ORIGINAL PAPER

Homelessness Prevention: The Effect of a Shallow Rent Subsidy

Program on Housing Outcomes among People with HIV or AIDS

Lisa K. Dasinger Æ Richard Speiglman

Received: 12 July 2006 / Accepted: 30 April 2007 / Published online: 19 June 2007Ó Springer Science+Business Media, LLC 2007

Abstract This paper presents results of an evaluation of

Project Independence (PI), a shallow rent subsidy program

with services coordination support for very low income

people with HIV or AIDS who live in Alameda County in

the San Francisco Bay Area. By providing a small rental

subsidy to eligible individuals and their families who are

already stably housed, the philosophy of the program is to

prevent homelessness before it starts. The housing out-

comes of 185 PI clients were compared to those of 218

people who were not enrolled in the program but were

presumed eligible for it, controlling for sociodemographic,

HIV disease, and behavioral health characteristics. Using

survival analysis techniques, non-program participants

were found to be more likely to leave their rental housing

at any given point in time compared to PI program par-

ticipants. After one year of follow-up, while 99% of PI

clients remained stably housed in their program-subsidized

rental unit, only 32% of comparison group clients were still

in rental housing. At two years, 96% of PI participants

remained independently housed, compared to only 10% of

non-participants. The success of the program suggests that

Project Independence should be replicated and evaluated in

other jurisdictions where a relatively high incidence and

prevalence of HIV/AIDS is combined with a lack of

affordable housing for low income households.

Keywords Housing subsidy �Homelessness �HIV/AIDS �

Case management � Survival analysis � Hazard regression

Introduction

Until recently, AIDS was considered a terminal disease

from which most infected persons usually died within two

years of diagnosis. With the development of new classes

of antiretroviral medications and treatment regimens

(HAART, or Highly Active Anti-Retroviral Therapy), im-

proved clinical management, and earlier detection of the

disease, HIV-infected and AIDS-diagnosed individuals

now have a greater chance of experiencing better health

outcomes and living longer than previously thought pos-

sible. However, even with these significant medical

breakthroughs, the challenges facing people with HIV or

AIDS are still numerous. One of the greatest of these is the

challenge of maintaining a stable and affordable place to

live.

The ability to stay employed and maintain adequate

health insurance can be seriously hampered for persons

with HIV disease (Kass et al., 1994; Yelin, Greenblatt,

Hollander, & McMaster, 1991). Loss of employment and

health insurance can mean lack of financial resources to

meet rent or mortgage payments, which may lead to

homelessness, an inability to get or maintain proper med-

ical care, and the subsequent worsening of the disease.

Further, lack of stable housing, among persons living with

HIV/AIDS as well as others, is associated with high rates

of drug use and risky sex behavior (Aidala, Cross, Stall,

Harre, & Sumartojo, 2005; Sethi et al., 2004), in turn

increasing risks among the general population. There is

also evidence of an association between change for the

better in housing status and decline in risk-taking behavior

L. K. Dasinger (&)Division of Workers’ Compensation, Department of IndustrialRelations, State of California, 1515 Clay Street, 18th floor,Oakland, CA 94612, USAe-mail: Ldasinger@dir.ca.gov

R. SpeiglmanSpeiglman Norris Associates, Oakland, CA, USA

123

AIDS Behav (2007) 11:S128–S139

DOI 10.1007/s10461-007-9250-7

(Aidala et al., 2005). A number of recent studies suggest

that persons living with HIV/AIDS who are homeless or

unstably housed are less likely to receive adequate medical

care than those who are stably housed, putting them at

risk for poorer health outcomes (Aidala, Davis, Abramson,

& Lee, 2001; Aidala & Lekas, 1998; Aidala, Messeri,

Abramson, & Lee, 2001; Smith et al., 2000). When they do

obtain medical care, individuals with HIV/AIDS who are

unstably housed or homeless find adherence to the HAART

medication regimen particularly challenging (National

Health Care for the Homeless Council, nd).

Lack of housing has other effects on the costs of care

and the system of care as a whole. Marginally housed and

homeless individuals are more likely than stably-housed

persons to use more expensive forms of care, such as

emergency rooms (Arno et al., 1995) and inpatient hospi-

talization (Smith et al., 2000), and are less likely to use

ambulatory care (Arno et al., 1995). Weissman et al.

(1996) found that patients being treated for HIV/AIDS

were more likely to be hospitalized if they were homeless.

Bonuck and Arno (1997) also found that lack of housing

was a significant factor affecting hospital discharge for

persons with HIV/AIDS.

Aidala and Lee (2000) examined factors predicting

moving from an unstable to a stable housing situation, or

maintaining a stable housing situation. Homeless persons

were significantly more likely to get housing by their next

interview if they received rental assistance or mental health

services. Additionally, rental assistance and other housing

services were the strongest predictors of maintaining

housing. Substance use services, for persons with a drug

history, contributed significantly to maintaining housing.

In a multivariate analysis of the effects of services and

housing assistance for unstably housed persons with HIV/

AIDS, services had some impact, but receipt of rental

assistance was the strongest predictor of both obtaining

housing and staying in housing once placed. In summary,

‘‘rental assistance was a necessary, but often not sufficient,

condition for getting and maintaining housing among HIV/

AIDS-infected individuals’’ (Aidala, 2001).

Recognizing the need to assist persons living with AIDS

or HIV to either obtain housing or keep their current

housing, AIDS and housing advocates nationwide have

argued that special resources needed to be created for

people living with AIDS that could be made available more

quickly than traditional housing programs typically allow.

To this end, a number of local jurisdictions have developed

and implemented what are being called ‘‘shallow rent’’

subsidy programs. The term ‘‘shallow’’ is in contrast to the

notion of a traditional ‘‘deep’’ subsidy – one that reduces

the recipient’s housing expenses to a level that is deemed

‘‘affordable’’ by the federal government. In a deep subsidy

program, such as the Section 8 Housing Choice Voucher

program or Shelter Plus Care, the household receiving the

subsidy typically pays the landlord no more than 30% of its

gross income, adjusted for certain factors such as number

of dependents, physical disability, extraordinary child care

or health care expenses, and the cost of utilities. The sub-

sidy program then pays the difference between the tenant

payment and the full rent. In this way the housing is made

‘‘affordable’’ to the participating household.

