the likelihood of a household having moved
recently decreases as the household’s income increases.
ƒ
ƒ
18% (22/125) of respondents have been denied or refused housing.
16% (21/125) of respondents have been evicted from housing.
There is a strong correlation between having been denied or refused housing and having
been evicted from housing. This suggests that an event of housing instability for
respondents is not isolated, but rather suggests a pattern of instability from the time of
applying for housing throughout tenancy and to the termination of housing.
ƒ
72% (79/109) of respondents have used emergency financial assistance to pay for
rent, mortgage, or utilities.
“My client is living with AIDS
and
has
a
wheelchair
because she’s an amputee.
She tries mightily to remain
independent
but
‘life
happens.’ Her car breaks
down, her roof leaks, her
water heater blows. When
these things happen, [our
emergency
rental
assistance] pays for her rent
so that she has the money
to
make
the
needed
repairs.”
Provider in Concord
This statistic indicates that a majority of households
have had to rely on emergency financial assistance at
some point when monthly income was not sufficient to
meet rent and utility payments. Emergency financial
assistance is paid in order to prevent eviction or the
shutoff of utilities.
These markers of housing instability demonstrate in
tangible terms the effects of the income/rental cost
comparisons outlined above. In order to get more
insight into these effects, the following section reviews
findings from consumer focus groups and interviews
with housing and HIV service providers around the
state.
The Effects of Housing Instability on Health and
Healthcare Access
Studies have indicated a positive link between stable
housing and access to healthcare. Following a large research cohort of persons living
with HIV and AIDS in New York City, a study in 2000 found that people living with
HIV/AIDS who receive both housing and support assistance are four times more likely to
enter health care systems than people with HIV/AIDS who are homeless.17 The same
research yielded a paper in 2002 that indicated that individuals who receive needed
housing services are over twice as likely to retain appropriate medical care than those not
17
A. Aidala, P. Messeri, D. Abramson, G. Lee, Housing and Health Care among Persons Living with
HIV/AIDS: CHAIN Report Update #37, (NY, NY: Joseph L. Mailman School of Public Health, Columbia
University, September 2001), 2.
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Page 23 of 80
January, 2006
receiving housing support.18 The data from our consumer focus groups around the state
as well as our provider interviews suggest that the link between housing and healthcare is
equally relevant for people living in New Hampshire.
In consumer focus groups, participants were asked “Of the HIV services you have
received or wish to receive, which three are the most important?” In all of the six groups,
participants listed housing as one of the top three most important services. One
participant explained, “If I don’t have housing, I can’t receive any other services.”
In addition to the decreased health outcomes from not accessing healthcare, participants
pointed to the detrimental effects of unstable housing on health itself, both physical and
mental. The uncertainty of unstable housing often caused tremendous amounts of stress
on participants and sometimes provoked issues of substance abuse or mental illness that
otherwise could have remained under control. Many participants noted that the
likelihood of relapsing was heightened when living on the streets or in shelters. One
participant stated, “I was bouncing from couch to couch. That plays on your mental
health. That plays on your stability.”
Providers supported these findings in key informant interviews. In addition to echoing
many of the concerns of consumers, providers discussed the health risks of entering
homeless shelters and other congregate housing settings for people living with
HIV/AIDS.
18
P. Messeri, D. Abramson, A. Aidala, F. Lee and G. Lee, “The impact of ancillary HIV services on
engagement in medical care in New York City,” AIDS Care 14, Supplement 1 (2002): S25.
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Final Report: NH AIDS Housing Assessment
Page 24 of 80
January, 2006
SECTION IV: BARRIERS TO HOUSING
While the housing resources discussed above provide an invaluable service to people
living with HIV/AIDS in New Hampshire, several barriers prevent people from accessing
these resources. Some barriers are almost inevitable, such as the geographic isolation
experienced by people living with HIV in some of the more rural parts of New
Hampshire, which prevents access to many of the resources based in the state’s urban
centers. For others, despite being able to access a housing resource such as a housing
voucher, the lack of suitable housing that meets the specific needs of people living with
HIV presents a barrier. Last, some state and federal regulations that restrict the clientele
that programs are able to serve, such as restrictions around credit history, criminal
history, and immigration status present a barrier to accessing housing resources.
Geographic Isolation
New Hampshire has a dramatic mix of urban, suburban and rural communities. The
southern part of New Hampshire has experienced rapid population increases in the past
decade, due to the natural increase of population (that is, more births than deaths) and to
the migration into New Hampshire from other states and international migration.
According to New Hampshire Employment Security's Economic and Labor Market
Information Bureau (ELMIB), from 2000 to 2003 the population of New Hampshire
grew at a faster rate than any other New England state.19 Coos, Carroll and Belknap
counties experienced negative natural growth; at the same time, Carroll and Belknap
counties experienced higher than average overall relative growth rates from 2000 to
2003.20 Hillsborough county experienced high growth rates in all three categories of
natural, internal and international migration.21
It is not surprising that more people living with HIV and AIDS reside in the counties with
highest populations (Hillsborough, Merrimack and Rockingham) than in those with the
lowest populations (Coos, Sullivan and Carroll). Forty percent (40%) of the state’s
people living with HIV/AIDS are in Hillsborough County, where the city of Manchester
is located, and another 21% are in Rockingham County. It follows that the majority of
the state’s resources for people living with HIV are centered in these urban areas in the
southern part of the state. Hillsborough County especially, with the cities of Manchester
and Nashua, has an incidence rate over twice that of Coos County. Additionally, the
incidence of AIDS (cases as a percentage of the general population) is definitely higher in
the three most populous counties, meaning that in terms of prevalence, AIDS is more of
an urban and suburban issue than a rural one in New Hampshire.
Though the prevalence of AIDS is lower in rural counties, the general disability rates are
far higher than rural areas. According to U.S. Census Bureau data, over 25% of Coos
19
New Hampshire Employment Security's Economic and Labor Market Information Bureau, Economic
Conditions in New Hampshire, “New Hampshire's population continues to grow,” May 2004,
<http://www.nhes.state.nh.us/elmi/pdfzip/econanalys/articles/pop2000.pdf>, ( August 23, 2005) 1.
20
Ibid, 2.
21
Ibid, 2.
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
Page 25 of 80
January, 2006
County residents report that they are disabled, whereas Rockingham, Stafford and
Hillsborough counties report rates under 16.4%.22 This may be related to the general
paucity of health care resources in rural areas and difficulties in accessing what resources
exist. According to a 2002 report funded by the National Health Care for the Homeless
Council (NHCHC), rural residents are more likely to die from heart and pulmonary
diseases and limitation in activity due to chronic conditions is more common.23 In
regards to HIV disease, this report also notes that “(a)lthough the prevalence of
HIV/AIDS is lower in rural than in urban practice settings…rural patients with HIV
infection tend to be diagnosed later.24 This report summarized the barriers of rural
residents to health care as follows:
ƒ
lack of transportation
ƒ
lack of health insurance and other entitlements
ƒ
Inaccessible/inadequate mental health and substance abuse services
ƒ
Limited access to secondary and tertiary care
ƒ
Primary care access barriers25
For those who live outside of these areas, then, the geographic isolation they experience
presents a significant obstacle to accessing housing resources. The 2002 NHCHC report
findings were echoed by results from our New Hampshire study. In consumer focus
groups, participants in rural areas expressed frustration in the lack of availability and
variety in services they are able to receive, compared to those in more urban areas.
Related to this, the lack of available transportation in order to access resources located
farther away was commonly stated. Some participants were able to access transportation
and travel far distances in order to access services, though it consumed a large part of a
day. For others, the inability to acquire transportation prevented them from accessing
resources altogether.
In interviews with service providers, those in places such as Lebanon and Keene
reiterated the difficulty in finding housing resources for clients. They discussed lengthy
processes necessary in order to locate and learn of resources for their clients. One
provider expressed this by stating, “It’s very difficult to find any resources or learn of any
resources. I feel very isolated. In order to find anything, I have to look around, call a
million people, and eventually you find one person somewhere that knows something.”
Many providers in rural areas described a lack of collaboration and communication
between other providers, further hampering their ability to serve their clients and direct
them to the resources they need. A provider in Keene stated, due to the nature of her
location she feels a sense of “doing it all on our own.” Another provider in Concord also
22
US Census Bureau, Census 2000 Summary File 3, Matrix P42.
Patricia Post, Hard to Reach: Rural Homelessness and Health Care (Nashville, TN: National Health
Care for the Homeless Council, January 2002), 11.
24
Ibid, 14.
25
Ibid, 18.
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
Page 26 of 80
January, 2006
23
described this feeling, and stated that due to the fact that many resources are countyspecific, there is little information that’s useful for other providers.
Providers also stated, as consumers did, that transportation is crucial to the ability to
access resources, especially for those in rural areas, and that a majority of their time is
spent driving clients to look at apartments and to other appointments. When asked what
services are most important for their clients, for those in rural areas, all providers
included transportation.
Housing that Does Not Fit the Needs of Persons Living with HIV/AIDS
For some, despite living in urban areas with many housing resources such as Manchester
and Nashua, the inability to find appropriate housing that meets the varied and special
needs of people living with HIV is a barrier. This can take many different forms.
In Manchester, for example, consumers and providers expressed a concern that the
housing that is affordable with a Section 8 voucher is substandard and will not pass
inspections. Housing that is safe and clean, for the most part, does not fall under the
rental cap that a Section 8 voucher requires. Additionally, providers in Manchester noted
the prevalence of housing with lead paint, which is unsafe for consumers who have small
children and will also cause an apartment to fail inspections.
For many people
living with HIV/AIDS
in recovery,
placement in a
neighborhood that
threatens their
sobriety is just as
dangerous as
unstable housing.
Another concern voiced by participants in Manchester is the
inability to find affordable housing in safe neighborhoods. For
many people living with HIV/AIDS in recovery, placement in a
neighborhood that threatens their sobriety is just as dangerous
as unstable housing. Housing that is affordable is often located
in neighborhoods with significant drug and alcohol use.
Lastly, providers in Concord discussed the large numbers of
people with HIV exiting the correctional systems as well as the
mental health facilities in Concord. These populations present
specific needs which need to be addressed in order to be stably
housed, such as re-entry programs, substance abuse programs,
counseling, and other mental health services. Affordable
housing that is not affiliated with these services does not adequately meet the needs of
these particular populations.
Poor Credit History
Across the state, providers and consumers stressed the impact of bad credit on one’s
ability to access housing. Participants stated that for some programs, credit reports are
part of a regular screening process and a poor credit history is an automatic denial from
housing. For other programs, participants stated, landlords have informal networks of
communication and a person’s failure to pay rent in one apartment can affect his ability
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 27 of 80
to lease up with another landlord years down the road. Survey data supported the claim
that bad credit is a powerful barrier to accessing housing.
ƒ
There is a strong correlation between having bad credit and having been denied or
refused housing.
ƒ
There is a loose correlation between having bad credit and not living in subsidized
housing.
ƒ
There is a loose correlation between having bad credit and experiencing
homelessness in the past 2 years.
Criminal History
Like poor credit history, criminal history has a powerful effect on one’s ability to access
housing. Many state and federally funded programs have criminal restrictions which
prevent a program from being able to house a person with specific crimes on record.
Additionally, once having accessed a housing resource such as a Section 8 voucher,
landlords are often unwilling to house a person whom they know has a criminal record.
For providers located near prisons who pick up many of the re-entering consumers, such
as those in Concord, this obstacle was especially apparent. Again, survey data supports
the statements of providers and consumers around the state.
ƒ
There is a strong correlation between having a history of incarceration and
experiencing homelessness in the last 2 years.
ƒ
There is a loose correlation between having a history of incarceration and not
living in subsidized housing.
Additionally, there is a strong link between those who have poor credit histories and
those who have a history of incarceration, meaning that many of the people facing the
obstacles associated with bad credit are simultaneously facing the obstacles of criminal
history, and vice versa.
Immigration Status
In the urban areas of Manchester and Nashua, the restrictions that prevent some federally
and state funded programs from serving undocumented immigrants presented a barrier to
housing. Moreover, often times these immigrants have the most needs. A provider in
Manchester expressed, “Our newest immigrants are arriving from Africa. [Social service
groups] bring them here, get them housed for three months, and then are no longer
involved. We’re working with them, and dealing with very basic needs like blankets.”
Data from the survey of people living with HIV/AIDS backs this idea up.
ƒ
There is a loose correlation between citizenship status and monthly income. This
suggests that an undocumented status presents barriers to accessing employment
and public benefits. Furthermore, undocumented immigrants who have lower
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 28 of 80
incomes than the general population, and are therefore more in need of subsidized
housing are barred from accessing it in many cases due to federal and state
regulations.
Providers at AIDS service organizations and other social service agencies report that they
are unequipped to deal with some of the complex needs of the immigrant population,
especially involving legal issues, immigration status, and access to benefits.
