Cross-Cutting Attributions

Cross-cutting allocations are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully.

There are 16 cross-cutting attribution categories in the database:

• Condoms: Commodities
• Condoms: Policy, Tools, and Services
• Construction
• Economic Strengthening
• Education
• Food and Nutrition: Commodities
• Food and Nutrition: Policy, Tools, and Service Delivery
• Gender: GBV (Gender Based Violence)
• Gender: Gender Equality
• Human Resources for Health
• Key Populations: FSW (Female Sex Workers)
• Key Populations: MSM (Men who have Sex with Men) and TG (Transgender)
• Motor Vehicles: Leased
• Motor Vehicles: Purchased
• Renovation
• Water

Except where noted, the following definitions for the cross-cutting attributions come from Appendix 2 of PEPFAR’s 2015 COP Guidance.

Adolescent Girls and Young Women (AGYW)

Countries should estimate the total amount of funding from their country budgets, not including central funds, which can be attributed to HIV prevention among adolescent girls and young women ages 9 to 24. OUs should include both preventing sexual violence and preventing HIV through avoiding sexual risk activities that focus on helping youth avoid risk before it begins (e.g., preventing sexual violence and any form of coercive/forced/non-consensual sex in the community, preventing early sexual debut, supporting healthy choices, and helping communities and families to surround these youth with support and education – all these activities must be grounded in evidence-based prevention programming), as well as preventing sexual violence and preventing HIV through reducing sexual risk activities that help youth reduce risk (e.g., limiting number of partners, condom use, PrEP, post-violence care).

Condoms: Commodities

This secondary cross-cutting budget attribution is meant to capture the cost condoms procured using bilateral funds including:

• Condoms for free distribution - The cost of condoms procured with bilateral funds for free distribution in clinical, community or other settings.
• Socially marketed condoms - The cost of condoms procured with bilateral funds for socially marketed condoms clinical, community or other settings.

Please note: most PEPFAR OUs order condoms through USAID’s Commodity Fund (CF) and do NOT pay for condoms using bilateral funds. Only those few OUs that are not eligible to order condoms through the CF and are therefore purchasing condoms with bilateral funds should be reporting through this secondary cross-cutting budget attribution.

Condoms: Policy, Tools, and Services

This secondary budget attribution should capture all activities with the following components:

• Development and/or Adaptation of National Condom Policies and Guidelines - The cost of developing or adapting national guidelines for condom procurement, distribution and promotion. This also includes activities that improve forecasting, procurement and distribution systems.
• Training and Curricula Development - The cost of training for health care workers, HIV prevention program staff, peer educators, and others to enhance their ability to promote and distribute condoms effectively and efficiently. This includes developing appropriate condom-related curricula for inclusion in pre- and post-service training programs and development of appropriate job aids.
• Condom promotion, distribution and provision - The cost of programs that promote, distribute and provide condoms (but not the cost of procuring condoms - this should be captured in the Condoms: Commodities cross-cutting budget attribution). This includes programs nested within existing clinical and community programs, such as programs for HIV-positive individuals or PMTCT programs, as well as costs for programs that focus exclusively on condom promotion.
• Equipment - The cost of procurement of any tools or equipment necessary to carry out condom programs, such as distribution boxes or dispensing machines, display stands, etc. This also includes more general procurement, logistics and inventory control costs.

Construction/Renovation

These attributions are meant to capture construction and renovation costs. Construction refers to projects to build new facilities, such as a health clinic, laboratory, or hospital annex or to expand an already existing facility (i.e. adds on a new structure or expands the outside walls). Renovation refers to projects with existing facilities intended to accommodate a change in use, technical capacity, or other infrastructure improvements. PEPFAR funded construction projects should serve foreign assistance purposes, will involve facilities that are provided to the partner government (or potentially to another implementing partner) as a form of foreign assistance, and are considered necessary to the delivery of HIV/AIDS-related services.

Importantly, from 2010 to 2012 the Construction and Renovation categories were combined in the COP documents and could not be tallied separately. Thus, when selecting 'Construction/Renovation', the database will automatically include the individual 'Construction' and 'Renovation' categories that exist for 2013 and beyond.