A shallow subsidy program, in contrast, sets a defined

payment which the program provides, and the subsidized

household must pay everything additional to complete the

full rent, generally with no cap. Essentially, in a shallow

subsidy program the program pays the same subsidy level

for every household of comparable size, while in a deep

subsidy program the amount paid by the program may vary

significantly depending on the actual household income of

each subsidy holder. In the case where the amount of the

shallow subsidy is enough to allow the participating

household to pay 30% or less of its adjusted gross income

for housing, it is effectively acting as a deep subsidy

program for that household. In most shallow subsidy

programs, however, the amount the program pays is not

enough to bring most participating households’ portion of

the rent down to the affordability standard.

Given the fact that waiting lists for Section 8 in many

communities are five or more years long, coupled with the

fact that people living with HIV/AIDS are at greater risk

for faster progression of the disease and mortality if not

living in a stable housing situation, AIDS and housing

advocates have argued that shallow rent subsidy programs

may provide a viable alternative to deep rent subsidy

programs for some individuals. In addition, it was argued

that with limited resources, providing the minimum-

required subsidy to keep a larger number of persons with

AIDS housed may be preferable to providing deeper sub-

sidies to fewer people. In response to the above state of

affairs and advocacy efforts, the federal Department of

Housing and Urban Development (HUD) created the

Housing Opportunities for Persons With AIDS (HOPWA)

program in 1992. Among other types of housing assistance

programs, HOPWA funds are being used by some com-

munities to cover the cost of shallow rent subsidy programs

on the condition that communities offer a range of pro-

grams, including deep subsidies for those with greater

needs, and that the status of persons receiving shallow

subsidies be regularly reviewed to ensure that they are

being adequately supported.

This report presents the results of an evaluation of

Project Independence (PI), a shallow rent subsidy program

with services coordination support for very low income

people with HIV or AIDS and their families who live in

Alameda County, California. The evaluation covers about

the first four and a half years of the program, from March

AIDS Behav (2007) 11:S128–S139 S129

123

1997 to October 2001. Two characteristics of the County

during that time—a high AIDS case rate and a paucity

of affordable rental housing for low income fami-

lies—underscored the need, first identified in 1995, for a

housing subsidy program that would help low-income HIV/

AIDS-infected individuals at risk for homelessness remain

stably and independently housed. The Oakland Eligible

Metropolitan Area (EMA), which covers both Alameda

County and nearby Contra Costa County, is among the

fifty-one metropolitan areas in the nation that are dispro-

portionately affected by HIV/AIDS and receive emergency

relief funding through the Ryan White CARE Act to

provide primary care and support services for people with

HIV disease. According to the Alameda County Health

Department, there were 1,854 people with AIDS and an

estimated 6,400 with HIV disease living in the County at

the end of 1997. During the study period, the AIDS case

rate in Alameda County exceeded both the state rate and

the national rate. In 1999, the County rate was 17.0 new

cases per 100,000 population, compared to a state rate of

11.5 and a nationwide rate of 9.3. Oakland was the hardest

hit area of the County, accounting for 51% to 65% of new

AIDS cases each year between 1980 and 2000 (Alameda

County Public Health Department, 2001).

In addition to the relatively high AIDS case rate, Ala-

meda County suffers from a shortage of affordable housing

for low income households. Fair Market Rents (FMR) for a

one bedroom apartment in the county increased 16% dur-

ing the study period from $633 per month in 1997 to $734

per month in 2001 (U.S. Department of Housing and Urban

Development). It is easy to see that the limited income of

many people with HIV/AIDS, many of whom collect

Supplemental Security Income (SSI) or Social Security

Disability Income (SSDI), simply is not enough to cover

the cost of a rental unit in Alameda County. In 2001, for

example, the monthly SSI payment was $531. Assuming no

other income, for a single person household in 2001, the

Section 8 Housing Choice Voucher program would require

the renter to pay 30% of that income, or $159, toward rent.

For a one-bedroom apartment renting at $734 per month,

Section 8 would therefore pay $421 toward the rent. In

contrast, Project Independence pays a fixed amount ranging

from $175 to $425 a month, depending on the size of the

household and the number of bedrooms. For the same

rental unit, PI would pay $225 per month, therefore leaving

$509—virtually the entire monthly SSI/SSDI benefit—to

be paid by the individual toward rent.

At the time this study was begun, Project Independence

was one of eleven shallow subsidy programs operating

across the nation, of which all but one served people living

with HIV/AIDS. Five of the programs are in the State of

California. The oldest of these programs began in 1996,

indicating that this is still a relatively new programmatic

approach. Many of the programs serving persons living

with HIV/AIDS rely on HOPWA funding, although other

sources being utilized include Ryan White AIDS CARE

Act funds, city general funds, and private funding. The

number of households served varied considerably, ranging

from 16 families in Monterey, California to 565 households

in Chicago. Subsidy amounts ranged from a low of $45 a

month to as high as $500 a month, with the majority falling

in the $150 to $300/month range. There is variation in the

amount of time each program provides subsidies. Some

programs provide only short-term subsidies. Chicago’s

subsidies lasted only three months, though they could be

extended for up to six months. In contrast, Denver’s

Shallow Rent Program subsidies lasted as long as partici-

pants continued to qualify, though they were to be re-cer-

tified every 21 weeks. Like recipients of deep subsidy

rental assistance, Project Independence clients may remain

enrolled in the program for as long as they remain eligible

for it.

Project Independence is just one component of the AIDS

housing continuum in Alameda County. The program

developed out of a year-long community-based needs

assessment and planning process which included the par-

ticipation of AIDS services providers, housing developers,

government staff, and persons living with AIDS. The

program was developed in response to the findings of a 600

person survey conducted in 1995 of people living with HIV

in the County, which found that almost half were at risk of

losing their rental housing if their incomes dropped by as

little as $100 a month. By providing a small rental subsidy

to eligible individuals and their families, the philosophy of

the program is to prevent homelessness before it starts.

The evaluation was designed to answer the following

questions: (1) How long do people in the program stay

independently housed?; (2) Do people in the program stay

independently housed longer than people who are not in the

program but are eligible for it?; and (3) Besides program

participation, are there other factors which predict how

long low income people with HIV/AIDS remain stably and

independently housed?

Description of Project Independence

Overview

Project Independence (PI) is a rental housing assistance

program for very low income people living with HIV/AIDS

in Alameda County, California. In existence since 1997, PI

targets HIV positive individuals and their families who are

already stably and independently housed in a rental unit in

the County, but whose low income puts them at risk for

homelessness.