Additionally, providers in Manchester stated that recent city policies have not been
supportive of the immigrant community. This lack of support has made accessing
resources for immigrants more difficult.
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January, 2006
Page 29 of 80
SECTION V: ASSESSMENT OF HOUSING RESOURCES AND GAPS IN SERVICES
The housing needs of people surveyed for this report are varied. With low and very low
incomes, many will need ongoing, long-term rental assistance in order to be able to afford
rental housing in markets across New Hampshire. These people will need not only rental
assistance but information regarding where to find housing resources and advocacy to
overcome some of the barriers to subsidized housing. Even with rental assistance such as
a Section 8 voucher in hand, many find it difficult to locate and secure a unit that meets
voucher guidelines, is reasonably safe and sanitary and that will still offer tenants
geographic access to medical care. Many also stressed the importance of emergency
rental assistance, in order to help prevent homelessness and evictions even when already
housed.
Through the focus groups, key informant interviews and the consumer survey, housing
related need among people with HIV and AIDS in New Hampshire can be summarized in
four points:
ƒ
Unmet need for long-term rental assistance
ƒ
Met need for emergency rent and utilities assistance
ƒ
Partially met need for housing information and advocacy
ƒ
Partially met need for supplementary resources to stabilize households
In a previous section we discussed most of the available housing-related resources
available for people living with HIV and AIDS in New Hampshire. In this section, we
will consider them in the context of the needs described and identified through the focus
groups, key informant interviews and the consumer survey.
Long-Term Rental Assistance
As discussed in the needs section earlier, the need for rental assistance typically is a
straight-forward function of low income levels. In the consumer survey, over 1/3 (43 of
125) of the respondents indicated that they received long-term rental assistance, either
through a tenant-based voucher such as Section 8 or HOPWA or by living in public
housing. About 25% (10/43) of these households received long-term rental assistance
from one of the HOPWA grants in the state. In the focus groups, consumers were asked
to indicate the most important services that they receive. In all six focus groups, housing
assistance was indicated as one of the most important services.
As noted in the resources section of this report, there are a variety of sources for longterm rental assistance in New Hampshire. However, the limited availability of each of
these resources compared to the large amount of need, taken with the uncertain future of
these resources, leads us to conclude that for the most part, the need for long-term rental
assistance is unmet. The following is an assessment of these different resources in terms
of meeting the housing needs of people with HIV and AIDS.
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 30 of 80
ƒ
Section 8 Housing Choice Vouchers: Section 8 vouchers are typically the most
popular form of rental assistance. They are portable and can be used in different
communities and even other states. They allow people to find their own
apartments. They are open-ended in terms of participation. However, demand for
them is high and waiting lists can be long.
Restricted federal support in recent years has meant that fewer new vouchers are
available; in some communities, housing authorities have had to shrink their
voucher pool due to funding cuts. Section 8 also comes with mandated
restrictions regarding criminal history and immigration status, making them
essentially unavailable for a fair number of people.
The New Hampshire Housing Finance Agency Section 8 program does have a
priority for people who have a ‘terminal illness,’ defined as facing death within
two years. Though this priority has served as an access point to NHHFA’s
Section 8 program in the past, it is increasingly non-applicable, as long-term
prospects for people with AIDS continue to improve.
ƒ
McKinney-Vento Homelessness Programs: The housing programs funded with
McKinney-Vento monies and organized through the three Continua of Care in
New Hampshire provide an alternative to the Section 8 program. McKinneyVento programs such as Shelter Plus Care and the Supportive Housing Program
are often run by local non-profit organizations rather than state or city public
agencies and thus are often more directly accessible for eligible people. They
target the homeless and for many programs target people who are disabled
including those who are infected with HIV/AIDS.
These programs usually have supportive services attached, as well, offering
participants access to other community resources. Unlike Section 8 (and public
housing), these programs do not have built-in restrictions and exclusions
regarding criminal history or immigration status, presenting lower barriers to
participation. However, eligible participants must meet strict definitions of
‘homelessness’ in order to be eligible, such as living on the street or in emergency
shelter. Those moving from couch to couch, for example, do not meet this
definition. This single factor can block eligibility for many.
ƒ
Housing Opportunities for Persons With AIDS (HOPWA): As noted, there
are three HOPWA programs that together cover the state. Long-term rental
assistance is one of the activities that the HOPWA program funds. In a recent
year (grant reporting years ending in 2003), 24 households in New Hampshire
received tenant-based rental assistance, representing under 10% of the
expenditures in that time frame on these three grants (the majority of funds across
the grants went to general supportive services, such as case management and
housing information). Though each grant varies in its activities, taken together
they provide only a modest amount of long-term rental assistance.
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January, 2006
Page 31 of 80
The HOPWA program, like the McKinney-Vento program, has very low barriers
to participation, only requiring HIV+ status and annual income at or below 80%
of local median income. It also has no built in requirements regarding
immigration status and criminal history. And like McKinney-Vento, it is usually
provided through local non-profits rather than through public agencies such as
housing authorities. Indeed, HOPWA services in New Hampshire are offered
through the very agencies people living with HIV and AIDS go for other support
and assistance. As a flexible resource, HOPWA is well-suited to address the
housing needs of HIV+ people who might face barriers such as bad credit,
criminal history or alien status in accessing other housing resources.
The Office of AIDS Housing at HUD has been making changes to the program
that is already affecting the three competitive HOPWA grants in New Hampshire,
especially in terms of balancing rental assistance and supportive services on the
grants. Last year, HUD required that grantees seeking to renew a grant needed to
pass a ‘permanent housing’ threshold, meaning that at least 50% of the grant’s
budget needed to support permanent housing activities (whether through rental
assistance or services to people in permanent housing). This year, HUD added an
additional requirement to renewals: no more than 35% of a grant’s budget can be
for case management and other supportive services; the bulk of the grant needed
to go towards housing assistance (either long-term or emergency). These two
requirements reflect a recent shift in the HOPWA program at the national level.
The implications for the three New Hampshire grants are significant. Taken
together, they direct the majority of their resources into case management and
supportive services. What this means is that by necessity, the HOPWA grantees
may need to devote more grant resources to the provision of housing assistance in
order to respond to HUD’s emerging HOPWA program priorities. That said, this
report’s findings support the need for the expansion of long-term rent assistance
in New Hampshire. As a program that is able to integrate housing assistance with
supportive services in a low-barrier community-based way, HOPWA funds would
be well-used to expand long-term rental assistance options for low-income people
with HIV disease in New Hampshire.
As discussed in the needs and barriers sections, the data from the consumer surveys
strongly indicates correlations among a number of factors, including low income, bad
credit and criminal histories and unstable housing history/experience of homelessness and
the need for rental assistance. In the focus groups as well as in the key informant
interviews, respondents indicated not only the importance of long-term rental assistance
but also the need for more resources. As one key informant put it, when asked what
could be done to increase affordable housing opportunities for HIV+ people in her area,
“more vouchers, period.”
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January, 2006
Page 32 of 80
Emergency Rent, Mortgage and Utility Assistance
In the consumer survey, almost 30% (37/125)
of the respondents indicated that they had
received emergency rent, mortgage or utility
assistance through one of the HOPWA grants
and 72% indicated that they had used
emergency rent or utilities assistance from any
source. This supports our finding from the
focus groups that there is a clear need for
emergency financial assistance to support
HIV+ people in their housing situations.
Moreover, the very high utilization rates,
taken out of the total population of people
living with HIV, indicate that the resources
available are adequately meeting this need.
“I first met my client 4 years ago. He
had a serious alcohol problem which
constantly landed him in jail or in
eviction proceedings. After many
attempts, we finally worked with the
county attorney’s office to tack a
mandatory rehab period on to one of
his many jail sentences. We kept
paying his rent, his utilities and kept
everything going for him until he
came back. He’s now completely
turned around and has been sober
for over a year. It didn’t happen
overnight though, and it wouldn’t
have been possible without the
[emergency] housing assistance.
Emergency rent, mortgage and utility
Provider in Concord
assistance is an example of an ounce of
prevention being worth a pound of cure.
Evictions or displacement due to non-payment
of rent cause substantial disruption in the
households affected, sapping family cash
resources for moving costs, disrupting access to care and services and taking children
away from schools. Fixed-term, temporary support of people facing eviction, foreclosure
or shut-off from utilities costs less per household than does long term rent assistance.
That said, the very high usage of emergency rental assistance may indicate that what
households actually require to avoid chronic housing instability are long-term solutions
such as an increase in income or permanent rental assistance.
Emergency assistance is available from a few different sources in New Hampshire.
ƒ
Low-Income Home Energy Assistance Program: The Low-Income Home
Energy Assistance Program (LIHEAP) is a federally funded program that
typically is funneled into local communities through local Community Action
Program agencies, such as Southwestern Community Services serving Cheshire
and Sullivan Counties and Rockingham Community Action serving Rockingham
County. Utility assistance is available annually to income-eligible households.
Assistance levels depend on income and on whether or not a household also
receives some form of rental assistance. Assistance can be fairly limited and
agencies often run out of funds before the winter months are over. More
information on the LIHEAP block grant in New Hampshire is available at
http://www.nh.gov/oep/programs/fuelassistance/index.htm.
ƒ
Ryan White CARE Act Title I: The Title I formula grant for the Boston
metropolitan area covers three counties in southern New Hampshire. As
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January, 2006
Page 33 of 80
mentioned in the resources section of this report, the Southern New Hampshire
AIDS Task Force receives approximately $93,000 (FY2005) to provide
emergency rent and utility assistance in Rockingham, Hillsborough and Strafford
counties. ‘Emergency Assistance’ is an eligible Title I activity and includes rent
and utilities assistance.
There are two issues to note here, both tied to the re-authorization of the CARE
Act. The CARE Act is up for re-authorization by Congress for the 2006 federal
fiscal year that begins October 1, 2005. First, the ‘maps’ that the Department of
Health and Human Service’s Health Resources and Services Administration
(HRSA) uses to distribute CARE Act formula funds will likely change. Based
upon the 2000 national census, the Office of Management and Budget (OMB)
updated national statistically based maps used to distribute all federal funds. In
2003, these new maps created major changes in the HOPWA formula program,
for example. Depending on how the re-authorization legislation is worded (and
how HRSA lawyers interpret this wording), the set of maps that will apply to the
CARE Act differ. How the Boston metropolitan area is defined will affect the
distribution of all Boston Title I funds in New Hampshire (including but not
limited to emergency assistance). With the two most likely maps, the Boston
area’s coverage in New Hampshire will either be expanded or eliminated all
together. Both options will have major implications for consumers of AIDS
related services in New Hampshire and the organizations that serve them.
Second, Congress might narrow the list of activities that CARE Act can fund.
Services might be limited to medically related activities and may not include
emergency assistance as a category. This would eliminate this CARE Act Title I
resource.
ƒ
Housing Opportunities for Persons With AIDS: The three HOPWA grants
complement the CARE Act monies from the Boston Public Health Commission in
providing emergency rent and utility assistance. Whereas CARE Act funds can
only be used to pay forward for emergency rent or utility payments, HOPWA can
pay backwards, for up to 21 weeks. HOPWA can also pay for up to 21 weeks of
mortgage payments for eligible households. HOPWA is unique among HUD
programs in allowing for these emergency payments. The goal of this activity is
to prevent homelessness or the shut-off of utilities.
The three HOPWA grants in New Hampshire devote a significant amount of their
resources to providing emergency assistance. In the annual reporting periods
ending in 2003, the three grants assisted 107 households. This is very significant,
given that in April 2004, there were 539 people living with HIV or AIDS in New
Hampshire. This means that during a 12 month period, agencies across New
Hampshire gave emergency rent, mortgage or utility assistance to approximately
20% of the households where at least one person is living with HIV or AIDS.
AIDS Housing Corporation
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January, 2006
Page 34 of 80
This very high annual utilization (emergency assistance can only be accessed
once a year under HOPWA regulations) indicates that a high number of HIV+
people in New Hampshire live in circumstances where income levels are low in
relation to housing costs, thus requiring the use of emergency assistance. Without
more information from the HOPWA grantees themselves, it is impossible to
determine but it may well be that households accessing emergency assistance in
order to remain stable may actually be in need of permanent, long-term rental
assistance in order to achieve financial stability. HOPWA grantees should
evaluate the usage of emergency assistance among their participants and
determine if participant needs would be better met by providing more long-term
rental assistance through their grants.
ƒ
Local Welfare Offices: New Hampshire has a unique system dating back to the
1800’s for meeting local welfare needs, wherein cities and towns are directly
responsible for providing relief for people unable to support themselves. Cities
and towns have their own welfare offices that can provide assistance, such as
emergency rent and utility relief. The kinds and levels of assistance vary greatly
between communities, as the services they provide are funded and developed by
the locale. Some communities ask that assistance be paid back. Local policies
vary greatly.
Housing Information and Advocacy
The identification of affordable housing resources can be an extremely difficult task.