Delivery

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Economic Strengthening

Countries should estimate the amount of funding for each activity that is attributable to economic strengthening activities, including:

• Economic Strengthening - The portfolio of strategies and interventions that supply, protect, and/or grow physical, natural, financial, human and social assets. For PEPFAR generally, this refers to programs targeting HIV-infected individuals in care and treatment programs, OVC due to HIV/AIDS, and their caregivers. These activities can include a variety of microfinance, vocational training and/or income generation.
• Microfinance - The range of financial products and services, tailored to meet the needs and demands of low-income or otherwise vulnerable populations. This includes group and individual lending, savings, insurance, and other financial products. Microfinance is distinguished from mainstream finance by its outreach to isolated and poor populations and its efforts to make financial services accessible and approachable to them, in terms of product design and delivery systems.
• Microenterprise - A very small-scale, informally organized business activity undertaken by poor people. Generally refers to enterprises with 10 or fewer workers, including the micro-entrepreneur and any unpaid family workers; many income generating activities fall into this category.
• Microcredit - A form of lending which involves very small sums of capital targeted towards microentrepreneurs and poor households. Microcredit can take the form of individual or group loans, and have varying terms, interest rates and degrees of formality. Microcredit is a type of microfinance.
• Market Development - A fundamental approach to economic development that recognizes and takes advantage of the fact that products and services are most efficiently and sustainably delivered through commercial systems. Market development encompasses more targeted strategies such as microfinance and microenterprise development.

Education

Efforts to promote effective, accountable and sustainable formal and non-formal education systems should be included in this secondary budget attribution. In particular, activities focused on basic education, which is defined as activities to improve early childhood education, program area education and secondary education delivered in formal or non-formal settings. It includes literacy, numeracy and other basic skills programs for youth and adults. Activities related to life skills training and HIV prevention education within the context of education programs or settings should also be included in this budget attribution. Please see the Technical Considerations for what can be included as Education.

Food and Nutrition: Commodities

This secondary budget attribution is meant to capture the provision of food commodities through food by prescription, social marketing, school feeding, OVC, PMTCT or other programs, including:

• Micronutrient Supplementation - The cost of micronutrient supplement provision according to WHO guidance or where individual assessment determines a likelihood of inadequate dietary intake of a diverse diet to meet basic vitamin and mineral requirements.
• Therapeutic, Supplementary, and Supplemental Feeding - The cost of facility- and community-based food support for nutritional rehabilitation of severely and moderately malnourished PLWHA, as well as supplemental feeding of mothers in PMTCT programs and OVC.
• Replacement Feeding and Support - The cost of antenatal, peri- and postpartum counseling and support to HIV-positive mothers concerning infant feeding options and vertical transmission; on-going nutritional and clinical assessment of exposed infants; replacement feeding support, including limited provision of infant formula where warranted; and associated counseling and program support through at least the first year of life, per national policies and guidelines.

Please note that "safe water" is NOT included in this definition of food and nutrition. It is addressed separately, in the definition for Water.

Food and Nutrition: Policy, Tools, and Service Delivery

This secondary budget attribution should capture all activities with the following components:

• Development and/or Adaptation of Food and Nutrition Policies and Guidelines - The cost of developing or adapting guidelines that provide a framework for integrating food and nutrition activities within the care and support of people infected and affected by HIV/AIDS, including OVC. This includes policies and guidelines that foster linkages with "wraparound" programs that address food security and livelihood assistance needs in the targeted population. This also includes activities that improve quality assurance and control for production and distribution of therapeutic and fortified foods for use in food and nutrition activities.
• Training and Curricula Development - The cost of training for health care workers, home-based care providers, peer counselors, and others to enhance their ability to carry out nutritional assessment and counseling. This includes developing appropriate nutrition-related curricula for inclusion in pre- and post-service training programs and development of appropriate job aids for health care workers.
• Nutritional Assessment and Counseling - The cost of providing anthropometric, symptom, and dietary assessment to support clinical management of HIV-positive individuals before and during ART as well as exposed infants and young children. This includes nutrition education and counseling to maintain or improve nutritional status, prevent and manage food- and water-borne illnesses, manage dietary complications related to HIV infection and ART, and promote safe infant and young child feeding practices. It also includes nutritional assessment, counseling and referral linked to home-based care support.
• Equipment - The cost of procurement of adult and pediatric weighing scales, stadiometers, MUAC tapes, and other equipment required to carry out effective nutritional assessment. This also includes more general procurement, logistics and inventory control costs.

Gender: Gender Based Violence (GBV)

This secondary cross-cutting attribution should capture all activities aimed at preventing and responding to GBV, For PEPFAR, GBV is defined as any form of violence that is directed at an individual based on his or her biological sex, gender identity or expression, or his or her perceived adherence to socially-defined expectations of what it means to be a man or woman, boy or girl. It includes physical, sexual, and psychological abuse; threats; coercion; arbitrary deprivation of liberty; and economic deprivation, whether occurring in public or private life. GBV is rooted in gender-related power differences, including social, economic and political inequalities. It is characterized by the use and abuse of physical, emotional, or financial power and control. GBV takes on many forms and can occur across childhood, adolescence, reproductive years, and old age. It can affect women and girls, men and boys, and other gender identities. Women, girls, including men who have sex with men and transgendered individuals are often at increased risk for GBV. While GBV encompasses a wide range of behaviors, because of the links with HIV, PEPFAR is most likely to address physical and sexual intimate partner violence, including marital rape; sexual assault or rape; female genital cutting/mutilation; sexual violence against children and adolescents; and child marriage.