S130 AIDS Behav (2007) 11:S128–S139

123

Subsidy Amounts

Since its inception, at any given time the PI program has

provided between 100 and 125 qualifying households with

a monthly rental subsidy. The subsidy amount, unchanged

during the program’s life, varies depending on household

size, rent, and the income of the eligible household, but

averages $225 per month. The maximum rental subsidy for

PI is calculated using a simple matrix based on the number

of bedrooms and household size, as shown in Table 1.1

Program Eligibility Criteria, Activities, and

Requirements

To be eligible for Project Independence, an applicant must

have a diagnosis of HIV or AIDS, be 18 years of age or

older (or be an emancipated minor), have an income at or

below 50% of the area median income, have a lease on a

rental unit within Alameda County, and be willing to en-

gage in services as needed that promote independent living.

At least 65% of households in the program are expected to

have incomes below 25% of the area median income.

Single individuals, adult couples, and families with chil-

dren are all eligible for the program, although three-quar-

ters of participants have been single adults. PI participants

do not have to be disabled, have substance abuse issues, or

have other problems to be eligible for the program, al-

though having such presenting issues does not preclude

enrollment in the program.

Before receiving a subsidy, the rental unit must pass a

federal housing quality standards (HQS) inspection, which

determines that the unit meets minimum material and

equipment conditions in order to ensure habitability, dura-

bility, health, and life safety. If an applicant’s unit does not

pass the inspection, it can be repaired and re-inspected, or

the applicant can choose to locate and move to another unit.

In addition to the rental subsidy, participants are pro-

vided with limited case management services—termed

‘‘services coordination’’—provided by one of three non-

profit community-based ‘‘hub’’ agencies. Participants also

have access to a range of community-based services for

persons living with HIV/AIDS, including more intensive

case management, primary medical care, food, mental

health treatment, substance abuse treatment, peer coun-

seling and other supportive services. These services do not

differ from those available to other persons living with

HIV/AIDS in Alameda County, but Project Independence

was designed to maximize the probability that participants

will be made aware of the range of possible services and be

assisted with gaining access to them. Contact with a ser-

vices coordinator has been required on a quarterly basis, at

minimum.

Program Administration

Project Independence is a collaboration of the County

Housing and Community Development (HCD) Department

and three non-profit ‘‘hub’’ agencies. Since the founding of

Project Independence these three agencies have received

Ryan White CARE Act funds, which are used to provide

primary care and support services for people with HIV

disease. The hub agencies accept program applications,

issue the rental subsidy checks to landlords, and provide

tenants with services coordination, including referrals to

supportive services. HCD approves applications, coordi-

nates the overall program, and, at the time of this evalua-

tion, conducted HQS inspections. New applications are

reviewed and processed on a first-come first-served basis as

existing clients leave the program.

Program Funding

At the time this evaluation was conducted, Project Inde-

pendence was funded by the Department of Housing and

Urban Development (HUD) under the Housing Opportu-

nities for Persons with AIDS (HOPWA) Special Project of

National Significance (SPNS) competitive program. Pro-

ject Independence was first funded in 1996 for a three-year

period, and the first subsidies were provided in March,

1997. PI has been renewed for three additional three-year

terms and is currently funded under a HOPWA Permanent

Supportive Housing grant. For the first two of the three

renewals the grant included funding to conduct a research

study of the impact and effectiveness of the PI program;

this study reports on the first of those.

Method

Research Design

Using a quasi-experimental retrospective longitudinal

comparison group design, the study compares the housing

Table 1 Project independence subsidy amounts

Studio/0 bedroom 1 bedroom 2 bedroom 3 + bedroom

1 person $175 $225

2 people $275 $325

3 people $325 $375 $425

1 The subsidy is actually the lesser of the maximum subsidy and thedifference between the rent and 30% of the household’s adjustedgross income. In 80% of cases, the qualifying household receives themaximum. Only if the maximum subsidy causes the household to payless than 30% of its adjusted income for rent and utilities is thesubsidy lower.

AIDS Behav (2007) 11:S128–S139 S131

123

outcomes of PI program participants to those of individuals

in a comparison group who appear to meet the requirements

of the program but are not enrolled in it. The outcome

evaluated is the duration of time individuals in both groups

remain in rental housing while continuing to meet the

income requirements of the program, controlling for soci-

odemographic, HIV diagnosis, and behavioral health char-

acteristics. The maximum length of follow-up for any

individual was four years eight months, the time from

program inception to final data collection for the evaluation.

Measures

An electronic database maintained by HCD provided

demographic and program participation data for Project

Independence participants, including age, gender, race/

ethnicity, stage of HIV disease at program entry, city of

residence, household size, total monthly household income,

income level ( £ 25% area median income (AMI) or 26–

50% AMI), size of rental unit (e.g., studio, 1-bedroom),

total monthly rent, amount of rental subsidy, program entry

and exit dates, and reason for exit, if applicable. Additional

information on Project Independence clients was obtained

from the Alameda County Public Health Department Office

of AIDS Administration (OAA) database, which contains

data on people who receive Ryan White-, HOPWA-, and/or

county-funded HIV/AIDS-related direct services. This

database was also used to obtain a comparison group for the

study. The OAA database consists of data collected on

‘‘Client Intake Forms’’ that are submitted by each HIV/

AIDS service provider in the county to OAA once each

fiscal year for each client who received services at that

agency during the year. Entry of this document into the

database creates a separate record for each client for each

agency for each contract year in the database. In addition to

providing demographic information comparable to that

available from the HCD database, the OAA database con-

tained the following variables that were used in this eval-

uation: primary language, HIV transmission categorie(s),

month/year of first positive HIV test, household composi-

tion, presence of other presenting issues (substance abuse,

mental health, STD, hepatitis, tuberculosis, homelessness),

and current housing status. An anonymous client ID, which

appears both in the HCD and the OAA databases, was used

to identify records that pertained to Project Independence

cases to obtain supplemental information about them, and to

exclude them from the comparison group.

Participants

HCD provided a final dataset for this evaluation on October

26, 2001, by which time a total of 256 client-households

had been served by the program since March 1, 1997.