This is true in both rural and urban communities. There is no central source or registry of
affordable housing information. People in need of long-term rental assistance must find
and apply for any number of different resources—Section 8 vouchers from various
sources, public housing, privately owned subsidized rental housing, HOPWA, etc.
Furthermore, consumers can often face a number of barriers to access and utilize
resources such as Section 8 vouchers. Some resources exclude people based on their
criminal history, others based on credit history. And even with a voucher, it can be very
difficult for consumers to find a landlord ‘willing’ to take the voucher, to find an
apartment that meets program guidelines or to find a unit near public transportation,
stores and services. As described in the needs and resource sections of this report, both
consumers and providers affirmed that housing information and advocacy is important.
Survey data, key informant interviews, and the future outlook of available resources
suggest that this need is partially met.
Housing information and advocacy are available from a few sources.
ƒ
Housing Opportunities for Persons With AIDS: The three HOPWA grants all
provide for housing information and referral services. At most of the AIDS
service organizations that receive HOPWA funding, there is a particular staff
person who focused solely on housing referral and advocacy. At the Southern
New Hampshire AIDS Task Force, there are two staff people who specialize
respectively in housing services and advocacy around benefits (including
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Final Report: NH AIDS Housing Assessment
January, 2006
Page 35 of 80
housing). However, all the agencies that receive HOPWA funds provide case
management and referrals to services; this usually includes housing related help.
As discussed in the housing resources section, one of the important housing
resources that is available to consumers is the access that comes when AIDS
service providers interact with local housing providers. When case managers and
other agency staff are well-connected to housing systems (and any other kind of
service systems), consumers benefit from providers’ networked knowledge of
available resources. Interviews with providers demonstrated that while this
collaboration is present in some of the southern urban centers, it is lacking in
other parts of the state.
The challenge for most AIDS service organizations is that they have limited staff
resources available. Staff can be easily stretched thin, needed to be informal
‘experts’ in any number of resource systems. It is challenging to keep up with
changes in medications, sort out local, state and federal benefits, know how to
find a detox bed or half-way house, and still have the capacity to understand the
myriad of affordable housing resources and their regulations. Close connections
with other affordable housing specialists in the community can help providers
connect with housing resources. Agencies receiving HOPWA funds should
cultivate such connections by participating in HUD Continuum of Care meetings
and other local community networks, in order to better connect their clients with
housing resources.
As mentioned in the resources section, Harbor Homes has created a website that
organizes housing and other resource information.
Harbor Homes has
periodically offered trainings to case managers around the state regarding
available resources, including housing and legal advocacy.
Whether in
connection with Harbor Homes, AIDS Housing Corporation or another local
community housing provider, housing specific trainings that give providers
resource and advocacy information should be developed and regularly offered.
The HIV Community Planning Group meetings might also be a good forum to
bring in speakers who can give AIDS service providers up to date housing
information.
ƒ
Legal Advocacy: As mentioned in the resources section, New Hampshire Legal
Services maintains a website with an excellent variety of ‘self-help’ housing
information pamphlets posted on it. Though posted on the web only in English,
some of the pamphlets are available in Spanish translation. Case managers should
take advantage of this information, familiarizing themselves with basic aspects of
state housing law in order to effectively help clients who may be facing eviction,
substandard housing conditions, or other legal matters.
ƒ
Other resources: Some larger communities have other housing advocacy and
information services available that HIV+ clients and their case managers may be
able to access. For example, Southwestern Community Services (SCS, serving
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January, 2006
Page 36 of 80
people in Cheshire and Sullivan counties), offers a variety of housing and
homelessness prevention related services. Through the Monadnock Area Housing
Coalition (MAHC) and the Sullivan County Housing Coalition (SCHC), SCS has
five housing programs: the Emergency/Transitional Shelter Program, the
Homeless Outreach and Intervention Program, the Prevention/Intervention
Program, the Housing Security Guarantee Program and the Rental Guarantee
Program. As noted in the resource section, many of the Community Action
agencies in New Hampshire have housing-related services.
Supplementary Resources for Stabilization
The focus groups, key informant interviews and survey results all support the notion that
many of the needs of HIV+ people relate directly to poverty and low-income. Consumers
across the state rely on a patchwork of locally available resources to stabilize their
households. In the focus groups, many participants felt like they were on a personal
treadmill, struggling to find transportation, get to medical appointments, deal with
insurance issues, keep up with their medications, pay the rent, get food, overcome various
barriers to resources, and deal with recovery and substance use issues. Indeed, the role of
case managers and housing advocates can often be a matter of helping clients manage all
of the issues that stem from poverty and just keep afloat. Consumers indicated the
importance of resources like case management, food pantries, and public and volunteer
transportation in helping them stabilize their situations.
Without going into great detail regarding the long lists of where consumers would find
such support, we can make some specific comments regarding AIDS specific services.
HIV related case management services in New Hampshire are primarily funded through
three sources: Ryan White CARE Act Title I funds from Boston, CARE Act Title II
funds through the state of New Hampshire (on a fee-for-service basis) and the three
HOPWA grants. As noted above, two of the sources of funding for case management
(and other services) in the most populous counties in the state are on uncertain footing.
The uncertainty surrounding CARE Act re-authorization has clear implications for New
Hampshire providers, especially if the Boston metropolitan area shrinks. Outside of
Rockingham, Stafford and Hillsborough counties, case management services are
particularly vulnerable. In those counties, the ‘balance of state’ HOPWA grant
complements state Title II funds to pay for case management. The statewide HOPWA
grant is up for renewal this year and an application has been submitted. With HUD’s
shift towards prioritizing rental assistance over services, the renewal of this grant and
how it might look in the future is an open question.
While the larger cities of southern New Hampshire are generally well-equipped with
supplementary resources such as food pantries, transportation assistance, support groups,
etc., outside of these cities these resources are scarcer. In focus groups, consumers
outside of these cities expressed the feeling that they lacked the safety net that comes
from having these resources available to fall back on.
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 37 of 80
SECTION VI: CONCLUSIONS AND RECOMMENDATIONS
This brief report provides an overview of the housing related needs of people with HIV
and AIDS in New Hampshire, some of the resources available to meet those needs, the
barriers that some experience in trying to access the available resources, and an analysis
regarding the adequacy of existing services to meet these needs.
We will conclude with some basic recommendations. In the next few months, we will be
discussing our conclusions and recommendations with various AIDS housing
stakeholders in New Hampshire, including contacts at the State’s Department of Health
and Human Services, the Manchester HUD Field Office, the HOPWA grantees, the HUD
Continua of Care, consumer representatives and AIDS service providers. Moving
beyond analysis, our goal is that this report helps stimulate and guide action. Our aim is
to develop an Action Plan that will help providers, consumers and funders identify
concrete steps for addressing the needs described in this report.
Permanent Affordable Housing
Long-term housing needs could be better addressed by the development of more
affordable resources. We recommend that the HOPWA grantees begin to do this by
increasing the amount of long-term rent assistance in their HOPWA grants. Ideally this
would be done in the context of grant renewals, with expanded requests for funding based
upon an increase in permanent assistance provision. All of the HOPWA grants are below
the budget cap set by HUD in the NOFA process. This report supports the request for
additional funds for this activity. Providing ongoing, tenant-based rental assistance can
be complicated for non-housing providers. HOPWA grantees could form a partnership
with the New Hampshire Housing Finance Agency in order to administer the resources
statewide. The statewide HOPWA grant in Vermont provides a good model of a
collaborative of AIDS service organizations working with a statewide agency to provide
rental assistance in connection with local case management.
A more challenging route would be to develop project-based affordable resources. This
process is complicated even for experienced agencies but there are a number of
organizations in New Hampshire that have done this, most notably Harbor Homes of
Nashua. They have used a variety of affordable housing finance tools to put together
projects, including an innovative condominium development for people with disabilities
using federal Section 811 funds. Through one of the HOPWA grants, they have also
been assisting AIDS Services of the Monadnock Region (ASMR) in its effort to develop
SRO units in Gilsum. The NHHFA has some funds available for the development of
affordable special needs housing and has expressed some interest in working on an AIDS
housing project (NHHFA has provided ASMR with some pre-development funding).
We recommend that key stakeholders develop a concrete realistic plan for the
development of more affordable AIDS housing resources in New Hampshire, with
technical assistance from AIDS Housing Corporation. Such a work plan would seek the
support and involvement of the local HUD office and relevant state agencies, in order to
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Final Report: NH AIDS Housing Assessment
January, 2006
Page 38 of 80
direct available resources towards this goal. In fact, the groundwork for such a work plan
has already been laid by the State of New Hampshire Interagency Council on
Homelessness. One of the four primary recommendations of the Council in its “Ten Year
Plan for Ending Homelessness” is the expansion of permanent housing resources for
special needs populations.26
Emergency Rent and Utilities Assistance
Though we consider this need to be met through high utilization of a variety of existing
resources in New Hampshire, we do note that the very high levels of use that we found
might indicate a deeper need for permanent rent assistance, as discussed above. We do
not conclude that emergency rent and utilities assistance is not necessary and important,
especially as an efficient means of spending valuable resources on homelessness
prevention. However, as noted above, it may be that some households that access
emergency services regularly or annually would be better served with permanent rent
assistance. We encourage the HOPWA grantees to consider the utilization of emergency
assistance in this context. With the information gathered for this report, we are not in a
position to draw a conclusion.
Housing Information and Advocacy
We consider that in-depth knowledge regarding available housing resources and that
housing advocacy skills are an essential means for connecting consumers to available
resources and ensuring their access. Here too, a little prevention is worth a lot of cure.
Though case managers around the state constantly are involved in helping their clients
with housing issues, the subsidized housing and tenant-landlord legal worlds can be
complicated. Also, levels of networking and collaboration of ASO staff and housing
providers varied across the state. We recommend that case managers across the state be
offered periodic housing information and advocacy training, ideally through a
collaboration of the HIV Community Planning Group and AIDS Housing Corporation or
a local organization, such as Harbor Homes. We also recommend that ASO and AIDS
Housing Corporation staff people participate actively in the local or state HUD Continua
of Care. These groups are currently engaged in comprehensive long-range planning for
addressing the housing needs of the homeless in New Hampshire. ASO’s and consumers
alike have a clear stake in such planning. These groups are also invaluable forums for
networking with other providers.
Other Services and Resources
In considering the web of other resources that HIV+ people rely upon to achieve housing
stability, we see the need for such services as partially met for two reasons. First,
resources are very unevenly distributed around the state. Second, some of the funding
that supports those resources—Ryan White CARE Act Title I (Boston) and HOPWA—
26
State of New Hampshire Interagency Council on Homelessness, Ten Year Plan for Ending
Homelessness: Outline, December 15, 2004, < http://www.nashua-coc.org/files/ich/nhtypout.pdf> (August
23, 2005).
AIDS Housing Corporation
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Page 39 of 80
January, 2006
may be facing considerable changes. Regarding the latter point, the impact that ASO can
have on federal policy decisions will be limited. However, agencies that use these funds
and the HIV Community Planning Group in general should be aware of these possible
and actual changes and consider how these and other resources are used and distributed.
For example, not only do we recommend that the HOPWA grantees increase the amount
that they spend on the provision of permanent housing, HUD is beginning to mandate
this. We also recommend that stakeholders in the provision of quality AIDS related
services, in concert with other interested groups such as the Continua of Care, address the
State of New Hampshire and the legislature regarding the need for increased state
funding and coordination of services and resources. Research such as this report and the
Continua’s Plans to End Homelessness can be used to advocate and plan for necessary
resources.
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 40 of 80
SECTION VII: ACTION PLAN
On September 30, 2005, AIDS Housing Corporation facilitated a meeting with various AIDS
housing stakeholders from around New Hampshire. At this meeting, AHC presented the findings
from the report and discussed its recommendations. Participants offered comments on the
findings, raised questions for clarification and brainstormed regarding action steps. AHC then
engaged in additional research, drafted an Action Plan and submitted it to stakeholders for
additional comment. This plan represents the result of that process. The plan presents
recommended actions, with concrete next steps for each.
Here is a summary of our recommended actions:
EXPAND PERMANENT AFFORDABLE HOUSING OPPORTUNITIES
1. Establish an AIDS Housing Committee that meets periodically to set priorities,
coordinate efforts and follow-up on this Action Plan.
2. Re-direct existing HOPWA competitive grant funds towards permanent housing.
3. Ensure Access to Set-Aside Housing Vouchers in New Hampshire for Persons with
Disabilities.
4. AIDS Service Organizations pursue opportunities to create set-aside units for persons
with HIV and AIDS in other community affordable housing developments.
PRESERVE AND UTILIZE HOMELESSNESS PREVENTION RESOURCES
1. New Hampshire AIDS service organizations (ASO’s) should identify, catalog and make
us of the various homelessness prevention and emergency assistance resources.
