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NEEDS OF SPECIAL POPULATIONS

HOUSING FOR PERSONS WITH DISABILITIES

According to the 1990 Census, 11% of St. Louis City’s 396,686 residents were living with a disability. While up-to-date estimates won’t be available until the results of next year’s census, there are clearly major and varied needs among the population of people with disabilities. A central need is for accessible, affordable, safe housing. Persons with both physical and mental disabilities are in dire need for housing that they can afford and use. In addition, some people with disabilities need supportive services which allow them to live independently, thereby increasing the need for a variety of unit sizes.

Current Services
The number of fair market housing units is increasing as a result of the Fair Housing Amendments Act of 1988, but the greatest need is for subsidized public housing, Section 8 units, group homes, and affordable (gap-financed) single family homes. The demand for such housing has increased as more and more people with disabilities have recognized their right and ability to live in the community, instead of institutions. Persons with mental retardation, developmental disabilities, mental illness, and physical disabilities all require a continuum of options that range from group homes or assisted living situations to independent living in their own single family homes or apartments. There is a strong and growing trend, led by the disability rights community in this nation, away from institutional living for people with disabilities and toward independent living in the community.

The demand is for accessible, affordable, safe housing that is integrated throughout residential neighborhoods. Priority for housing choice for disabled City residents has been a salient issue during the public involvement process.

Meeting the housing needs of people with physical disabilities and the challenges they face is heavily concentrated on the area of accessibility, safety and affordability. Options for persons with physical disabilities range from subsidized public housing units, Section 8 units, and non-subsidized units. Some non-profit groups, such as Paraquad, Inc., own and operate accessible apartment complexes because the availability of integrated apartments is so limited. Paraquad is an independent living center that assists people with disabilities in finding adequate housing and support services. Other housing referral sources in the City include MR/DD, the Office on the Disabled, and Paralyzed Veterans of America.

Supportive services for persons with disabilities are offered through a variety of agencies. The City’s Office on the Disabled makes referrals as does the Productive Living Board. Access Resources of Missouri, Inc., provides housing advocacy for people with disabilities. Paraquad provides services such as housing advocacy, information and referral, community education, personal assistance services, and independent living programs. Helpful supportive services include: Adapt-Ability, Call-A-Ride, Metropolitan Employment and Rehabilitation Services, and the State Division of Vocational Rehabilitation which is the largest provider of training and educational services.

Needs and Challenges
The most common challenges faced by persons with disabilities is the need for a variety of accessible, safe and affordable housing options, some of which may include support services which enable them to maintain their independence. Accessibility to, and the lack of, these services presents barriers that are both psychological and physical.

Current trends indicate the shift from institutional care to the provision of independent living options that provide integrated living in the community. Matching individuals with appropriate housing and supportive services in community settings continues to challenge the resources of advocates and service providers. The problems are compounded by low incomes, fixed incomes, and poor quality of accessible design in new construction.

Recommendations
The city should collaborate with advocacy groups for the disabled community to enact a variety of changes in the coming years

a) Adopt a policy that housing or public improvements projects supported with public funds incorporate Universal Design criteria into the overall design.

Over the last five years the Community Development Agency has assisted with the construction or renovation of almost 2800 dwelling units. The City should commit to ensuring that new construction housing projects incorporate universal design standards, unless there is some extraordinary reason for an exception. Applying such rigorous requirements in all rehabilitation projects may not be feasible, given the goals of producing affordable housing. Nevertheless, each rehabilitation project supported with CDBG or Home Investment Partnership funds should examine the potential for incorporating accessible design features.

Provide training for City staff, design professionals, nonprofit and for-profit developers, and other interested parties on the principles of Universal Design.

The automatic consideration of universal design principals will occur only if a proactive effort is made to inform those in the design profession about their use. The city should identify resources that can be used to prepare informational material and to teach those who prepare construction plans and those who review them. Ideally this initiative would be carried out on a regional basis with support from local governments, local professional associations and local disability advocacy groups.

Provide funding to emergency shelters that is specifically earmarked for making modifications to their facilities so they can accommodate homeless people with disabilities.

Funds have been used previously to make HOPE House accessible and, through the ABLE program with the City’s Office of the Disabled to assist businesses with a small grant when they are unable to secure a building permit because of access problems. A program for insuring that shelters were accessible would make sense, recognizing that available resources may not allow every shelter to be improved in the short term.