The comparison group was drawn from the OAA dataset,

which consisted of 19,003 intake records representing 5,565

unique client IDs. Intake dates ranged from January 1997 to

July 2001. The comparison group was selected in the fol-

lowing way. First, the earliest intake record in the OAA

database for which all of the following were true was used

to select a group of individuals eligible for the comparison

group: (1) intake date ‡3/1/97, the first month PI subsidies

were issued; (2) intake occurred at one of the three hub

agencies; (3) HIV positive or AIDS diagnosis; (4) ‡18 years

of age; (5) household size £ 5, the largest household size of

PI households; (6) total household income £ 50% AMI,

adjusted for household size and intake date; and (7) living in

rental housing or apartment/house. Cases were excluded if,

on the same intake record, any of the following applied: (1)

‘‘living with relatives/friends,’’ suggesting the individual

may have been doubled up with others rather than living

independently; (2) client IDs partially matching those of PI

clients’, to safeguard against including a PI client who had

more than one client ID in use, due to typos and other

factors. Cases without at least one later intake record where

housing status and income were known were excluded. For

remaining cases, the most recent intake record for which

housing status and income were known, where no inter-

vening records existed with unknown housing status and

income, was chosen. This was so that a longitudinal mea-

sure of length of time in rental housing and the income

eligibility of the individual for the program could be cal-

culated for members of the comparison group.

After application of the above criteria to the OAA

database, only 238 client IDs, or 4.3% of all client IDs,

remained for inclusion in the comparison group. Most

clients were excluded from the comparison group because

they were never in rental housing or their housing status

was unknown. Fewer clients were excluded because they

had only one intake record in the OAA database or had

missing data on income or household composition, which

made the determination of income level, and hence PI

eligibility, impossible.

It is important to note that eligibility of comparison

group members for PI is unknown in four areas: whether the

client held the lease on the rental unit, whether the rental

unit met HUD housing quality standards, the rent amount

and its relationship to HUD fair market rents and the client’s

income, and the willingness of the client to participate in

services needed for independent living. The comparison

group may therefore have contained some individuals who

would not have been eligible for the program.

Data Analysis

The analytic technique used for the evaluation is Cox

proportional hazards regression, a time-to-event or survival

S132 AIDS Behav (2007) 11:S128–S139

123

analysis technique (Cox & Oakes, 1984). As its name

implies, survival analysis was developed in the context of

studying time to death, disease onset, or disease recurrence

among clinical populations, typically in evaluating the

effectiveness of a given treatment. Clinical trials typically

measure the length of time from study entry to a disease

endpoint—the ‘‘event’’—for a treatment and a control

group. Time-to-event (survival) analysis allows inclusion

of patients who fail to complete the trial or do not reach the

study endpoint before the study ends (censored data) by

making comparisons between the number of survivors in

each group at multiple points in time. Survival analysis

techniques are especially important since excluding

patients who do not reach the endpoint from the analysis

could introduce considerable bias because the length of

survival for these patients prior to study exit is important

information that contributes to the power and validity of

the study.

The main results of a Cox analysis are typically de-

scribed in two ways. Time-to-event curves, also called

cumulative survival curves, provide estimates of the pro-

portion of individuals in each group still ‘‘surviving’’ at

any given point in time after study entry through the

study’s maximum follow-up period, where everyone’s

‘‘start time’’ is standardized to time ‘‘zero.’’ The ‘‘relative

hazard,’’ also called the ‘‘hazard ratio,’’ is a number that

indicates the instantaneous increase or decrease in risk of

experiencing the study event at any given point in time

relative to a baseline reference group, e.g., the treatment

versus control group. The hazard ratio cannot be used to

describe how much faster/sooner this event may occur, but

only the instantaneous relative risk of it occurring for one

group compared to another. Hazard ratios greater than one

indicate an increased risk of the event occurring and ratios

less than one a decreased risk. An assumption of propor-

tional hazards regression is that the hazard ratio is constant

over time.

In the context of this evaluation, the outcome of interest

is the time an individual remains independently housed in a

rental unit after entrance into the study. The event of

interest is therefore loss of independent, rental housing. For

the Project Independence and the comparison group, loss of

housing included living with relatives/friends, in a hotel/

motel, or in transitional housing, being homeless (in

emergency shelter or on the streets), residing in a psychi-

atric, substance abuse treatment, hospital or other medical

facility, residing in jail/prison, or ‘‘other’’ at last obser-

vation. For Project Independence clients, loss of housing

also included moving into Section 8, Shelter Plus Care, or

some other form of deep subsidized housing, being evicted

or losing the lease, or living in ineligible housing. The

study follows individuals from the time they either entered

the program (PI participants) or the study (comparison

group), when first observed to be housed in a rental unit

and eligible for the program, until their housing status

changed, or until follow-up data are no longer available.

For those still independently housed in a rental unit at

the time of last observation, the ‘‘true’’ survival time is

only known to be a value greater than the time observed

from study entry to the last observation. For these indi-

viduals, the time-to-event duration is unknown, and the

final observation is said to be ‘‘censored.’’ We do not know

how much longer the individual remained or will remain in

their current housing situation after the final observation.

Housing outcomes were also considered censored if (1) the

individual became income ineligible for the Project

Independence program at last observation, i.e., household

income exceeded 50% AMI, (2) the individual left the

County, or (3) the individual died. The latter two condi-

tions were only known for PI clients. Individuals with

censored housing outcomes contribute data to the compu-

tation of the survival curve up until the time right before

their final observation date.

All available variables were individually tested for their

association with time remaining in rental housing using the

Cox method. Variables with a significant association with

housing outcome in bivariate survival analyses (P £ .10)

or, as with age, which are commonly used as a control

variable, were retained for the final analyses presented

here. All analyses were conducted using SPSS version

11.0. The research was approved by the institutional review

boards serving the Public Health Institute (Oakland, CA)

and Speiglman Norris Associates (Oakland, CA).

Results

We first describe sociodemographic, income, HIV status,

and behavioral health characteristics of PI participants and

members of the comparison group. We then present the re-

sults of a multivariate survival analysis of the effect of pro-

gram involvement (Project Independence vs. Comparison

Group) on the length of time in independent rental housing

while controlling for other key factors. Deidentified names

are used for the hub agencies (A, B, and C) so as not to single

out any particular hub agency as ‘‘better’’ or ‘‘worse’’ in

terms of producing a positive housing outcome.