2. ASO’s and persons living with HIV/AIDS, perhaps through the CARE Planning Group,
should communicate to the state legislature and relevant state agencies the importance
and cost-effectiveness of homelessness prevention resources for disabled, low-income
households, especially individuals with incomes under 30% of median income.
3. The HOPWA grantees and sponsors, the State and the Boston Public Health Commission
should continue to plan their programs collaboratively through the CARE Planning
Group, as providers and consumers across the state will need to respond together to
changes in state and federal funding, as well as to changes in local needs.
EXPAND AND SUPPORT HOUSING INFORMATION & ADVOCACY SERVICES
1. HOPWA grantees and sponsors, CPG members and other stakeholders should seek or
create opportunities to be educated regarding fundamental housing information, such as
eviction prevention and basic affordable housing information.
2. HOPWA grantees, CPG members and other providers should network with other service
and housing providers by participating in local HUD Continua of Care groups.
3. Cities and towns regularly submit ‘consolidated plans’ to HUD regarding all of their
housing and community development programs, as discussed in the report. Providers
should participate in these processes; they represent valuable opportunities to impact
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 41 of 80
local priorities. Providers should make sure that the needs of low-income persons with
HIV, AIDS and other disabling conditions are among your local priorities.
ACTION #1: EXPAND PERMANENT AFFORDABLE HOUSING OPPORTUNITIES
AHC’s report found a need for long-term rental assistance for persons living with HIV
and AIDS in New Hampshire.
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35% (43/124) of the survey respondents indicated that they currently
received long-term rental assistance of some kind, whether tenant-based
(Section 8) or project-based (public housing).
25% (30/116) of the respondents indicated that they were currently in need of
long-term rental assistance and were not currently receiving such assistance.
59% (44/74) of the respondents who indicated that they used emergency
financial assistance to pay rent, mortgage and utilities were also currently in
need of long-term rental assistance.
What kinds of units and model of housing are proposed to meet this need?
Focus group participants and key informants indicated that housing stability for many
persons with HIV and AIDS in New Hampshire requires a diversity of supports,
including rental assistance, case management, food pantries, utilities assistance, etc.
We received no indication from either the focus groups or the key informant interviews
that congregate-type or ‘community’ residences were needed by persons living with HIV
and AIDS. In other locales (such as Boston), many AIDS housing programs were
established before the advent of protease inhibitors and current HIV treatment regimes.
Housing was often developed as a place for persons with advanced complications from
AIDS-related illnesses to receive final care in a home-like setting with intensive, often 24
hour services. With dramatic changes in the long-term prognosis of HIV disease in
general, people living with HIV and AIDS typically prefer to living in housing situations
that combine the support they might need to stay housed with the maximum of
independence.
With this in mind, we recommend that any units developed for persons living with HIV
and AIDS in New Hampshire be scattered-site and independent, either through tenant- or
project-based assistance.
Services to support persons living in the community would be provided through existing
community-based providers, including HOPWA sponsors, other AIDS service providers,
local visiting nurses associations, home health care providers, etc. Housing units funded
through HOPWA would include links to case management to coordinate such
individualized support for housed participants.
How many units are needed?
It is difficult to extrapolate from the survey results to the entire HIV+ population in New
Hampshire, since the survey respondents were not selected randomly or following any
stratification based on the HIV+ population. Nonetheless, survey numbers give us some
concrete indication of need for rental assistance.
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
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At least 1/4 of the respondents had an un-met current need for long-term rental assistance
and most of the persons utilizing emergency assistance indicated a need for long-term
rental assistance. Given the non-random selection survey respondents, it would be
unsound to extrapolate from these numbers to the entire population of persons living with
HIV in New Hampshire. However, since a significant amount of the emergency rental
assistance for persons with HIV/AIDS in New Hampshire is provided through the 3
HOPWA grants and survey respondents were all recruited through agencies dispersing
HOPWA funds, it is more reasonable to base a need estimate from the utilization
numbers for those grants.
Based on the survey responses regarding unmet need for long-term assistance especially
by users of emergency assistance, we assume that 1/3 of the households that accessed
HOPWA emergency rent, mortgage and utilities assistance in one recent 12 month
reporting period were actually in need of long-term rental assistance. Based on the most
recent Annual Progress Reports (APR) submitted to HUD for the 3 grants, 175 persons
accessed emergency assistance in a 12-month period.
We estimate, then, that at least 58 households affected by HIV and AIDS in New
Hampshire have a current un-met need for long-term rental assistance. We believe that
this is likely a conservative estimate but is reasonable based upon available numbers.
If we broke this down regionally and according to the 3 HOPWA grants, estimated need
would look more like this:
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Greater Manchester: 15 households
Nashua: 16
Balance of State: 27 (with 11 in Concord)
Reviewing emergency assistance utilization data from the 3 HOPWA grants, there is
need for assistance serving a variety of sized households. In Nashua, for instance, over
70% of the households served were in 2+ bedrooms. Developed resources should
therefore serve a variety of household sizes.
What would it cost to meet this need?
To estimate the costs of funding 58 new units of long-term rental assistance across the
state, we are assuming that all would be in the form of ongoing, tenant-based rental
assistance. Costs for the capital development of project-based units, such as units setaside for HIV+ persons in a larger affordable development, would be much different
(total development costs for individual units typically run into the tens of thousands of
dollars). We explore below a few development possibilities but estimated costs here are
based on tenant-based rental assistance.
To estimate costs, we used a bedroom size mix based upon annual utilization of
emergency rental assistance on the 3 HOPWA grants. We assumed extremely low
incomes based upon SSI (Supplemental Security Income) rates for New Hampshire,
approximated participant rent payments of $150 (accounting for utility allowances),
deducted this from the Fair Market Rent limits for the various bedroom sizes and applied
a value weighted for bedroom size mix to get an conservative average per household cost.
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 43 of 80
In Manchester, we estimate that average per household program costs for rental
assistance would be approximately $8,791 per year. To house 15 households of various
bedroom sizes, it would costs about $132,000 per year.
In Nashua, we estimate per household programs costs of $10,531. To house 16
households, it would cost about $168,000 per year.
For the balance of the State, we estimate annual costs of $7,692 per household. To house
27 households in the rest of the state, including Concord and Portsmouth, it would cost
about $208,000 per year.
Total estimated costs for providing rental assistance to 58 households per year: $508,000
(about $8,760 per household).
Steps to Meet Un-met Long-Term Housing Needs:
Participants in our action plan meeting were cautious regarding solutions that would
involve the capital development of real property for ownership and leasing by non-profit
AIDS Service Organizations (ASO’s). None of the ASO’s in New Hampshire currently
own or manage affordable rental property (although AIDS Services of the Monadnock
Region is pursuing the purchase of an SRO building in Gilsum). Rather, participants
favored a so-called ‘non-development’ approach. This would involve solutions that don’t
require that ASO’s enter into the development of affordable rental properties. The two
primary non-development solutions would be the funding of tenant-based rental vouchers
or the securing of ‘set-aside’ units within a larger affordable rental project for use by
persons living with HIV and AIDS.
1. Re-direct HOPWA funds towards permanent housing.
The most straight-forward way to create tenant-based rental assistance would be to reallocate funds within the 3 New Hampshire HOPWA grants. If the analysis of this report
is correct, then some of the funds currently allocated for emergency assistance in the 3
grants might be more appropriately directed towards long-term rental assistance. Reallocation can take place either as an amendment of a current grant or through the
renewal process.
Amending a current grant is the simplest of these alternatives, only requiring the approval
of the local HUD Field Office that oversees the particular grant. The renewal process is
another opportunity to change a grant, though line items can only increase by 20% under
normal HOPWA renewal guidelines (and overall grant amounts typically are not
increased).
Amending HOPWA grants would only go a short ways towards meeting this need. First,
there will continue to be a need for important HOPWA emergency rent, mortgage and
utilities assistance provided through these grants. Second, it would be much more costly
per household to provide monthly rent assistance than to provide 21 weeks of emergency
assistance, meaning that redirected emergency dollars will serve fewer households
(annual HOPWA emergency assistance only averaged about $900 per household across
the state; compare with annual costs between $7,000 and 11,000 per household). Finally,
none of the grants have enough resources to match the need in their area. In the most
recent 12 month HOPWA reporting period, the total amount that all 3 HOPWA grants
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 44 of 80
spent on emergency rent, mortgage and utilities assistance was only just over $175,000.
If 1/3 of this was directed towards rental assistance, it would only house 6-8 households.
Action Steps:
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HOPWA grantees redirect HOPWA assistance into permanent housing,
through grant amendments with HUD’s Manchester Field Office.
AIDS Housing Corporation provides technical assistance as needed to
grantees to assist in determining amendments amounts and implementing
tenant-based rental assistance.
2. Ensure Access to Set-Aside Housing Vouchers in New Hampshire for Persons with
Disabilities.
There are about 250 housing vouchers available in New Hampshire specifically for low
income persons with a disability. By location, they break down as follows:
ƒ Dover Housing Authority: 30
ƒ Harbor Homes: 75
ƒ Keene Housing Authority: 50
ƒ Lebanon Housing Authority: 17
ƒ Manchester Housing Authority: 4
ƒ Nashua Housing Authority: 9
ƒ NH Housing Finance Authority: 64
These vouchers represent a variety of allocation streams that HUD has created over the
last decade primarily designed to house disabled persons in scattered site housing as an
alternative to placing them in federally funded project based housing with the elderly.
Represented in these numbers are Section 8 vouchers (Project Access, Fair Share SetAsides, ‘Certain Developments’, ‘Designated Housing’) and vouchers funded using 811
program funds (‘Mainstream Vouchers’). Many (though not all) persons with HIV/AIDS
would meet the HUD definition of ‘disabled’, which is broader than the Social Security
Administration’s determination standard. More detailed information regarding these
often unknown programs can be found on the Technical Assistance Collaborative’s
(TAC) website, at: http://www.tacinc.org/index/viewPage.cfm?pageId=31
As discussed on the Technical Assistance Collaborative’s website and in the September
2004 edition of their newsletter, Opening Doors (http://www.c-c-d.org/od-sept04.htm),
there have been substantial problems at the local level regarding these various dedicated
vouchers. As TAC reports, many housing authorities have not tracked the use of these
vouchers over time, meaning that there is the possibility that they have been issued or reissued to persons who are not disabled.
In 2004 and 2005, HUD issued instructions to housing authorities and non-profits
administering these various vouchers regarding the need to maintain these vouchers as for
disabled persons (and document compliance). TAC estimates that as many as 1/3 of
these vouchers may have been issued to persons without disabilities, despite eligibility
restrictions. According to a recent survey from TAC, many housing authorities are not
even aware that they have such set-aside vouchers in their housing portfolio.
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 45 of 80
Action Steps:
AIDS Housing Corporation follows TAC in recommending that local disability
advocates, including AIDS service providers, contact the local administrators of these
set-aside vouchers to determine the following:
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Are they aware that they have such set-aside vouchers in their housing
portfolio?
Were 100% of the vouchers issued to persons with disabilities?
Are vouchers being re-issued only to eligible persons upon turnover, as
required?
Harbor Home and Keene Housing Authority both have vouchers funded
through the ‘Mainstream Voucher’ program, using HUD 811 program funds
(and not Section 8 funds). Are these vouchers being held harmless from any
local freezes on Section 8 Housing Choice Voucher Program funds (since
they are funded outside of HCVP)?
Advocacy information on this issue can be found at:
http://www.tacinc.org/index/viewPage.cfm?pageId=145
3. AIDS Service Organizations pursue opportunities to create set-aside units for persons
with HIV and AIDS in other community affordable housing developments.
The development of affordable housing is time and resource intensive and requires
significant capacity and commitment to create new units. Many of the AIDS service
providers in New Hampshire would be legitimately wary of taking on the capital
development of affordable housing. With this in mind, AHC recommends that AIDS
service providers consider so-called ‘non-development’ options, such as partnering with
other local community development organizations to create set-aside units for persons
with HIV/AIDS. A variety of potential development partners exist around the state. The
key to this strategy would be to establish working relationships locally with such groups,
using a variety of development resources to fund housing for persons with HIV/AIDS.
Potential financing resources include:
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New Hampshire Housing’s ‘Special Needs’ Housing Program. The financing for
Special Needs Housing Program projects may be from a combination of sources
such as HOME and the Federal Home Loan Bank’s Affordable Housing Fund.
The applications for financing consideration are accepted on a competitive basis
two times annually. Rules for this program can be found at:
http://www.nhhfa.org/rules/hfa112.pdf.
This funding is awarded twice annually, through a competitive competition. It
covers new construction, acquisition and/or rehabilitation, reconstruction or
conversion. Assistance is limited to $600,000 per project. This program “is
intended to be available to projects which provide a service component to the
occupants and which would require levels of funding beyond which the private
financial models are willing to invest.” Eligible projects include “permanent
rental housing, single room occupancy (SRO), transitional housing, and group
homes/shelters with ongoing social service programs relative to the needs of the
residents.” Housing for persons with HIV/AIDS is among the stated priorities
for this program. In fact, one of the first uses of this program was for 4 units
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 46 of 80
developed in Dover, set aside for persons with HIV/AIDS through AIDS
Response Seacoast in partnership with a private developer.