Explore setting up a fund that landlords can use to make permanent accessibility modifications in existing units thereby increasing the number of private housing stock units available to tenants with disabilities.

With a disproportionate number of older rental units in the City of St. Louis, there is a huge demand for rehabilitation loans to assist landlords in maintaining or improving their property. For the most part, rental property owners are not assisted except when a full scale gut renovation is undertaken or is limited cases such as the Management Assistance Program. However, if a reasonable set of guidelines could be set up whereby landlords competed for the assistance and committed to giving priority to disabled tenants, a demonstration program would make sense. As always, the challenge will be finding sufficient resources.

Establish tax credits for landlords who make accessibility modifications using their own capital.

This could be a valuable incentive for property owners to increase the volume of accessible units. At issue would be extent to which the incentive should be at the state level and / or the local level, and the size of the "tax expenditure." Among the issues would be whether both a fund and tax incentive were necessary and affordable.

If one curb cut is installed at an intersection, all other corners should also contain curb cuts.

Resolution of these situations should be a high priority. Curb cuts should be in a straight line with the opposing cut in order for wheelchair users to go up and down safely. Where pedestrian crossing lanes are striped, they should be within the lanes for safety reasons.

Continue monitoring of City programs using federal dollars to insure compliance with applicable regulations.

The City must ensure that all entities receiving Community Development Block Grant and other federal funds are in compliance with the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 1973, the Fair Housing Amendments Act of 1988 so that people with disabilities are not excluded from CDA funded activities or programs.

Resources
Currently a relatively small portion of the federal funds are allocated for improvements relating to the disabled community. CDA has a multi-year contract, along with the County and City of Florissant, to help build and maintain a database of accessible housing. Capital improvement projects are supported from time to time in order to make specific public or non-profit facilities accessible. There is also the aforementioned ABLE program in conjunction with the City’s Office of the Disabled.

HIV/AIDS POPULATION

The service delivery system for persons with HIV/AIDS in St. Louis is nationally recognized; however, it continues to be outpaced by the need for HIV/AIDS housing and other dedicated services. While 5,253 persons with HIV and AIDS had been counted in the metropolitan area by May 1999, estimates suggest this may represent less than 70% of the actual cases. Of these, the vast majority reside in the City of St. Louis.

With the recent introduction of new, promising drug treatments for HIV/AIDS, the importance of adequate housing has received a new emphasis. The strict regimens required for the success of these drugs dictates that other areas of the individual’s life be free from as much anxiety as possible. Housing provides the necessary foundation for proper nutrition, hygiene, emotional stability and other elements necessary to maintain good health. People who are in a stable living environment are also more capable of adhering to a health and pharmaceutical regimen. These new drugs have dramatically reduced the number of deaths from AIDS. Individuals in need of housing are living longer, and new infections have not decreased, creating a increased number of eligible clients who enter the swollen care system and remain there for long periods of time.

Most alarming is the fact that these newly infected individuals are women and youth in dramatically increasing numbers and represent the African American community in extraordinarily disproportionate numbers. Sixty five percent of those with new HIV infections are African American, with the percentage of infection even higher in African American women and youth (80% and 83% respectively). An African American MSM (man who has sex with men) is 4.3 times more likely than a Caucasian MSM to contract HIV. An African American woman is 14 times more likely than a Caucasian woman to contract HIV.

[ Table III-C-3, AIDS INCIDENCE, AIDS PREVALENCE AND HIV PREVALENCE BY DEMOGRAPHIC GROUP AND EXPOSURE CATEGORY ]

The one thing all of these individuals have in common is poverty and its associated ills, including limited access to health care. In St. Louis, as nationally, HIV/AIDS remains the leading cause of death for young adult African Americans.

Yet news about the advances in HIV/AIDS treatments has lured at-risk populations, some federal legislators, and the philanthropic public into a false sense that the AIDS crisis has abated. Even as new infections increase among women, youth, and minorities, public and private programs addressing prevention and care face marginal increases or flat funding.

Local officials and providers in the St. Louis region address housing needs through a Continuum of Care model that seeks to provide a fluid array of services from the time of an HIV diagnosis through various phases of serious and terminal illness or recovery and independence.