Both the descriptive and multivariate analyses are lim-

ited to individuals with no missing values on all the vari-

ables of interest. This resulted in a sample size of 187 for

the Project Independence group and 219 for the compari-

son group. Most (91%) of the 69 PI clients lost from the

analysis had no data on other presenting issues in the OAA

database during the time they were enrolled in PI. Since

including these cases in the analysis and dropping the

variables for other presenting issues did not change the

AIDS Behav (2007) 11:S128–S139 S133

123

significance and/or effect size of other variables in the

analysis, the model with more variables and fewer cases is

presented here.

Table 2 shows that the PI group and the comparison

group did not statistically differ in terms of age, presence

of substance abuse issues, or hepatitis. Sociodemographi-

cally, members of the comparison group were more likely

to be female (32.4% vs. 21.4%), black (72.6% vs. 59.9%),

living with others (54.8% vs. 23.0%), have a household

income at or below 25% of the area median income (90.0%

vs. 64.7%), and be unemployed during their time in the

study (87.7% vs. 76.5%). Regarding health characteristics,

they were more likely to have AIDS (92.7% vs. 59.9%),

and to have purportedly contracted HIV through intrave-

nous drug use (34.7% vs. 18.7%), but less likely to have

self-identified as having a mental health issue (21.9% vs.

39.6%). In addition, almost all comparison group clients’

baseline intake was conducted at hub agency A (94.1%)

compared to 38% of PI clients. No comparison group client

had an initial study intake at hub agency C. This distri-

bution of comparison group clients among the hub agencies

is not surprising, given the distribution of intakes among

the three hub agencies represented in the OAA database.

To the degree that each of the variables in Table 2 has an

impact on length of time in independent rental housing, it is

important to control for these variables in the multivariate

analysis.

Table 3 shows the results of the multivariate survival

analysis. Since there were no statistically significant dif-

ferences between White, Asian/Pacific Islander, and Native

American clients on housing outcome in the bivariate

analysis, and the sample size of the latter two categories

was too small to treat them as separate groups, these were

placed into a single category. The analysis also excludes

clients with ‘‘other’’ gender, due to small sample size,

resulting in 185 PI clients and 218 comparison group cli-

ents included in the final analysis.

By far the most significant predictor of time remaining

in independent rental housing, while controlling for other

variables in the analysis, is program status. Members of the

comparison group were 3.83 times more likely to lose their

rental housing at any point in time after entrance into the

study than Project Independence participants (P < .001).

Smaller but significant effects were seen for the impact of

hub agency, race/ethnicity, employment, mental health,

and hepatitis on the risk of leaving rental housing. Age,

gender, living alone, household income level, history of

injection drug use, stage of HIV disease, and having a

substance abuse issue, although significant in bivariate

analyses, were not associated with the risk of losing rental

housing in the multivariate analysis.

The hub agency through which individuals entered the

study was significantly associated with the risk of losing

rental housing, independent of enrollment in PI. PI and

comparison group individuals who enrolled through Hub

Agency B had a decreased risk of 0.53 times that of Hub

Agency A clients of losing their rental housing at any given

point in time (P < .05). The risk of leaving rental housing

among clients of Hub Agency C was 0.16 times the risk

among Hub Agency A clients (P < .01). Possible reasons

for these observed differences are the following: (1) clients

served by each agency may have differed systematically in

ways relating to housing outcome which were not mea-

sured in this study, e.g., more disadvantaged, harder to

serve, or more precariously housed, (2) hub agencies may

have differed in levels of case management, services

coordination, other operating practices, and/or the provi-

sion of other services that affect a client’s ability to remain

housed, and (3) in terms of PI clients, the hub agencies may

have applied differential selection criteria when recom-

mending clients for the program, biasing the results toward

a more or less favorable outcome.

Compared to White, Asian/Pacific Islander, and Native

American clients, the risk of losing rental housing was 1.54

times greater for Black clients (P < .10) and 2.61 times

greater for Hispanic clients (P < .01). Whether these dif-

ferences are attributable to cultural differences in preferred

living arrangements, discrimination, the kinds of services

received, or other factors is unknown. Among members of

the comparison group, Blacks and Hispanics who lost their

rental housing were more likely to end up living with rel-

atives and friends than Whites, Asian/Pacific Islanders and

Native Americans (data not shown).2 Of Blacks who left

rental housing, 36.3% indicated ‘‘lives with relatives/

friends’’ on the final client intake form used for the last

observation in the analysis, and of Hispanics, 55.6%

mentioned this living arrangement. Only 13.6% of Whites,

Asian/Pacific Islanders, and Native Americans who left

rental housing had this final housing outcome. Although

from the perspective of the goals of Project Independence,

doubling up with friends and relatives is a ‘‘negative’’

outcome, it may be preferred by some individu-

als—perhaps among certain racial/ethnic group lines—to

living alone and/or independently.

Clients who were not employed during their time of

observation in the study had an increased risk of leaving

rental housing that was 1.41 times that of individuals who

had a part-time or full-time job at some point during par-

ticipation in the study (P < .05). Employment may be

associated with a number of factors which increase the

ability of an individual to remain stably housed, for

example, greater levels of self-sufficiency, health, and self-

advocacy that enable the client to secure needed services

and supports to stay housed.

2 Comparable data on the PI participants are not available.

S134 AIDS Behav (2007) 11:S128–S139

123

The risk of losing rental housing for individuals with a

mental health issue was 0.59 times the risk for individuals

without a mental health issue (P < .05). Similarly, pre-

senting with hepatitis was associated with a decreased risk

of losing rental housing of 0.44 times (P < .01). One

possible explanation of these findings is that these indi-

viduals, by virtue of self-disclosing a mental health or

hepatitis issue, may be more likely to get help with these

Table 2 Characteristics ofProject Independence versuscomparison group clients

* P \ .05, ** P \ .01,*** P \ .001 (Pearson chi-square)