The advantage of this resource is its flexibility. Its disadvantage is the cap on
assistance, meaning that this resource would typically not be a sole source of
project financing. Also, as word of the program has gotten out, New Hampshire
Housing has been receiving more requests than it can fund.
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New Hampshire Housing Low-Income Tax Credit Program. Low-Income
Housing Tax Credits are one of the primary means for financing affordable
housing development in the United States. In 2004, New Hampshire Housing
issued over $2.25M in tax credits for 7 New Hampshire developments. The
significance of this program for meeting the housing needs of persons with
HIV/AIDS is that New Hampshire Housing’s ‘Qualified Allocation Plan’ that
guides this program contains a number of priorities that would favor ‘special
needs’ developments created by non-profit organizations.
http://www.nhhfa.org/lihtc_2006QAP_draft.htm
Specifically, the QAP awards points if the project has ‘service enriched units,
with services ‘actively linked’ to the project. Maximum points for this are
awarded for Single Room Occupancy (SRO) units or transitional housing units.
The project must have a design and service package that comprehensively
addresses the needs of the homeless or transitional clientele. Also, 10% of the
tax-credits are set-aside for non-profits whose mission in part to ‘foster lowincome housing development’.
The advantage of this program is that it can bring large amounts of capital to
projects. The disadvantages of this program are its complexity, that Tax Credit
projects usually need to be large in order to be economically viable and that it
only brings affordability down to persons at 50% or so of Median Income. As
our report has demonstrated, many persons living with HIV and AIDS in New
Hampshire are below 30% of Median Income, with many below the federal
poverty level. Units financed with tax credits would need additional
development capital or operating subsidies to drive affordability down far enough
for such persons.
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HOPWA: HOPWA monies can be used for the acquisition, rehabilitation or
conversion of properties for use by persons living with HIV and AIDS. It can
also be used for the new construction of Single Room Occupancy and
Community Residence units. The current HOPWA competitive grants have
scant resources for the capital development of new units. However, HUD offers
new HOPWA grant opportunities through its annual Super-NOFA procurement
process. The Super-NOFA is typically released in the Spring of each year. A
development project that included in part or in full permanently affordable units
for use by persons with HIV and AIDS would likely be a competitive use of
HOPWA funds. Depending on the terms of the NOFA, potential recipients of
HOPWA grants include non-profit organizations and municipalities.
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 47 of 80
•
The New Hampshire Community Loan Fund
The New Hampshire Community Loan Fund has a Community Housing Program
that promotes the development of affordable housing in New Hampshire through
the provision of loans and technical assistance. This program “fills critical gaps
in the complex system by which affordable housing is financed and helps
community groups that are tackling their first housing project to get
started.” For more information, see:
http://www.nhclf.org/programs/housing/community/index.html.
Action Steps:
Practically speaking, few of the AIDS service organizations in new will be interested in
or willing to take on the capital development and ownership of affordable housing
projects. However, ASO’s could pursue partnerships with other affordable housing
organizations and low-income housing developers to create ‘set-aside’ units for persons
with HIV and AIDS in other local projects.
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AIDS Service Organizations (especially the HOPWA grantees and sponsors
but including CARE act recipients) should form a housing committee that
sets a housing agenda for persons with HIV and AIDS in NH. This
committee can direct and promote collaboration with local affordable
housing developers to create supported units in the community, set aside for
persons with HIV and AIDS.
Collaboration with local affordable housing developers would assist them in
their need to target populations prioritized by various funding streams, as
with the Low Income Housing Tax Credit program through New Hampshire
Housing.
This committee could also help redirect and enhance HOPWA grant funds in
NH by coordinating priorities based upon the findings of this report.
A housing committee could be facilitated by AIDS Housing Corporation.
ACTION #2: PRESERVE AND UTILIZE HOMELESSNESS PREVENTION RESOURCES
Our report found that many persons living with HIV and AIDS in New Hampshire have very low
incomes and rely on a variety of resources to prevent homelessness. It will be important to
preserve and continue to fund emergency assistance around the state. In the most recent reporting
period, $193,493 was spent from the 3 HOPWA grants and Ryan White CARE Act Title I funds
along on emergency assistance for persons with HIV and AIDS in New Hampshire. Having
resources available for homelessness prevention (e.g. emergency rent and utilities assistance) is
an extremely cost-effective means of avoiding the personal, social and monetary costs of
displacement from housing. The average household emergency assistance amount from the 3
HOPWA grants was only $1,008; for CARE Act funds, it was only about $650 per household.
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HOPWA: All 3 of the competitive HOPWA grants in New Hampshire currently
provide emergency rent, mortgage and utilities assistance across the state. In the
most recently reported year, the 3 grants combined to serve 175 eligible households,
or almost 20% of the documented persons living with HIV and AIDS in New
Hampshire. Even if HOPWA funds from these 3 grants were diverted into long-term
rental assistance, as recommended above, resources should be reserved for
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 48 of 80
emergency assistance. If 1/3 of the grants’ expenditures on emergency assistance
were diverted to rental assistance, then at least $115,000 would be retained for
emergency assistance. This would still enable the HOPWA grants to serve an
estimated 115 households annually.
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Ryan White CARE Act Title I: As discussed in the report, CARE monies that come
into New Hampshire from the Boston Public Health Commission are a significant
homelessness prevention resource for persons with HIV and AIDS in Rockingham,
Stafford and Hillsborough counties. In the most recent one-year reporting period,
$81,000 was spent on emergency assistance, serving 125 households in Southern
New Hampshire (about $650 per household).
It is difficult to plan for this resource, given the dramatic uncertainties surrounding
the expected re-authorization of the CARE Act, which will likely affect both where
and how CARE Act monies can be spent.
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Other Resources: Participants in the Action Plan group identified a variety of other
homeless prevention resources that might be available for persons with HIV and
AIDS in New Hampshire. For example, the State of New Hampshire has been
shifting financial resources away from paying for emergency shelter and more
towards homeless prevention. New Hampshire Housing can pay for up to 3 months
rent for housing homeless households through its Emergency Housing Program. The
City of Nashua has a revolving loan fund that can provide both emergency and
rental-start up monies to eligible households. Some of these resources are for
families only or for households with an ability to repay loans and so many not meet
the needs of very low-income individuals with HIV and AIDS in New Hampshire.
Fuel assistance is available from Community Action agencies across the state, based
on income eligibility.
Based on recent utilization of emergency assistance, we can estimate that continued emergency
homelessness prevention assistance for at least 175 households a year will continue to be needed.
This will cost approximately $175,000 per year.
Action Steps:
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New Hampshire AIDS service organizations (ASO’s) should identify,
catalog and make us of the various homelessness prevention and emergency
assistance resources.
ASO’s and persons living with HIV/AIDS, perhaps through the CARE
Planning Group, should communicate to the state legislature and relevant
state agencies the importance and cost-effectiveness of homelessness
prevention resources for disabled, low-income households, especially
individuals with incomes under 30% of median income.
The 3 HOPWA grantees, the State and the Boston Public Health Commission
should continue to plan their programs collaboratively through the CARE
Planning Group, as providers and consumers across the state will need to
respond together to changes in state and federal funding, as well as to
changes in local needs.
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 49 of 80
ACTION #3: EXPAND AND SUPPORT HOUSING INFORMATION & ADVOCACY SERVICES
The dissemination of knowledge and information is crucial to every prevention effort and the
prevention of homelessness is no exception. Homelessness prevention and housing placement
both require knowledge, skill and up-to-date information. For many providers of services to
people with HIV and AIDS, housing issues reasonably take a back seat to helping people with
pressing medical issues. Nonetheless, providers of all sorts should be prepared to provide some
level of assistance on this issue, if even referral to other local resources.
Action Steps:
1. Educate providers:
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HOPWA grantees and sponsors, CPG members and other stakeholders
should seek or create opportunities to be educated regarding fundamental
housing information, such as eviction prevention and basic affordable
housing information. AIDS Housing Corporation is a possible provider of
such education.
AIDS Housing Corporation should work with the HOPWA grantees and
other stakeholders to create educational opportunities for providers.
2. Network for local information:
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HOPWA grantees, CPG members and other providers should participate in
local HUD Continua of Care groups. The Balance of State Continuum, for
example, has a few localized area service delivery groups that meet regularly
for the purpose of exchanging housing information. The Nashua Continuum
of Care is also very active. Information for these groups can be obtained
from the Continua of Care contacts, listed at:
http://www.hud.gov/offices/cpd/homeless/programs/cont/coc/nh/index.cfm.
New Hampshire should also consider establishing regional housing education
and information centers across the state, perhaps through some of the
Community Action agencies. These centers could provide general affordable
housing information, as well as help provide connections to landlords and
property owners. Such centers have been very effective in Massachusetts
with promoting access to stable housing and preventing homelessness.
3. Participate in local planning:
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Cities and towns regularly submit ‘consolidated plans’ to HUD regarding all
of their housing and community development programs, as discussed in the
report. Providers should participate in these processes; they represent
valuable opportunities to impact local priorities. Providers should make sure
that the needs of low-income persons with HIV, AIDS and other disabling
conditions are among your local priorities.
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 50 of 80
Appendix A: HOPWA Grant Management27
Grants management activities assist HUD, grantees, project sponsors, and potential
participants to make the best use of HOPWA funds. It includes ensuring and
documenting compliance with regulations, monitoring and reporting on program and
client outcomes, and coordinating with other planning processes so that communities can
maximize progress toward the main HOPWA goals of increasing housing stability,
reducing homelessness, and improving access to health care and supportive services.
HUD has set a national goal that HOPWA resources will assist 80 percent of recipients to
achieve these outcomes by 2008.
Grants management helps communities plan for and develop comprehensive strategies
for HIV/AIDS housing and services and prioritize which services and programs to fund.
By ensuring sound and efficient management of HOPWA programs, identifying program
and area deficiencies, and building collaboration and exchange between funders,
grantees, and project sponsors, grants management improves services for people living
with HIV/AIDS and reduces disparities in access to assistance. It also demonstrates the
importance and effectiveness of HOPWA programs to the public and policymakers when
funding levels and priorities are determined.
HUD plays several roles in grants management. In addition to providing operating
instructions for grantees each year and Field Office’s regular monitoring visits, HUD has
developed a number of information management tools to help grantees and project
sponsors achieve, maintain, and document high performance, as well as meet local and
HUD objectives.
APPLICABLE REGULATIONS AND OMB CIRCULARS
A number of regulations and circulars shape grantees’ and project sponsors’
administration of HOPWA programs and funding.
Regulations:
•
24 CFR Part 574 - Housing Opportunities for Persons with AIDS provides the
statutory guidance for grantees in determining the activities that are eligible under the
HOPWA program, the responsibilities of grantees and project sponsors, grant
administration, and other federal requirements.
This can be found at:
www.access.gpo.gov/nara/cfr/waisidx_05/24cfr574_05.html.
•
24 CFR Part 84 - Uniform Administrative Requirements for Grants and
Agreements with Institutions of Higher Education, Hospitals, and Non-Profits
applies to grantees that are nonprofit organizations. It includes information on costs,
contracts, record keeping, and monitoring project sponsors’ compliance with grant
agreements. This can be found at:
www.access.gpo.gov/nara/cfr/waisidx_02/24cfr84_02.html.
27
This appendix was substantially adapted from material authored by AIDS Housing of Washington and is
used with permission of the author.
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
Page 51 of 80
January, 2006
•
24 CFR Part 85 - Administrative Requirements for Grants and Cooperative
Agreements to State, Local, and Federally Recognized Indian Tribal Governments
provides information to grantees at government agencies about costs, contracts, record
keeping, and monitoring project sponsors’ compliance with grant agreements. This
can be found at: www.access.gpo.gov/nara/cfr/waisidx_05/24cfr85_05.html
•
Operating instructions are issued yearly. Grantees comply with the instructions from
the funding year of their grant award. Operating instructions for formula and
competitive
HOPWA
grants
can
be
found
at:
http://www.hud.gov/offices/cpd/aidshousing/library/index.cfm.
Circulars:
•
A-87 - Cost Principles for State, Local, and Indian Tribal Governments describes
eligible costs for government agencies, including HOPWA administrative costs. This
can be found at: www.whitehouse.gov/omb/circulars/a087/a087-all.html.
•
A-89 - Federal Domestic Assistance Program Information details reporting
requirements for the collection and submission of information for federally-funded
programs. This can be found at: www.whitehouse.gov/omb/circulars/a089/a089.html.
•
A-102 - Grants and Cooperative Agreements with State and Local Governments
establishes uniform standards for federal agencies administering grants and
agreements with state and local governments.