[ Table III-C-4, HOUSING FOR PEOPLE WITH HIV ILLNESS (AIDS), IN-HOME/OUTPATIENT CARE ]

Curent Services
General services for persons with HIV/AIDS in St. Louis are coordinated by the Missouri Department of Health and the Metropolitan AIDS Program through such funding sources as the Ryan White Care Act (Titles I, II, III, IV) and State of Missouri General Revenue. Twenty-six case managers housed at the St. Louis Health Department and six other service delivery sites coordinate a full complement of health care and social support services for the 1,658 individuals enrolled in the system as of September 30, 1999.

General or non-housing service providers include:

• The State Department of Health Bureau of HIV/AIDS Care and Prevention administers the Ryan White AIDS Drug Assistance Program (ADAP) and funds from State and Federal sources, addressing a variety of health and social support services. Services are provided in local agencies, private doctors offices, clinics, etc.
• St. Louis Metropolitan AIDS Program offers testing, counseling, access to AIDS waivers, case management, and education. Ryan White Title I funding administered through Metro AIDS offers primary care, home care, and social support services to persons with AIDS. Services are provided off-site and on-site.
• Blacks Assisting Blacks Against AIDS (BABAA) provides case management, minority outreach, education and prevention services. The agency was recently awarded a large minority outreach and prevention grant through the CDC’s Congressional Black Caucus Initiative and other grants totaling $700,000. Services are provided on-site and off-site.
• Cardinal Glennon Children’s Hospital provides health care for hemophiliac adults and children who are infected with HIV. Services are provided on-site.
• Food Outreach provides nutritious frozen meals, dietary supplements, and a grocery program for individuals with HIV illness. Services were consolidated at a new site in October, 1999, and a congregate feeding program will be added. Services are on-site and off-site.
• Project ARK (AIDS Resources for Kids) coordinates services for children and youth affected by HIV, as well as for their parents.
• Archway Communities/Basic Community Alternatives/DART. These programs provide substance abuse treatment programs to the public including persons with HIV/AIDS.
• Helena Hatch Special Care Center for Women was funded through a federal grant to Washington University which ended October, 1999. Plans are underway to insure clinic and social support services are made available through the existing case management system and other primary care providers.
• St. Louis Effort for AIDS provides case management and operates the AIDS Hotline. Other services include the "Buddy" program, treatment education, targeted outreach and education to at-risk populations, support groups, a work place reentry program and a speakers bureau. Services are offered on-site and off-site.
• St. Louis Children’s Hospital provides health care to HIV/AIDS affected children and a support group for HIV/AIDS affected families. Services are provided on-site.
• St. Louis ConnectCare HIV Clinic is a Title III funded clinic which provides primary health care and case management to low-income individuals. Services are provided on-site and off-site.
• Washington University AIDS Clinical Trials Unit is operated by an NIH research grant and provides health care and prescription drugs for active subjects. Services are provided on-site.
• DOORWAYS: An Interfaith AIDS Residence Program is the primary provider of housing for people living with HIV/AIDS in the St. Louis EMA. DOORWAYS offers a clearinghouse program, the Own Home rental and utility assistance program, the Residential Program and the Supportive Housing Facility. The Residential Program consists of three independent apartment buildings, and the Supportive Housing Facility offers licensed residential care including meals, supervision, 24-hour nursing, IV and oral medications, and social services. Through all of its programs, DOORWAYS assists up to 500 people each month with emergency, transitional and permanent housing. A fifth building with 14 units dedicated to families with children will open in June of 2000.
• Peter & Paul Community Services operates a variety of shelter, meal, treatment, and outreach programs who are homeless (not specifically HIV+) in St. Louis. Since 1996, Peter & Paul has operated the Positive Direction program, which provides 10 beds of emergency and transitional housing to homeless adults living with HIV/AIDS. Peter & Paul was successful in seeking funding to develop a 17-bed Safe Haven (or enhanced shelter) for multiply diagnosed individuals with HIV/AIDS and mental illness/substance abuse issues. They are currently in negotiations with a south St. Louis neighborhood about a site they have selected.
• Salus Place is a six-bed, privately funded transitional facility operated by the Alexian Brothers, a Roman Catholic Religious order of priests and brothers. It offers transitional housing for men in recovery.