Project Independence (N = 187) Comparison Group (N = 219) P

% N % N

Age

18–30 9.6 18 7.8 17

31–50 78.6 147 82.6 181

51+ 11.8 22 9.6 21

Gender *

Female 21.4 40 32.4 71

Male 77.5 145 67.1 147

Other 1.1 2 0.5 1

Race/Ethnicity *

White 27.8 52 19.6 43

Black 59.9 112 72.6 159

Hispanic 8 15 5.9 13

Asian/Pacific Islander 3.7 7 0.5 1

Native American 0.5 1 1.4 3

Lives Alone ***

Yes 77 144 45.2 99

No 23 43 54.8 120

Household Income ***

£ 25% AMI 64.7 121 90 197

26%–50% AMI 35.3 66 10 22

Employed PT or FT **

Yes 23.5 44 12.3 27

No 76.5 143 87.7 192

HIV Status ***

HIV+ 40.1 75 7.3 16

AIDS 59.9 112 92.7 203

Injection Drug User ***

Yes 18.7 35 34.7 76

No 81.3 152 65.3 143

Substance Abuse Issue

Yes 25.7 48 22.4 49

No 74.3 139 77.6 170

Mental Health Issue ***

Yes 39.6 74 21.9 48

No 60.4 113 78.1 171

Hepatitis

Yes 16 30 13.2 29

No 84 157 86.8 190

Hub Agency ***

A 38 71 94.1 206

B 30.5 57 5.9 13

C 31.6 59 0 0

AIDS Behav (2007) 11:S128–S139 S135

123

problems. The help received, in the form of additional

case management or other services, may in turn facilitate

staying stably housed, on its own or through its association

with other services received. The group of people who did

not present with a mental health or hepatitis issue may have

included individuals who actually had these problems, but

by lack of self-disclosure, did not receive needed help.

Self-disclosure of a behavioral health issue may be asso-

ciated with a greater level of self-advocacy.

Figure 1 shows the estimated proportion of people

remaining independently housed in a rental unit over time

as a function of program status (Project Independence vs.

comparison group), while controlling for all other factors

in the multivariate analysis. The graph presents a striking

picture of the positive impact of Project Independence on

keeping individuals stably housed. After half a year of

follow-up, 99% of Project Independence clients were still

in rental housing compared to 65% of comparison group

clients. After one year of follow-up, while 99% of Project

Independence clients were still in their PI-subsidized

unit, only 32% of comparison group clients were still in

rental housing. At two years follow-up, the percentage

of Project Independence clients estimated to be in rental

housing remained high at 96%, while the percentage of

comparison group clients still in rental housing had

dropped to 10%. Unadjusted for other variables, the

average time in rental housing for program participants

was 1,416 ± 77 days, or 3.9 years. The corresponding

figure for individuals in the comparison group was

372 ± 58 days, or 1.0 years

Table 3 Results of multivariate survival analysis of the effect ofprogram participation and other variables on time in independent,rental housing

Variable HazardRatio

95% ConfidenceInterval

Program-related variables

Program status

Project Independence 1

Comparison Group 3.83*** 2.79–5.25

Hub agency

A 1

B 0.53* 0.29–0.97

C 0.16** 0.05–0.54

Sociodemographic variables

Age

18 – 30 1

31 – 50 1.48 0.79 – 2.76

51+ 1.21 0.56 – 2.61

Gender

Female 1

Male 1.21 0.83 – 1.77

Race/Ethnicity

White, Asian, or Nat. Am. 1

Black 1.54 0.97 – 2.44

Hispanic 2.61** 1.29 – 5.28

Client Lives Alone

No 1

Yes 1.28 0.91 – 1.80

Household Income

£ 25% MFI 1

26%–50% MFI 1.01 0.79 – 1.29

Employed PT or FT

Yes 1

No 1.41* 1.03 – 1.92

HIV-related variables

Injection drug user

No 1

Yes 1.25 0.86 – 1.81

Stage of HIV Disease

AIDS Diagnosis 1

HIV+, not AIDS 1.21 0.71 – 2.06

Other Presenting Issues

Substance Abuse

No 1

Yes 1 0.62 – 1.60

Mental Health

No 1

Yes 0.59* 0.36 – 0.95

Hepatitis

No 1

Yes 0.44** 0.24 – 0.80

* P < .05, ** P < .01, *** P < .0001

Time in rental housing (years)

43210

la

vivr

uS

evit

alu

mu

C

1.0

.8

.6

.4

.2

0.0

Program Status

Project Independence

Comparison Group

Fig. 1 Survival function by program participation, adjusted for allother variables

S136 AIDS Behav (2007) 11:S128–S139

123

Discussion

The results of this evaluation provide strong support for the

success of the Project Independence Program in meeting its

objective of keeping low income people with HIV/AIDS

and their families independently housed. The average time

in rental housing for program participants, unadjusted for

other variables, was 3.9 years, for the nearly five years

since the program began in March 1997 to October 2001.

When adjusted for sociodemographic, HIV disease, and

behavioral health characteristics, members of a comparison

group of individuals who met program eligibility criteria

but were not enrolled in the program were 3.8 times more

likely to leave their rental housing at any given point in

time compared to Project Independence program partici-

pants. After one year of follow-up, an estimated 99% of

Project Independence clients were still living in their rental

unit, compared to only 32% of comparison group clients,

adjusted for sociodemographic, HIV-related, and behav-

ioral health factors. At 2 years follow-up, only 10% of

comparison group clients were still housed in a rental unit,

compared to 96% of Project Independence participants.

The hub agency through which the client was enrolled

into the study was also found to be associated with time

remaining independently housed in a rental unit. Further

investigation of the reasons accounting for the observed

hub agency differences in housing outcomes is needed in

order to maximize the success of all clients in maintaining

their housing. Although the independent influence of re-

ceipt of services coordination support, case management,

or any other kind of service, on housing outcome could not

be studied due to lack of readily available data, evidence

from another study provides some support for the added

beneficial effect of services. In the study by Aidala and Lee

(2000) of 600 people with HIV/AIDS living in New York

City, social services were found to have some impact on

the maintenance of a stable housing situation, although

receipt of a rental subsidy had a bigger impact. Further

studies are needed to determine the degree to which addi-

tional client characteristics and the uptake of the services

coordination component of the program, as well as utili-

zation of other kinds of services, affect housing outcomes.

In a later evaluation of the Project Independence pro-

gram, which studied housing outcomes among PI clients

only over a longer time frame (from March 1997 to

December 2005), the effect of hub agency was no longer

significant (Speiglman & Dasinger, 2006). This study

found that clients who enrolled in the program later were

more likely to remain successfully housed for a longer

period of time than those who had enrolled earlier. Inter-

views with hub agency and other program staff suggest that

program implementation or start-up issues, and a more

open application process, with less attention to or under-

standing of who would best be served by the program, may

partly account for the hub agency differences seen in the

program’s earlier years. A third potential factor mentioned

by key informants is that treatment of the disease was not

as good in earlier as in subsequent years.