This can be found at:
www.whitehouse.gov/omb/circulars/a102/a102.html.
•
A-110 - Uniform Administrative Requirements for Grants and Agreements With
Institutions of Higher Education, Hospitals, and Other Non-Profit Organizations
describes federal agency standards for administering grants and agreements with
nonprofit organizations, including procurement, record keeping, and administrative
oversight. This can be found at: www.whitehouse.gov/omb/circulars/a110/a110.html.
•
A-122 - Cost Principles for Non-Profit Organizations establishes eligible costs for
nonprofit organizations, including indirect cost rates and administrative costs. This
can be found at: www.whitehouse.gov/omb/circulars/a122/a122.html.
•
A-133 - Audits of States, Local Governments, and Non-Profit Organizations tells
grantees what to expect and how to prepare for audits from federal agencies, as well as
what auditors are looking for in assessing risk. This can be found at:
www.whitehouse.gov/omb/circulars/a133/a133.html.
REPORTING AND MONITORING
Outcome-Based Evaluation
Reporting and monitoring help document and enhance programs’ progress toward
measurable outcomes. According to the Government Performance and Results Act, all
federal programs must document progress toward specific measurable objectives.
HOPWA outcomes center around promoting housing stability through permanent
supportive housing. The HOPWA program’s overall outcome goal is that assisted
households have been enabled to better maintain a stable living environment in housing
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 52 of 80
that is safe, decent, and sanitary, and to reduce the risk of homelessness and improve
access to HIV treatment and other health care.
All HOPWA grantees are responsible for establishing reasonable client and program
outcome goals on achieving housing stability that can be quantified annually. Outcomes
should include the number of eligible people shown to have established or maintained
housing stability each year through HOPWA housing assistance and related supportive
services, including reduced homelessness and improved access to healthcare and other
supportive services.
Grantees should also set, measure, and report on planned annual housing assistance
outputs, comparing anticipated results to actual achievements. Measured outputs should
include the projected and actual number of low-income households with people living
with HIV/AIDS benefiting from HOPWA assistance, by the type of housing assistance
provided and by each project each year. Optional outputs could also include the number
of client contacts by service, permanent housing client plans established by case
managers, and jobs created by programs. Increased access to permanent housing and
improved household self sufficiency can be measured with evidence such as increased
income, reduced need for government subsidies and support.
As of the publication of this report, HUD is in the process of adapting HOPWA grants
and report to fully incorporate performance measures. The Office of HIV/AIDS Housing
at HUD has released draft reporting tools for both the formula and competitive programs
(see below for more information on HOPWA reporting). The Office has also produced
two webcasts that are available on its website concerning these changes. Draft tools and
the webcasts can be viewed on the HOPWA program’s main page at:
http://www.hud.gov/offices/cpd/aidshousing/index.cfm.
Monitoring and Reporting Processes
Nationally, monitoring and reporting help identify trends in program delivery and key
issues and needs. Congress and the Government Accountability Office (GAO) depend on
reported information about performance and needs to make policy and funding decisions.
At the grantee and project sponsor level, monitoring and reporting ensure that
requirements, OMB-specified standards, and stated program goals are met, and that funds
are used for eligible purposes. Monitoring tracks where funding is going, what assistance
it supports, who is being served, whether it is being used effectively and leveraged with
other funding sources, and whether outcomes are being met. Grantees must report to
HUD within 90 days of the close of the grantee’s program year.
In order to report to HUD, grantees depend on information submitted by project sponsors
about client demographics, project outputs and outcomes, and funds expended by
activity. Project sponsors should have processes and plans in place to collect data and
assess project and client baselines and progress. Grantees should regularly monitor
project sponsors, to ensure and enhance existing data collection, file maintenance, and
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 53 of 80
accounting systems, as well as to document project sponsors’ appropriate use of funds
and compliance with grant agreements, regulations, and circulars.
HUD Field Offices use monitoring visits and risk analyses and assessment tools to
evaluate grantees and to establish local monitoring priorities. The five key assessed
categories are financial, physical, management, satisfaction, and services. Typically, the
factors that Field Offices consider in risk assessment include the program type,
complexity, capacity, recent problems, past monitoring issues, financial concerns, timely
use of funds, and total amount of the grant.
Tools
HUD is in the process of redesigning the Integrated Disbursement and Information
System (IDIS) to incorporate new department-wide performance measures and offer
grantees easier access to information that they can use to assess their progress in program
implementation, grant spend-out, and client-level outcomes. As this process is unfolding,
Community Planning and Development (CPD) has introduced new monitoring and
reporting tools, and the Office of HIV/AIDS Housing is in the process of revising and
updating existing reporting mechanisms, with a particular focus on the Annual Progress
Report (APR) for competitive grantees and the Consolidated Annual Performance
and Evaluation Report (CAPER) for formula grantees.
The end result of these efforts will be a more integrated and user-accessible method of
recording, tracking and reporting on key data and benchmarks for all HUD contractors
and grantees. In the short term, the Office of HIV/AIDS Housing and its HOPWA
technical assistance providers will be developing additional guidance on using these
tools, creating case studies of best practices in the field, and offering nationwide training
to assure that all grantees and program sponsors are knowledgeable about their respective
roles and responsibilities and have access to appropriate information, templates, and
guidance to use them consistently and effectively.
Competitive grantees report on their activities at the end of each program year using the
Annual Progress Report (APR), which provides HUD with information about activities,
expenditures, accomplishments, beneficiaries, and outcomes of HOPWA-funded
programs. In revising the APR in 2005, the Office of HIV/AIDS Housing is incorporating
new performance measures to assess housing stability, reduced homelessness, and access
to healthcare and supportive services.
Competitive grantees awarded funds in 2003 or later include updated logic models with
their APRs. Logic models link HUD’s strategic goals and policy priorities with grantees’
program goals and outcomes, and demonstrate how planning for the use of resources
resulted in measurable outputs and client outcomes over the previous operating year.
Formula grantees also report annually on activities, expenditures, accomplishments,
beneficiaries, and outcomes for their HOPWA-funded programs through the
Consolidated Annual Performance and Evaluation Report (CAPER) and Integrated
AIDS Housing Corporation
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January, 2006
Page 54 of 80
Disbursement and Information System (IDIS). Information submitted in the CAPER
and IDIS should be consistent and demonstrate that HOPWA funds and other resources
are being used to meet the housing and supportive services needs of low-income people
living with HIV/AIDS and their families in coordination with the local consolidated
planning process and other comprehensive community plans and housing strategies.
Grantees use the Line of Credit Control System (LOCCS), HUD’s accounting and
reimbursement system, to draw down funds as they expend them. Timely use of LOCCS
is important to not only help Field Offices monitor and document the allocation of funds,
but also because grantees can use LOCCS reports to make sure that funds are being spent
steadily and within the term of their grant.
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January, 2006
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Appendix B: HOPWA and Ryan White CARE Act Service Areas
AIDS Housing Corporation
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January, 2006
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AIDS Housing Corporation
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January, 2006
Page 57 of 80
Appendix C: Data Tables
The following charts compares the demographics of (from left to right) the 39
participants of the 5 focus groups held for this study, the 125 survey respondents of this
study, and the total population of persons living with HIV/AIDS throughout New
Hampshire, a total of 978 persons.
GENDER
100
78.4
80
Percent
76
63
60
37
40
24
20.8
Males
Females
20
0
Focus groups
Survey respondents
NH
RACE
100
80
Percent
86.1
76.8
67.6
White
60
Black/ African American
40
20
0
13.5
13.3
10.4
Focus groups
Survey
respondents
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
0.01
4
American Indian/ Native
Alaskan
NH
Page 58 of 80
ETHNICITY
100
88.7
84
77.1
80
Percent
60
40
22.9
12.8
20
0
Focus groups
Hispanic/ Latino
11.3
Survey
respondents
Non-Hispanic/ Non-Latino
NH
AGE
100
80
Percent
60
18-29
30-39
40-49
50-59
47
40
24.8
20
46.4
4.8
0
23
23
19.2
Survey respondents
7
NH
*f
or NH statewide data, the age group of 18-29 does not include people ages 18 and 19. However, since those living
with HIV/AIDS ages 19 and under is such a small data set (<12), this chart still gives a good comparison of the ages
of survey respondents to the general population of persons living with HIV/AIDS.
MODE OF EXPOSURE
100
80
60
40
Men who have sex with
men (MSM)
54.5
36
22
28
16.7
20
28.8
Heterosexual sex
Other (including IDU)
0
Focus groups
NH
*The survey used different categories for tracking mode of exposure, making comparisons unavailable for the
purpose of this table.
AIDS Housing Corporation
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January, 2006
Page 59 of 80
Poverty levels among persons
accessing NH CARE Program
Services
<100% Federal
Poverty Level
25%
101-200%
Federal
Poverty Level
>200% Federal
Poverty Level
42%
33%
Income for an individual on SSI*
INCOME VS. RENT
900
800
700
600
SSI for individual($)
500
400
1BR FMR ($)
300
200
100
M
an
ch
es
te
r
Na
sh
Po
ua
rts
m
ou
Be
th
lkn
ap
Co
Ca
.
rro
l
l
Ch
Co
es
.
hi
re
C
Co o.
os
Co
G
ra
.
fto
Hi
ll s
n
Co
bo
ro
.
ug
M
h
er
r im Co .
ac
Ro
k
ck
C
in
o.
gh
am
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ra
.
ffo
rd
Co
.
0
FMRs for 1-bedroom apartments**
* SSI benefits are for an individual in New Hampshire, as of January 2005, or $570/month. SSI benefits differ for
couples and those with shared living expenses, and can be found on Social Security Online, http://ssacusthelp.ssa.gov.
** Fair Market Rents (FMRs) are developed by the HUD and taken from the 2005 Final Revised Data, available at
http://www.huduser.org/Datasets/FMR/FMR2005R/map/nh_FY2005_FMR.pdf.
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 60 of 80
Appendix D: Focus Group Materials
Focus Group Agenda ---- 3 hours total time
11:00 – 11:15
Introduction (Alison, Jonathan & Anne)
Ground Rules
Purpose of Focus Group
Consent Form /Survey
Participants will give real name or fake name
11:15 – 11:20
Of the HIV services you have received or wish to receive, which three services
were the most important? ROUND ROBIN
11:20 – 11:35
We would like to talk about HIV services related to your medical needs……
11:35 – 11:50
We would like to talk about HIV services related to the support services
11:50 – 12:05
We would like to talk about your experience receiving education & training on
living with HIV……
12:05 – 12:15
Buffer in case Introductions &/or questions take longer
12:15 – 12:45
Lunch break
12:45 – 1:15
We would like to talk about services related to your daily living
needs….
AIDS Housing Corporation will incorporate their specific questions here.
1:15 – 1:25
What do you think the role is of individuals living with HIV in
preventing new HIV infections?
1:25 – 1:35
Have you received any prevention support services? Examples of prevention
support services include one on one counseling (AKA Prevention Case
Management), assistance with notifying partners of possible exposure (AKA
Partner Counseling and Referral Services), etc. If yes, what prevention support
service was the most important to you?
1:35 – 1:40
What one thing would you change to improve services for people living with
HIV in New Hampshire? ROUND ROBIN
1:40 – 1:50
Typically, it is recommended that people living with HIV visit a medical
provider at least one time per year to receive a CD4 count, viral load or
antiretroviral medications. Do you know anyone living with HIV that does NOT
regularly see a medical provider? What are some of the things that prevent
individuals for doing so?
1:50 – 1:55
Is there anything else you would like us to know? Are there any questions that
we can answer before we end the session?
1:55 – 2:00
Closing / Incentives
AIDS Housing Corporation
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January, 2006
Page 61 of 80
A CONSENT FORM FOR FOCUS GROUP PARTICIPANTS
A needs assessment on people living with HIV/ AIDS in New Hampshire is being conducted by
Alison Paglia, on behalf of the New Hampshire Department of Health and Human Services and
the New Hampshire Community Planning Group and in collaboration with the AIDS Housing
Corporation. You have been asked to participate in a focus group that will be a part of a report
about the care and prevention needs, as well as the housing needs, of people with HIV/AIDS in
New Hampshire.
If you agree to take part in this focus group, you will be asked to sign this consent form. Then,
we will start with an anonymous survey and move to the focus group questions.
My participation in the project is entirely voluntary.
I understand that I may end my participation at any time, for any reason.
As you will notice, the focus group is being recorded in order to assist us in writing the final
report. We will do everything we can to prevent any violation of your privacy or confidentiality.
No one except the other members of the focus group and the facilitators will know your identity.
The facilitators have promised not to give any of your confidential information to others. This
consent form will be kept separate from the completed report and will not be connected to the
information that you give us. The final report will not contain any names or other identifying
information.
CONSENT: The purpose and procedures of this focus group have been explained to me and I
understand them. I have been told about the purpose and benefits of this project and I understand
them. I agree to participate.
