Matching Intent to Implementation: Evaluating the Housing Opportunities for Persons with AIDS (HOPWA) Program

Background: The federal Housing Opportunities for Persons with AIDS (HOPWA) program provides housing for previously homeless people living with HIV/AIDS (PWHA), linking them to services, and improving medication adherence. While HOPWA recipients have shown some improved outcomes in evaluations, the results are not significantly different from other psychosocial interventions for PWHA that do not utilize housing. This is contrary to research that has established the salience of housing, over and above other interventions, in maintaining health for PWHA. This qualitative study compares the experiences of PWHA and their HOPWA service providers in the city of Philadelphia, to the goals of HOPWA, examining areas of alignment and divergence between the two.

Methods: We conducted semi structured in-depth qualitative interviews from 2012 to 2015 with 72 participants: 32 service providers, and 40 HOPWA recipients. The HOPWA legislation and program guidelines were thematically coded to identify goals, that were then matched to emergent themes from the interviews. A grounded theory approach utilizing sensitizing concepts was utilized to code the interviews. Recruitment was terminated when conceptual saturation was reached.  

Results: HOPWA enunciates an ideological goal of empowered citizenship through a right to housing, with two linked logistical goals: 1) reducing HIV risk environments, and 2) linking to services.

Service provider and participant experiences align with the first logistical goal: HOPWA reduces risk environments by: a) removing participants from chaotic street cultures, b) improving collectivity by bringing together PWHA, and c) increasing self-efficacy through the establishment of privacy.

However, progress towards the second logistical goal, and ultimately the overarching ideological intent, are thwarted by several implementational elements of the program. Linkages to services, and empowered citizenship are undermined by: a) the lack of a housing-first orientation (where housing is not contingent on other factors), b) long waiting-lists, and obtuse logics surrounding rankings on the list, c) lack of co-located services utilizing the matrix model of care, d) complicated bureaucratic protocols, e) macroeconomic factors such as lack of feasible housing options due to landlord bias, and gentrification, and f) lack of accommodations for vulnerable communities such as sex workers, substance users, , people with a mental illnesses, the recently incarcerated, and single mothers with children. In particular, the ideological intent of citizenship is undermined by subjective reactions to these challenges that are marked by a sense of: a) medical objectification, b) precarious survival leading to over-dependence on HOPWA housing when it materializes, and c) forcible “shoehorning”  into bureaucratic categories in order to game the program.

Conclusions: The benefits of meeting the first logistical goal are undone in part, by the challenges of progressing towards the others. The implementation of the program on the ground plays an essential role in creating these contradictions. Policy and implementation implications, both on the direct practice, and structural levels include: 1) training personnel to align actions and services with goals, 2) co-locating services in HOPWA houses, 3) establishing housing-first orientations, 4) creating dedicated HOPWA housing for vulnerable communities, and 5) working with city housing departments to create non-gentrified zones for housing.