In addition to program-related factors, a number of other

client characteristics significantly predicted length of time

in rental housing, namely, race/ethnicity, employment, and

presenting with a mental health or hepatitis issue. His-

panics were 2.6 times more likely to leave rental housing at

any given point in time and Blacks were the 1.5 times more

likely compared to Whites, Asian/Pacific Islanders and

Native Americans. Many factors, whether a product of

client attitudes, expectations, and behaviors, attitudes and

behavior of landlords, or other, ‘‘environmental’’ condi-

tions, could have contributed to observed differences by

race/ethnicity.

However, it is noteworthy that findings from other

examinations of what is termed ‘‘housing dynamics’’ differ

from ours. Generally, Black and Hispanic recipients of

housing assistance are less likely than others to leave the

housing subsidies. In a sense, they ‘‘conserve’’ the avail-

able housing resources. Using a hazard model from late

1980’s Survey of Income and Program Participation (SIPP)

data to estimate tenure in housing programs, Hungerford

(1996) found that, compared to others, Blacks were sig-

nificantly less likely to depart subsidized public housing

(P < .10) and, though not significantly so, also less likely

to leave subsidized rental housing. More recently, relying

on stratified, random samples of recipients of assistance in

the 1995–2000 period from the Department of Housing and

Urban Development through the Multifamily Tenant

Characteristics System and Tenant Rental Assistance Cer-

tification System databases, Ambrose (2005) found stron-

ger results: African-American households have a much

lower probability of leaving both public housing and ten-

ant-based assisted housing programs, compared with White

households. Hispanics, compared with non-Hispanics, are

significantly less likely to depart assisted housing. They are

also less likely to leave public housing (P < .10). Finally,

Olsen, Davis, and Carrillo (2005) report similar findings in

their study of HUD data for the 1995 to 2002 period. The

interpretation is that Blacks and Hispanics, like other

groups with relatively fewer social options, exhibit greater

tendencies to retain subsidies.

Although we have no data to directly interpret our

contrary race/ethnicity finding, we believe research on this

matter is critically important. Very low income people

living with HIV or AIDS receiving housing assistance

through the Project Independence program arguably face

even more challenges than other populations of individuals

who receive housing assistance. In that context, compared

to the situation for Whites, an array of biographical and

AIDS Behav (2007) 11:S128–S139 S137

123

societal conditions may have a greater limiting influence

on Black and Hispanic clients’ ability to access the kinds

of services and/or supports necessary to maintaining

stable—and subsidized—housing.

Having a part- or full-time job was associated with a

decreased risk of losing rental housing, as was having a

disclosed mental health or hepatitis issue. These variables

may each be associated with a higher level of self advocacy

and/or self-sufficiency, which in turn are associated with

obtaining the kinds of services and supports that are nec-

essary to maintaining stable housing.

The main limitation of the study is that the compara-

bility of the comparison group and the Project Indepen-

dence group is not entirely known. Among members of the

comparison group, no information was available about

rent amounts, quality and size of the unit, or whether the

client’s name was actually on the lease. Nor was it known

whether comparison group members were committed to

engaging in activities that would facilitate living indepen-

dently. Comparison group members may have been paying

a larger share of their household income toward rent, in

comparison to Project Independence participants both be-

fore and after receiving the rental subsidy, which would put

them at more of an economic disadvantage. Although an

attempt was made to limit the comparison group to clients

who were living independently by excluding individuals

whose initial eligible intake indicated ‘‘living with rela-

tives/friends,’’ this was no guarantee that the client was

actually on a rental lease agreement and living indepen-

dently. Members of the Project Independence group may

also have been in stable housing before entering the pro-

gram longer than comparison group clients when they were

entered into the study. Interestingly, most (94%) compar-

ison group members were clients of the hub agency which

showed the poorest housing outcomes. The housing out-

comes for clients at that hub agency may have been con-

founded with other client and/or hub agency characteristics

that were not measured in this study, but which were

associated with poorer housing outcomes.

Another study limitation is the relative lack of precision

in the measurement of time in rental housing for compar-

ison group clients versus Project Independence clients.

Unlike the PI clients, whose continued participation in the

program was dependent upon hub agencies’ verification of

the client’s housing situation throughout program partici-

pation, the housing situation of comparison group clients

was only known at the moment of intake at the community-

based agencies at which they received services. It was

therefore not possible to know exactly when a comparison

group member’s housing status changed. The program

departures of PI clients who left the county were treated as

non-failure outcomes, assuming that the clients’ moves

represented greater self-sufficiency. In fact, we have no

data on the situations in which former clients found

themselves. It is probable that some departures were to less

independent and less stable settings. These measurement

errors produce both under- and overestimates of time in

rental housing among both groups.

Despite the limitations of the study, the large difference

in housing outcomes observed between the Project Inde-

pendence group and the comparison group strongly sup-

port the conclusion that Project Independence is successful

at helping low income HIV/AIDS-affected households

remain independently and stably housed. The importance

of a Project Independence-type subsidy also rests in the

fact that it can be made available relatively quickly to a

large number of individuals. In comparison, a deep rental

subsidy such as Section 8 requires a much larger sum of

money to help the same number of people. Nevertheless,

the Project Independence evaluation did not benefit from a

randomized, controlled design. Given the ethical chal-

lenges and other difficulties in fielding such rigorous

studies, we believe it would be appropriate to repli-

cate—and evaluate—the Project Independence program in

other areas of the state and country experiencing a rela-

tively high incidence and prevalence of HIV/AIDS com-

bined with a lack of affordable housing for low income

households. We note that the model of a shallow rental

subsidy plus services coordination may prove relevant for

other populations. Demonstration programs which include

an evaluative component might apply the Project Inde-

pendence model to any number of client groups. We would

encourage prospective studies, with more comprehensive

data collection across a number of factors, including some

follow-up of clients departing the program.