____________________________________
Please PRINT your name on the line above
____________________________________
Please SIGN on the line above
__________________
Date
Consent to Quote:
In certain situations, something that you say may be very interesting or useful and the facilitators
may want to include it in the evaluation report. Again, neither your name nor any identifying
information about you will be attached to a quotation. You may revoke this consent at any time,
or indicate when you would prefer that something you say not get quoted.
May we have permission to quote you?
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
_____ Yes
______No
Page 62 of 80
Focus Group Participant Questionnaire
Do not write your name on the survey. All of the information collected on this survey will
remain anonymous. If you feel uncomfortable answering any question, leave it blank.
1. Gender
□ Female
□ Male
□ Transgender
2. Age
□ 13 – 17
□ 18 – 24
□ 25 – 34
□ 35 – 44
□
□
□
3. What is your sexual orientation?
□ heterosexual / straight
□ gay / lesbian
35 – 44
45 – 54
55 years or older
□
□
bisexual
unsure / questioning
4. What is your ethnicity?
□ Hispanic or Latino
□ Non Hispanic or Latino
5. What is your race? (Chose all that apply)
□ American Indian or Alaskan Native
□ Black or African American
□ Native Hawaiian or other Pacific Islander
□
□
□
Asian
White
Other
6. Which of the following best describes your residency status?
□ United States citizen
□ Refugee / Asylee
□ Permanent Legal Resident
□ Undocumented
7. Where are you living now?
□ Rental property
□ Shelter
□ Own home
□ Staying with friends
□ Live with family
□ Subsidized housing
□ Halfway house / drug treatment
□ Other (Please specify ____________________________________)
AIDS Housing Corporation
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January, 2006
Page 63 of 80
8. Have you had to move in the past 2 years?
□ YES
□ NO
If yes, how many times?
□ 1
□ 3
□ 2
□ 4 or more
9. How many people live in your household? _______________
10. What is your household monthly income?
□ $ 0 - $500
□ $1501 - $2000
□ $500 - $1000
□ $2001and up
□ $1001 - $1500
11. Have you ever been evicted (turned out/ asked to leave from your housing)?
□ YES
□ NO
12. Have you ever been incarcerated (in prison or jail)?
□ YES
13. Do you regularly use alcohol?
□ YES
□
NO
14. Do you regularly use illicit drugs?
□ YES
□
NO
□
NO
15. How long ago did you learn you were HIV-positive?
□ Less than 1 year
□ 5 to 9 years
□ 1 to 4 years
□ 10 years or more
16.
How do you think you became infected with HIV?
□ Male-to-Male Sex
□ Injection Drug Use
□ Heterosexual Contact
□ Sex with Injection Drug User
□ Blood Disorder or Blood Transfusion □ Unknown
□ Other (Please specify ______________________________________________)
17. What type of health insurance do you have?
□ Medicaid
□ Medicare
□ Private Insurance (HMO)
□ HMO
□ Private Insurance (not HMO)
□ Military (TriCare, etc.)
□ None
□ Other (Please specify _____________________________ )
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January, 2006
Page 64 of 80
18. In the last 12 months, how many times have you received medical attention?
□ Not at all
□ 5 to 8 times
□ 1 time
□ 9 or more times
□ 2 to 4 times
19. When was your last CD4 count?
□ Within the last 3 months
□ 3 to 6 months
□
□
7 to 12 months
1 year or more
20. When was your last viral load test?
□ Within the last 3 months
□ 3 to 6 months
□
□
7 to 12 months
1 year or more
21. When did you last take antiretroviral drugs (i.e. drug cocktail, HAART)?
□ Within the last 3 months
□ 7 to 12 months
□ 3 to 6 months
□ 1 year or more
□ never
AIDS Housing Corporation
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January, 2006
Page 65 of 80
Appendix E: List of Key Informants
Chris Stendale, Director
Crossroads House, Portsmouth
Wendy Furnari, Case Manager
Southern New Hampshire AIDS Task Force,
Peter Kelleher, Director
Harbor Homes, Nashua
Bridge Belton-Jette
Greater Nashua Neighborhood Housing Services, Nashua
Lillye Ramos-Spooner, Director
GMAP, Manchester
Maureen Healey, Case Manager and Prevention Case Manager
ACORN, Lebanon
Susan MacNeil, Director
AIDS Services of the Monadnock Region, Keene,
Norm Flateau, Case Manager
MVAP, Concord
Andy LaBrie, Director of Homelessness Program
Community Action Program Belknap-Merrimack Counties, Concord NH
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 66 of 80
Appendix F: Survey Materials
Survey Recruitment Letter
February 24, 2005
Hello Would you like to receive a $35 gift card to Hannaford, Wal-Mart, Shaws, or Rite Aid?
Do you live in New Hampshire?
Would you like to give input on HIV prevention and care services in New Hampshire?
The NH HIV Community Planning Group is conducting an anonymous survey of people living
with HIV/ AIDS with the help of AIDS Housing Corporation and the New Hampshire
Department of Health and Human Services. The survey asks about the needs of people living
with HIV/ AIDS. The survey results will be used to inform decisions regarding HIV prevention
and care in the state of NH.
We hope you will help us by filling out a survey.
There are two ways you can get an anonymous survey. You can get one at a
participating ASO between 03/07/05 to 03/28/05. The participating ASO’s are listed on the
back of this letter. Or, you can call the NH HIV Hotline at 1-800-752-2437 and ask them to
confidentially mail a survey to you. English and Spanish surveys are available.
We hope that you will fill out an anonymous survey and return it by 03/28/05. The first
200 people to return the completed survey in the postage paid envelope and the postage
paid incentive post card will receive gift cards in the mail worth $35. To protect your
privacy the incentive post card and the survey will be mailed to two separate addresses
and the information you provide on the survey will not be connected to your name or
mailing address in anyway.
Thank you for your help!
If you have any questions about the survey, please call 603-995-1222.
If you would like information about HIV/AIDS services available in New Hampshire and/or
would a copy of the final report (available in June of 2005),
please call: 1-800-852-3345 - Extension # 4502.
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 67 of 80
AIDS Community Resource Network
85 Mechanic St. #240
Lebanon, NH 03166
Toll free: 1-800-816-2220 or (603) 448-8887
Monday – Friday 8:00 AM – 4:00 PM
Any questions? Ask Maureen Healey
AIDS Response Seacoast
1 Junkins Ave.
Portsmouth, NH 03801
Toll free: 1-800-375-1144 or (603) 433-5377
Monday – Friday 9:00 AM - 5:00 PM
Any questions? Ask Assiah Russell
AIDS Services for the Monadnock Region
103 Roxbury St. # 306
Keene, NH 03431
Toll free: 1-800-639-7903 or (603) 357-6855
Tuesday 9:00 AM – 5:00 PM
Wednesday 11:30 – 3:30
Friday 11:30 – 3:30
Any questions? Ask Patrick Preston
Greater Manchester AIDS Project
170 Lowell Street
Manchester, NH 03104
Toll free: 1-800-639-1122 or (603) 623-0710
Monday – Friday 9:00 AM – 5:00 PM
Any questions? Ask Lillye Ramos-Spooner
Merrimack Valley AIDS Project
8 Wall Street PO Box 882
Concord, NH 03302 or (603) 226-0607
Monday – Friday 10:00 AM – 2:00 PM (preferred)
Any Questions? Ask Norm Flateau or Joyce Gardner
Southern NH AIDS Task Force
111 Lock Street
Nashua, NH 03064
Toll free: 1-800-942-7437 or (603) 595-8464
Monday – Friday 9:00 AM – 5:00 PM
Any Questions? Ask Kolin Melendy
NH AIDS Hotline
1-800-752-2437
AIDS Housing Corporation
Final Report: NH AIDS Housing Assessment
January, 2006
Page 68 of 80
New Hampshire Needs Assessment Survey
Do not write your name on the survey. Al of the information collected on this survey will
remain anonymous. Your survey will help us plan for HIV-related services in New Hampshire.
Please answer each of the questions to the best of your ability. If you feel uncomfortable
answering any question or do not know the answer, leave it blank. Your individual answers
will not be shared with anyone. Please answer only one survey.
The first 200 people to return the attached stamped post card and the completed survey by
03/28/05 in the postage paid pre-addressed envelope will receive $35.00 in gift cards to local
stores like Hannaford, Rite Aid, and Wal-Mart. The information you provide on the post card
will only be used to mail the gift cards; the information will not be connected to the survey.
Thank You for your help !!!!
1. Do you have HIV?
□ Yes
□ No (If no, please Stop.
Do not complete this survey. Do not return it.)
2. Have you been diagnosed with AIDS?
□ Yes
□ No
3. What is your gender?
□ Female
□ Male
□ Transgender – Male-to-Female
□ Transgender – Female-to-Male
4. What month were you born?____________________ What year were you born?______________
5. What is your sexual orientation?
□ Heterosexual or straight
□ Homosexual, gay or lesbian
□ Bisexual
□ Unsure or questioning
6. What is your ethnicity?
□ Hispanic or Latino
□ Not Hispanic or Latino
7. What is your race? (Check all that apply)
□ American Indian or Alaskan Native
□ Black or African American
□ Native Hawaiian or other Pacific Islander
□ Asian
□ White
□ Other, specify: ________________________
PLWHA Needs Assessment 69
8. Which of the following best describes your citizenship status?
□ United States Citizen – Born in US
□ Waiting for documentation of residency
□ United States Citizen – Foreign Born
□ Undocumented
□ Permanent or Temporary Legal Resident
9. Where are you living now?
□ Rental property
□ Shelter (Skip to 11)
□ Own home (Skip to 11)
□ In a friend’s home (Skip to 11)
□ In a family member’s home (Skip to 11)
□ Halfway house / drug treatment (Skip to 11)
□ Homeless (Skip to 11)
□ Other, Please specify ____________________(Skip to 11)
10. If you rent, is your rent subsidized housing, Section 8 or other public housing?
□ Yes
□ No
11. What city or town do you currently live in? ____________________________________________
12. Have you moved in the past 2 years?
□ Yes
□ No
If yes, how many times?
□ 1
□ 3
□ 2
□ 4 or more
13. Have you been homeless or without a place to live in the past 2 years?
□ Yes
□ No
14. Have you ever had bad credit get in the way of getting housing?
□ Yes
□ No
15. How many people live in your household? _______________
16. What is the monthly income of your entire household before taxes?
□ $ 0 - $500
□ $1501 - $2000
□ $500 - $1000
□ $2001 and up
□ $1001 - $1500
17. What is your source of income? (check all that apply)
□ Salary / wages
□ Emergency Assistance
□ SSI (Social Security)
□ Veteran’s Assistance
□ SSDI (Social Security – Disability)
□ Unemployment
□ TANF / Welfare
□ Other, please specify _________________________
PLWHA Needs Assessment 70
18. Have you ever been evicted or asked to leave where you were living?
□ Yes
□ No
19. Have you ever been refused or denied housing?
□ Yes
□ No
20. Have you ever been incarcerated, in prison or jail?
□ Yes
□ No
21. Have you received HOPWA (Housing Opportunities for Persons with HIV) services?
□ Yes
□ No
If yes, which of the following did you receive (check all that apply)?
□ Short term mortgage / rental assistance
□ Utility payments
□ Long term rental assistance
□ Security Deposit
□ Mental Health Counseling
□ Moving Truck Rental
□ Substance Abuse Treatment
□ Public transportation expenses related to HIV
□ Medical Equipment
□ Food Vouchers
22. How often do you use alcohol and/or other drugs?
□ Daily
□ Less than once a month
□ Weekly
□ Never
□ Monthly
□ In recovery
23. When you use drugs, which ones do you use? (Check all that apply)
□ Alcohol
□ Heroin
□ Marijuana
□ LSD/other Hallucinogen
□ Cocaine
□ Crystal Meth/ Speed/ XTC/GHB
□ Tobacco
□ NONE
□ Other, specify:___________________________________________________________________
24. How long have you known you were HIV-positive?
□ Less than 1 year
□ 5 to 9 years
□ 1 to 4 years
□ 10 years or more
□ Don’t remember
25. How do you think you became infected with HIV? (Check all that apply)
□ Sex with male
□ Heterosexual sex with bisexual male with HIV/AIDS
□ Sex with female
□ Heterosexual sex with injection drug user with HIV/AIDS
□ Injection drug use
□ Heterosexual sex with a person with HIV/AIDS
□ Other, Please specify _____________________________________________________________
26. Are you enrolled in the New Hampshire CARE Program?
□ Yes
□ No
PLWHA Needs Assessment 71
27. Are you a client of one of the following NH AIDS Services Organizations; AIDS Community
Resource Network (ACORN), AIDS Response Seacoast (ARS), AIDS Services for the Monadnock
Region (ASMR), Greater Manchester AIDS Project (GMAP), Merrimack Valley AIDS Project (MVAP), or
Southern NH AIDS Task Force (SNHATF)?