[ Table III-C-5, Inventory of HIV/AIDS Housing Resources in the St. Louis EMA ]

Needs and Challenges
As indicated in the introduction to this section, the dual impact of increased infections in the poorest and most vulnerable populations (African Americans, women and youth) and decreased deaths in the general population (because of more successful drug protocols) has created an undeniable pressure on housing providers to create more housing and service opportunities.

Those who require services - predominantly poor people of color - have had fewer life-long resources and opportunities. In the needs assessment done by the St. Louis Regional HIV/AIDS Planning Council for their 2000 Ryan White Care Act application, these individuals and families expressed a variety of unmet needs, including all health services, substance abuse and mental health treatment, transportation, legal advocacy, and respite care for parents. Emergency utility assistance and housing are the highest social support needs they cite after case management. Housing providers report that many who were infected as youth or young adults, some of whom are already parents themselves, also need assistance with basic life skills such as home management, personal and environmental hygiene, scheduling and keeping appointments, parenting, managing their finances and so on. Housing providers are challenged to fulfill a more expansive role in the lives of their tenants.

At the same time that more people need more help, federal funds are shrinking. Information obtained from the Department of Housing and Urban Development at <"http://www.hud.gov> indicates that the St. Louis EMA may experience a loss of $7,996,000 in funding for HUD programs. The mark up of the FY 2000 federal budget by the House of Representatives includes a $10 million reduction in funding for HOPWA (Housing Opportunities for People with HIV/AIDS). If these budget cuts occur, HUD estimates that 152 homeless persons and persons living with AIDS and 648 families in the metropolitan area would be adversely impacted. Additionally, 5-12 new jurisdictions may become eligible for HOPWA funds, further reducing the formula award to cities such as St. Louis.

Table III-C-6, ST. LOUIS EMA HOPWA

  Year      Formula Allocation    Amount Contracted
  FY 1994       $807,000              $780,239
  FY 1995         92,000               792,000
  FY 1996        737,000               737,000
  FY 1997        843,000               843,000
  FY 1998        888,000               888,000
  FY 1999      1,059,000             1,059,000
  Total       $5,126,000            $5,126,000

The Ryan White Care Act, which contributes about $50 million nationally toward HIV/AIDS housing has published the final draft of HAB Housing Policy 99-02 further restricting the ways that those funds can be spent on housing by local EMA’s. It is clear that funding dedicated to persons with HIV is not adequate to begin to meet their housing needs.

Along with the silver lining of successful new treatments for HIV comes the storm cloud of reality that the medications do not work for everyone; even if they do work, they fail at a rate of 50% after two years; and homeless and marginally housed individuals are often denied these life saving drugs for lack of refrigeration, regular meals, fresh water, safe storage, and the ability to stick to a strict and complicated regimen. Furthermore, those who have failed on one or more medications can give a drug resistant strain of the virus to those to whom they transmit HIV. According to the 1998 HIV/AIDS Housing Plan developed by AIDS Housing of Washington, housing is a key factor in medication adherence.

Those with active substance abuse have the greatest difficulty finding and maintaining transitional and permanent housing. While all categories of persons living with HIV list housing as an unmet need, MSM’s of color (men of color who have sex with men) and IV drug using individuals have an even higher need for transitional housing. Yet locating these types of facilities has proved exceedingly difficult in the St. Louis area. Peter & Paul Community Services, which has funding for 16-20 Safe Haven beds and an adjunct drop-in center with comprehensive services, has had to abandon several favorable sites and geographically split the drop-in center away from the housing component due to neighborhood resistance.

While most of the housing providers (except Salus Place which targets people in recovery) operate on a full or a modified harm reduction policy relative to illegal substances, this approach to behavior change, which has been so successful in other parts of the country, is not broadly accepted in this region.

SHP grants have been used to develop and operate three facilities (47 units open now and 17 more as soon as the Safe Haven opens) for people living with HIV/AIDS. The grant funding of an 11 unit building offering independent living apartments expires in 2001. The grant funding 36 units of residential care with comprehensive nursing and social services for those with HIV who are too ill to live alone expires in 2001, and the grant funding for the Safe Haven ends in 2001. Presently these projects represent 43% of the local units dedicated exclusively to people with HIV/AIDS (more when the Safe Haven opens).