Project Independence and other housing programs can

be evaluated not only in terms of effects on stable housing

and the prevention of homelessness but also in terms of

their effects on maintaining or improving health and

avoiding unnecessary high cost health care such as hospi-

talization. Elsewhere, housing has been found to predict

lower HIV risk and less risk of transmission of HIV as well

as improved health outcomes. Another approach, which has

been considered but not yet implemented in Alameda

County, would involve studies that examine clients’ versus

controls’ access to and utilization of health-related and

other services and measure the cost-effectiveness of Project

Independence. Each of these topics is addressed in a recent

policy paper from the National AIDS Housing Coalition

(2007), which considers housing a ‘‘promising structural

intervention to prevent and treat HIV’’ (p. 5). Whether

considering housing outcomes, HIV transmission, the

promotion of positive health outcomes, appropriate use

of outpatient, emergency, and inpatient services, or cost

effectiveness, shallow rent subsidy programs with associ-

ated supportive services should be examined in comparison

S138 AIDS Behav (2007) 11:S128–S139

123

to other housing models: deep subsidy programs, housing-

first programs, and programs with more, and less, sup-

portive services. Where causal effectiveness in preserving

housing and health—of HIV seropositive people as well as

others—as a result of these programs can be demonstrated,

additional support will be generated and more individuals

at risk of losing housing will be assisted so that they can

keep their homes and protect their own and the commu-

nity’s health.

Acknowledgments This paper is based on an evaluation of ProjectIndependence that was completed by the authors in 2002 withfunding from the Alameda County Community DevelopmentAgency, Housing and Community Development Department (HCD),through a Housing Opportunities for Persons with AIDS Program(HOPWA) Special Project of National Significance (SPNS)competitive grant from the Department of Housing and UrbanDevelopment (HUD) to HCD. HCD subcontracted with the PublicHealth Institute to perform this initial evaluation (Contract# SPNS-99-04). Additional funding for this paper was provided by a HOP-WA Program Permanent Supportive Housing Renewal grant fromHUD to HCD and a subcontract with Speiglman Norris Associatesfor a follow-up evaluation of Project Independence (Contract #C-2005-207). We would like to thank the following current orformer HCD and Alameda County Office of AIDS Administrationofficials who assisted with the evaluations: Katharine Gale, LindaGardner, Laura Hansen, Tom Mosmiller, Sandra Pastermack, HazelWeiss, and Riley Wilkerson. Over the course of this study several ofthe Alameda County officials served as invaluable sounding postsand, along with the editor and two anonymous reviewers, veryhelpful critics.

References

Aidala, A. A. (2001). Personal communication, November.Aidala, A. A., Davis, N., Abramson, D., & Lee, G. (2001). Housing

status and health outcomes among persons living with HIV/

AIDS. New York: Columbia University.Aidala, A. A., & Lee, G. (2000). Housing services and housing

stability among persons living with HIV/AIDS. New York:Columbia University.

Aidala, A. A., & Lekas, M. (1998). Top client-identified unmet needs

for medical and social services. New York: Columbia Univer-sity.

Aidala, A. A., Messeri, P., Abramson, D., & Lee, G. (2001). Housingand health care among persons living with HIV/AIDS. NewYork: Columbia University.

Aidala, A., Cross, J. E., Stall, R., Harre, D., & Sumartojo, E. (2005).Housing status and HIV risk behaviors: Implications forprevention and policy. AIDS and Behavior, 9(3), 251–265.

Alameda County Public Health Department (2001). AIDS epidemi-ology report, Alameda County, California, 1980–2000. Oakland.

Ambrose, B. W. (2005). A hazard rate analysis of leavers and stayersin assisted housing programs. Cityscape: A Journal of Policy

Development and Research, 8(2), 69–93.Arno, P. S., Bonuck, K. A., Green, J., Fleishman, J., Bennett, C. L.,

Fahs, M. C., Maffeo, C., & Drucker, E. (1995). The impact ofhousing status on health care utilization among persons with HIVdisease. Journal of Health Care for the Poor and Underserved,

7(1), 36–49.Bonuck, K. A., & Arno, P. S. (1997). Social and medical factors

affecting hospital discharge of persons with HIV/AIDS. Journalof Community Health, 22(4), 225–232.

Cox, D. R., & Oakes, D. (1984). Analysis of Survival Data. London:Chapman and Hall.

Hungerford, T. L. (1996). The dynamics of housing assistance spells.Journal of Urban Economics, 39(2), 193–208.

Kass, N. E., Munoz, A., Chen, B., Zucconi, S. L., & Bing, E. G.(1994). Changes in employment, insurance, and income inrelation to HIV status and disease progression. Journal of

Acquired Immune Deficiency Syndrome, 7(1), 86–91.National AIDS Housing Coalition. (2007). Transforming fact into

strategy – developing a public health response to the housingneeds of persons living with and at risk of HIV/AIDS. PolicyPaper from the Second National Housing and HIV/AIDSResearch Summit. Washington, D.C.: The National AIDSHousing Coalition.

National Health Care for the Homeless Council (nd). The health careof homeless persons: A manual of communicable diseases andcommon problems in shelters and on the streets. RetrievedAugust 12, 2005.

Olsen, E. O., Davis, S. E., & Carrilo, P. E. (2005). Explaining attritionin the housing voucher program. Cityscape: A Journal of Policy

Development and Research, 8(2), 95–113.Sethi, A. K., Celentano, D. D., Gange, S. J., Gallant, J. E., Vlahov, D.,

& Farzadegan, H. (2004). High-risk behavior and potentialtransmission of drug-resistant HIV among injection drug users.Journal of AIDS, 35(5), 503–510, cited in National AIDSHousing Coalition, nd.

Smith, M. Y., Rapkin, B. D., Winkel, G., Springer, C., Chhabra, R., &Feldman, I. S. (2000). Housing status and health care serviceutilization among low-income persons with HIV/AIDS. Journalof General Internal Medicine, 15(10), 731–738.

Speiglman, R., & Dasinger, L. K. (2006). Alameda county projectindependence evaluation, phase 2: A longitudinal study of ashallow rent subsidy program for people with HIV/AIDS.Oakland: Speiglman Norris Associates.

U.S. Department of Housing and Urban Development (2006) FairMarket Rents. Accessed September 24, 2006. http://www.hud-user.org/datasets/fmr.html.

Weissman, J. S., Cleary, P. D., Seage, G. R., Gatsonis, C., Haas, J. S.,Chasan-Taber, S., & Epstein, A. M. (1996). The influence ofhealth-related quality of life and social characteristics on hospitaluse by patients with AIDS in the Boston Health Study. Medical

Care, 34(10), 1037–1054.Yelin, E. H., Greenblatt, R. M., Hollander, H., McMaster, J. R.

(1991). The impact of HIV-related illness on employment.American Journal of Public Health, 81(1), 79–84.

AIDS Behav (2007) 11:S128–S139 S139

123