□ Yes
□ No
PLWHA Needs Assessment 72
28. What type of health insurance do you have?
□ Medicaid
□ Medicare
□ Private Insurance
□ Military (TriCare, etc.)
□ Other, specify
□ None
____________________
29. In the last 12 months, have you had any of the following? (Check all that apply)
CD 4 count
□ Yes □ No – if no, why not?________________________________
Viral Load Test
□ Yes
□ No – if no, why not?________________________________
Antiretroviral Therapy
□ Yes
□ No – if no, why not?________________________________
30. How soon after being diagnosed with HIV or AIDS did you see a doctor or a nurse about your HIV
infection?
□ Never
□ 0 – 6 months
□ 7-12 months
□ 1 year or more
□ Other, Specify: ___________________________________________________________________
31. Since learning that you were HIV positive, have you gone 12 months or more without seeing a
doctor or a nurse about your HIV infection?
□ Yes
□ No
If Yes, why? (Check all that apply)
□ I did not have health insurance
□ I did not know where to go
□ I had bad experiences with doctors or nurses
□ I could not get an appointment
□ Services were not available where I lived
□ Did not think a medical provider could help
□ I could not find a doctor that speaks my language
□ I was afraid others would find out I have HIV
□ I could not take time off of work
□ I could not keep my appointments
□ I did not have a stable enough living situation
□ Other, please specify: _____________________________________________________________
32. Since learning that you were HIV positive, have you gone 12 months or more without taking your
HIV medications? □ Yes
□ No
□ Never taken HIV medications
If Yes, why? (Check all that apply)
□ I cannot pay for them
□ My doctor says I do not need them
□ Side effects
□ Drug holiday (a break from taking my HIV medications)
□ I do not think I need the medications
□ I cannot take them regularly due to an unstable living situation
□ My doctor will not prescribe them until my living situation is more stable
□ My doctor will not prescribe them until I am clean and sober
□ Other, please specify:
Directions: Please indicate whether or not you need the following HIV- related services, if you
use the services, and then circle the answer that best rates your experiences with this service.
Medical/Health
Services
Do you need
this service?
Have you used
this service?
How easy or hard is it for you to get
this service?
(please circle your answer)
Regular HIV care
□ yes
□ no □ yes
□ no
Easy
Medium
Hard
Emergency medical care
□ yes
□ no □ yes
□ no
Easy
Medium
Hard
Home Medical Care
□ yes
□ no □ yes
□ no
Easy
Medium
Hard
Women’s Health (family
planning, pregnancy)
Dental Care
□ yes
□ no □ yes
□ no
Easy
Medium
Hard
□ yes
□ no □ yes
□ no
Easy
Medium
Hard
Eye Care
□ yes
□ no □ yes
□ no
Easy
Medium
Hard
Nutritional Supplements
HIV Medications
□ yes
□ no □ yes
□ no
Easy
Medium
Hard
□ yes
□ no □ yes
□ no
Easy
Medium
Hard
Physical Therapy
In general which of the following has been a problem for you when you have tried to get medical/health
services? Please check all that apply.
□ No problem
□ Services not at a convenient time
□ I did not know where to go
□ Too long of a wait
□ Transportation
□ Discrimination because of HIV status
□ Child Care
□ Discrimination because of race/ethnicity
□ Service not available
□ Discrimination because of sexual orientation
□ I did not qualify for service
□ Concerned about my privacy
□ I could not afford service
□ Nervous or afraid of what people may say
□ They do not speak my language
□ Not in a stable enough living situation to get this service
□ Other, please specify: ___________________________________________________________________
In general, how satisfied have you been with the medical/health services you received?
□ very satisfied
□ somewhat satisfied
□ somewhat dissatisfied
□ very dissatisfied
Please list the services you were dissatisfied with:
PLWHA Needs Assessment 74
Directions: Please indicate whether or not you need the following HIV- related services, if you
use the services, and then circle the answer that best rates your experiences with this service.
Support Services
Do you need
this service?
Have you used
this service?
How easy or hard is it for you to get
this service?
(please circle your answer)
Case Management
□ yes
□ no
□ yes
□ no
Easy
Medium
Hard
HIV/AIDS Support
Group(s)
Mental Health Counseling
□ yes
□ no
□ yes
□ no
Easy
Medium
Hard
□ yes
□ no
□ yes
□ no
Easy
Medium
Hard
Substance Abuse
Treatment
Legal Assistance
□ yes
□ no
□ yes
□ no
Easy
Medium
Hard
□ yes
□ no
□ yes
□ no
Easy
Medium
Hard
In general which of the following has been a problem for you when you have tried to get support
services? Please check all that apply.
□ No problem
□ Services not at a convenient time
□ I did not know where to go
□ Too long of a wait
□ Transportation
□ Discrimination because of HIV status
□ Child Care
□ Discrimination because of race/ethnicity
□ Service not available
□ Discrimination because of sexual orientation
□ I did not qualify for service
□ Concerned about my privacy
□ I could not afford service
□ Nervous or afraid of what people may say
□ They do not speak my language
□ Not in a stable enough living situation to get this service
□ Other, please specify: ___________________________________________________________________
In general, how satisfied have you been with the support services you received?
□ very satisfied
□ somewhat satisfied
□ somewhat dissatisfied
□ very dissatisfied
Please list the services you were dissatisfied with:
PLWHA Needs Assessment 75
Directions: Please indicate whether or not you need the following HIV- related services, if you
use the services, and then circle the answer that best rates your experiences with this service.
Daily Living
Do you need
this service?
Have you used
this service?
How easy or hard is it for you to
get this service?
(please circle your answer)
Food Bank and/or Food
Vouchers
Emergency Financial
Assistance (utilities, rent)
Homemaker Services
(shopping, cleaning, etc.)
Long-term rental assistance
(section 8 / public housing)
Housing Search Assistance
□ yes
□ no □ yes
□ no
Easy
Medium
Hard
□ yes
□ no □ yes
□ no
Easy
Medium
Hard
□ yes
□ no □ yes
□ no
Easy
Medium
Hard
□ yes
□ no □ yes
□ no
Easy
Medium
Hard
□ yes
□ no □ yes
□ no
Easy
Medium
Hard
Landlord/tenant Advocacy
□ yes
□ no □ yes
□ no
Easy
Medium
Hard
Security Deposit & Moving
Assistance
□ yes
□ no □ yes
□ no
Easy
Medium
Hard
In general which of the following has been a problem for you when you have tried to get daily living
services? Please check all that apply.
□ No problem
□ Services not at a convenient time
□ I did not know where to go
□ Too long of a wait
□ Transportation
□ Discrimination because of HIV status
□ Child Care
□ Discrimination because of race/ethnicity
□ Service not available
□ Discrimination because of sexual orientation
□ I did not qualify for service
□ Concerned about my privacy
□ I could not afford service
□ Nervous or afraid of what people may say
□ They do not speak my language
□ Not in a stable enough living situation to get this service
□ Other, please specify: ___________________________________________________________________
In general, how satisfied have you been with the daily living services you received?
□ very satisfied
□ somewhat satisfied
□ somewhat dissatisfied □ very dissatisfied
Please list the services you were dissatisfied with:
PLWHA Needs Assessment 76
Directions: Please indicate whether or not you need the following HIV- related services, if you
use the services, and then circle the answer that best rates your experiences with this service.
Education
& Training related
to living with HIV
Information about treating
HIV/AIDS
Help taking HIV
medications
Help dealing with the side
effects of HIV medications
Information about the
transmission of HIV
Nutrition Counseling
Do you need
this service?
Have you used
this service?
How easy or hard is it for you to get
this service?
(please circle your answer)
□ yes
□ no □ yes
□ no
Easy
Medium
Hard
□ yes
□ no □ yes
□ no
Easy
Medium
Hard
□ yes
□ no □ yes
□ no
Easy
Medium
Hard
□ yes
□ no □ yes
□ no
Easy
Medium
Hard
□ yes
□ no □ yes
□ no
Easy
Medium
Hard
In general which of the following has been a problem for you when you have tried to get education and
training related to living with HIV? Please check all that apply.
□ No problem
□ Services not at a convenient time
□ I did not know where to go
□ Too long of a wait
□ Transportation
□ Discrimination because of HIV status
□ Child Care
□ Discrimination because of race/ethnicity
□ Service not available
□ Discrimination because of sexual orientation
□ I did not qualify for service
□ Concerned about my privacy
□ I could not afford service
□ Nervous or afraid of what people may say
□ They do not speak my language
□ Not in a stable enough living situation to get this service
□ Other, please specify: ___________________________________________________________________
In general, how satisfied have you been with the education and training services you received?
□ very satisfied
□ somewhat satisfied
□ somewhat dissatisfied □ very dissatisfied
Please list the services you were dissatisfied with:
PLWHA Needs Assessment 77
Directions: Please indicate whether or not you need the following HIV- related services, if you
use the services, and then circle the answer that best rates your experiences with this service.
HIV Prevention Education Services
PCRS (assistance informing your
previous sexual and needle sharing
partners about their HIV risk without
sharing your name)
PCM (individual counseling from a
licensed professional for help with safer
sex and/or drug use)
IRRC (individual counseling from a paraprofessional to help you with safer sex
and/or drug use)
Group counseling to help you with safer
sex and/or drug use
Support group about HIV prevention with
other people living with HIV
Support from another person living with
HIV that is trained as an educator
Hotline or someone on the phone to talk
about safer sex
Internet chat with someone to talk about
safer sex
Free condoms
Do you
need this
service?
□ yes
□ no
Have you
used this
service?
□ yes
□ no
How easy or hard is it for you to get
this service?
(please circle your answer)
Easy
Medium
Hard
□ yes
□ no
□ yes
□ no
Easy
Medium
Hard
□ yes
□ no
□ yes
□ no
Easy
Medium
Hard
□ yes
□ yes
Easy
Medium
Hard
□ no
□ no
□ yes
□ yes
Easy
Medium
Hard
□ no
□ no
□ yes
□ yes
Easy
Medium
Hard
□ no
□ no
□ yes
□ yes
Easy
Medium
Hard
□ no
□ no
□ yes
□ yes
Easy
Medium
Hard
□ no
□ no
□ yes
□ yes
Easy
Medium
Hard
□ no
□ no
Information about cleaning drug works
□ yes
□ yes
Easy
Medium
Hard
□ no
□ no
Syringe Access (Information about
□ yes
□ yes
Easy
Medium
Hard
getting clean drug works)
□ no
□ no
In general which of the following has been a problem for you when you have tried to get HIV prevention
education services? Please check all that apply.
□ No problem
□ Services not at a convenient time
□ I did not know where to go
□ Too long of a wait
□ Transportation
□ Discrimination because of HIV status
□ Child Care
□ Discrimination because of race/ethnicity
□ Service not available
□ Discrimination because of sexual orientation
□ I did not qualify for service
□ Concerned about my privacy
□ I could not afford service
□ Nervous or afraid of what people may say
□ They do not speak my language
□ Not in a stable enough living situation to get this service
□ Other, please specify: ___________________________________________________________________
In general, how satisfied have you been with the HIV prevention education services you received?
□ very satisfied
□ somewhat satisfied
□ somewhat dissatisfied □ very dissatisfied
Please list the services you were dissatisfied with:
PLWHA Needs Assessment 78
Directions: Place a mark in the box that best describes your behavior.
Since I have known I was HIV
infected, I have done this
behavior….
I have had receptive vaginal sex
without a condom
I have had insertive vaginal sex
without a condom
I have had receptive anal sex without
a condom
I have had insertive anal sex without
a condom
I have had sex with someone I know is
not HIV infected
I have had sex with someone whose
HIV status is unknown to me
I have had sex with someone I know is
HIV infected
I have had sex with someone whose
name I did not know
I have been paid for sex
I have paid for sex
I have found sex partners on the
internet
I have had sex in public areas like
bathhouses, parks, rest areas, etc.
I have shared needles or works when
injecting drugs.
I have had sex with an injection drug
user
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
In the past 12 months. I have
done this behavior…
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
□ Yes
□ No
□ Do not do this behavior
Thank you for completing the survey.
Please remember to return the survey in the attached postage paid envelope
and fill out and return the stamped post card so you receive your gift card.
To protect your privacy, the survey and post card are being sent to different addresses.
Incentive Post Card
PLWHA Needs Assessment 79
Name: ________________________
Address: _____________________
___________________Apt #: _____
City:__________________State: NH
Zip Code ________________
Check the stores that you would like
to receive a gift card from:
□ Wal-Mart
□ Hannaford
□ Rite-Aid
Every effort will be made to give you gift
cards for the store(s) you request, but
supplies are limited. Due to processing
time, it will take approximately 3 weeks to
send your gift card.
To:
Survey Gift Card
P.O. Box
Contoocook, NH
03229
Incentive Post Card (reverse side)
Your time and honesty is appreciated!
80
PLWHA Needs Assessment