Recommendations
In April 1999, CDA convened a round table discussion including representatives from Peter & Paul Community Services, Doorways, Salus House, BABAA, and St. Louis Effort for AIDS. Reflections of their comments are included throughout this document.

In May, 1998, AIDS Housing of Washington brought together a diverse group of experts, providers, and consumers to create a regional HIV/AIDS housing plan. Among those providing key informant interviews were representatives from: ACCESS Program, Metro St. Louis AIDS Case Managers, Alexian Brothers Salus Place, Peter & Paul Community Services, Archway Communities, St. Clair County (IL) Health Department, Bethany Place, St. Louis Department of Health and Hospitals, Blacks Assisting Blacks Against AIDS, St. Louis Community Development Agency, DOORWAYS: An Interfaith AIDS Residence Program, U. S. Department of Housing and Urban Development, Homeless shelter providers, Metro East (IL) AIDS Case Managers

In addition, focus groups including a total of 68 consumers were held at the following sites or with the following organizations: Positive Voices, Bethany Place, Blacks Assisting Blacks Against AIDS, DART, Helena Hatch Special Care Center, Archway Communities, Peter & Paul Community Services, Wood River, IL

The following recommendations include those made by that recently convened planning body.

a) Allocate HOPWA funds proportionally between Missouri and Illinois based on case counts using the same formula as is used for Ryan White Title I funding. Each state would use funds for its specific local needs relative to HIV/AIDS housing.

Give the highest priority for HOPWA and other funds to the preservation and improvement of existing subsidy assistance programs and housing units already operating or under development.

Continue the existing HIV/AIDS utility, mortgage and rental assistance programs from HOPWA and other sources at current or increased levels. Support resource development and resource identification personnel for these programs and provide case management and drug and alcohol counseling personnel for the Supportive Housing Facility.

Leverage significant other national, state, and competitive funds by using HOPWA and other sources to support the operations deficits of HIV/AIDS dedicated 811 and SHP projects at Delmar, Tenth & Lami, Jefferson Park, Maryland Avenue, Mama Nyumba, and the Safe Haven.

b) Make every effort to identify mainstream housing funds that can be "set-asides" for the long-term HIV/AIDS housing portfolio.

It is urgent that the SHP grants supporting 47 units of dedicated HIV/AIDS housing on Delmar and Maryland (and supporting the Safe Haven when it opens in the near future) be renewed and increased in the 2001 funding cycle.

c) Appoint a representative to the Continuum of Care process operated by the Department of Human Services and ensure that CDA and the Department of Health advocate with Human Services for the inclusion and expansion of funding for these projects in the year 2000 application cycle.

d) Encourage providers to find significant core funding for new projects and new subsidies in programs that are federal competitions or are not HIV/AIDS dedicated.

These include but are not limited to HUD Section 811 (Capital Advance and Mainstream Section 8), HOPWA SPNS, Missouri Housing Trust Fund, Shelter Plus Care, Housing Authority Section 8 Voucher Set Aside, and CDBG funds.

e) Finalize a contract between an HIV housing agency contract and the Missouri Department of Mental Health and/or the St. Louis Housing Authority to administer a Shelter + Care program for people living with HIV/AIDS.

f) Prevail upon the Metropolitan St. Louis HIV Health Services Title I Planning Council and the Ryan White Title II Consortia to increase levels of commitment of Ryan White funds to emergency services, short term and transitional housing.

Ryan White is the second largest source of funding for HIV/AIDS housing in the EMA, yet trends indicate a reluctance within HRSA to continue funding housing. It will be a high priority to substitute HOPWA and other local funds to replace any diminishment of Ryan White funds for HIV/AIDS housing subsidies.

g) Create a central intake within an AIDS housing agency for all HIV housing related referrals.

Resources
Table III-C-7 provides a detailed analysis of the HIV-AIDS housing resources available in the St. Louis Eligible Metropolitan Area (EMA). Of significance is the fact that there remains a gap of 802 units on a monthly basis. Multiplying this gap by an average monthly cost of $350 leaves a funding gap of $280,700 per month, or $3,368,400 per year.

[ Table III-C-7, Analysis of HIV/AIDS Housing Resource Gaps in the St. Louis EMA]