Examples of activities for "Preventing and Responding to Gender-Based Violence" include: Collection and Use of Gender-related Strategic Information: assess differences in power and gender norms that perpetuate GBV as well as gender and societal norms that may facilitate protective actions against GBV and changes in attitude and behaviors; analysis of existing data on different types of GBV disaggregated by sex, age and geography, and in relation the HIV epidemiology in order to identify priority interventions and focus in the context of PEPFAR programs; analysis of treatment, care and referral services data by sex and age to ensure the unique needs of actual and potential victims are being met; employ rapid assessment, situational analyses and other quantitative and qualitative methods to understand norms and inequalities perpetuating GBV:

• Implementation: Screening and counseling for gender-based violence (GBV) within HIV/AIDS prevention, care, and treatment programs; strengthening referrals from HIV/AIDS services to GBV services and vice versa; strengthening post-rape care services, including the provision of HIV PEP; interventions aimed at preventing GBV, including interpersonal communication, community mobilization and mass media activities; programs that address societal and community norms that perpetuate violence against women and girls and other marginalized populations; that promote gender equality; and that build conflict resolution skills; strengthening linkages between health, legal, law enforcement, and judicial services and programs to prevent and mitigate gender-based violence; interventions that seek to reduce gender-based violence directed at children and related child protection programs; support for review, revision, and enforcement of laws and for legal services relating to gender-based violence, including strategies to more effectively protect young victims and punish perpetrators
• Capacity building: capacity building for U.S. government staff and implementing partners on how to integrate GBV into HIV prevention, care and treatment programs; capacity building for Ministry of Women’s Affairs, Ministry of Health or other in-line Ministries to strengthen national GBV programs and guidelines; pre and in-service training on the identification, response to and referral for cases of intimate-partner violence, sexual violence and other types of GBV; assist in development and implementation of agency-, government-, or portfolio-wide GBV strategy
• Monitoring and Evaluation: strengthening national and district monitoring and reporting systems to capture information on provision of GBV programs and services, including HIV PEP within health facilities
• Operation Research: to better understand the associations and pathways between GBV and HIV/AIDS; identify promising practices in training and protocol for the effective delivery of GBV screening and services and of GBV prevention programs; evaluate the impact of comprehensive GBV programming on HIV and GBV outcomes of interest

Activities marked as GBV will now be required to provide additional information on specific acuities supported. Upon ticking the GBV crosscutting attribution box a drop-down menu of activities will appear. Teams should select all that apply.

• GBV Prevention
• Collection and Use of Gender-related Strategic Information
• Implementation
• Capacity building
• Monitoring and Evaluation
• Operation Research
• GBV Care
• Collection and Use of Gender-related Strategic Information
• Implementation
• Capacity building
• Monitoring and Evaluation
• Operation Research

Gender: Gender Equality

This secondary cross-cutting attribution should capture all activities aimed at ensuring that men and women have full rights and potential to be healthy, contribute to health development and benefit from the results by taking specific measures to reduce gender inequities within HIV prevention, care and treatment programs. This would consist of all activities to integrate gender into HIV prevention, care, and treatment and activities that fall under PEPFAR’s gender strategic focus areas

• Changing harmful gender norms and promoting positive gender norms
• Promoting gender-related policies and laws that increase legal protection
• Increase gender-equitable access to income and productive resources, including education
• Equity in HIV prevention, care, treatment and support

Examples of these activities include:

• Collection and use of Gender-related Strategic Information: Analysis of existing HIV prevention, care, and treatment portfolios and/or individual programs to understand and ensure appropriate response to: gender norms, relations and inequities that affect health outcomes; variation across populations and population subsets (by sex and age) in terms of gender norms, roles and resource needs; differences in power that affect access to and control over resources between women and men, girls and boys, which are relevant to health objectives; key gaps and successful programs in gender integration across HIV prevention, care and treatment; analysis of access and adherence to treatment includes analysis of data by sex and age and assessment of barriers to service by men and women; employ rapid assessment, situational analyses and other quantitative and qualitative methods to understand gender norms and inequalities in the context of HIV prevalence and programming
• Implementation of: HIV prevention interventions redressing identified gender inequalities; Legal, financial or health literacy programs for women and girls; programs designed to reduce HIV that addresses the biological, cultural, and social factors that disproportionately impact the vulnerability of women, men or transgender individuals to the disease, depending of the setting and type of epidemic; a PMTCT or HTC program that implement interventions to increase men’s meaningful participation in and use of services; specific programming for out-of-school adolescent and preadolescents who are often the most vulnerable, including males and married adolescent girls; male circumcision programs that include efforts to reach female partners, mothers and other women in the community and incorporate messages around gender norms in pre and post counseling
• Capacity building: assist in development and implementation of agency-, government-, or portfolio wide gender strategy; conduct training for U.S. government staff and implementing partners on women, girls, and gender equality issues, as well as capacity building on how to integrate gender into HIV prevention, care and treatment programs; capacity building for Ministry of Women’s Affairs or the Gender Unit within a Ministry of Health; capacity building interventions for HIV-positive women to assume leadership roles in the community and programs; training for health service providers on unique needs and risks of specific sub-populations such as adolescent girls and older, sexually-active men
• Operational Research: to better understand gender-related barriers and facilitators to HIV prevention, care and treatment programs; identify HIV-related needs and risks specific to adolescent girls and young women; promote constructive male engagement strategies to increase uptake of male circumcision, other prevention strategies, HTC, treatment, and care among adult men
• Monitoring and Evaluation: of programs and services through the use of standardized indicators and strengthening monitoring systems be able to document and report on accessibility, availability, quality, coverage and impact of gender equality activities; ensure that data is disaggregated by sex and age

Activities marked as GBV will now be required to provide additional information as part of a drop-down menu. Teams should select all that apply.

• Changing harmful gender norms and promoting positive gender norms
• Collection and Use of Gender-related Strategic Information
• Implementation
• Capacity building
• Monitoring and Evaluation
• Operation Research
• Promoting gender-related policies and laws that increase legal protection
• Collection and Use of Gender-related Strategic Information
• Implementation
• Capacity building
• Monitoring and Evaluation
• Operation Research
• Increase gender-equitable access to income and productive resources, including education
• Collection and Use of Gender-related Strategic Information
• Implementation
• Capacity building
• Monitoring and Evaluation
• Operation Research
• Equity in HIV prevention, care, treatment and support
• Collection and Use of Gender-related Strategic Information
• Implementation
• Capacity building
• Monitoring and Evaluation
• Operation Research

Gender: Reducing Violence and Coercion

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Human Resources for Health

This attribution includes the following:

• Workforce Planning
• Human Resource Information Systems (HRIS)
• In-Service Training
• Pre-Service Education
• Task shifting
• Performance Assessment/Quality Improvement
• Retention
• Management and Leadership Development
• Strengthening Health Professional Regulatory Bodies and Associations
• Twinning and Volunteers
• Salary Support

Key Populations: MSM and TG

This budget attribution is meant to capture activities that focus on gay men, other men who have sex with men including male sex workers, and those who do not conform to male gender norms and may identify as a third gender or transgender (TG). Broader definitions can be found in Appendix ____. These activities may include 1) implementation of core HIV prevention interventions for MSM/TG that are consistent with the current PEPFAR technical guidance; 2) training of health workers and community outreach workers; 3) collection and use of strategic information; 4) conducting epidemiological, social science, and operational research among MSM/TG and their sex partners; 5) monitoring and evaluation of MSM/TG programs; and 6) procurement of condoms, lubricants, and other commodities essential to core HIV services for MSM/TG.

Activities marked as Key Population: MSM/TG will now be required to provide additional information on activities. Teams should select all that apply and must select at least one tick-box if there is funding in this crosscutting attribution.

Please include the amount of the budget allocated to MSM and TG activities and check all of the following boxes that apply:

• Implementation of core HIV prevention interventions for MSM/TG that are consistent with the current
• PEPFAR technical guidance
• Training of health workers and community outreach workers
• Collection and use of strategic information
• Conducting epidemiological, social science, and operational research among MSM/TG and their sex partners
• Monitoring and evaluation of MSM/TG programs
• Procurement of condoms, lubricants, and other commodities essential to core HIV services for MSM/TG

Key Populations: Sex Workers

This budget attribution is meant to capture activities that focus on sex workers. Relevant activities include: 1) implementation of core HIV prevention interventions for SWs consistent with PEPFAR guidance on sexual prevention; 2) training of health workers and community outreach workers; 3) collection and use of SI on SWs and clients; 4) conducting epidemiological, social science, and operational research among SWs, their partners, and clients; 5) monitoring and evaluation of SW programs; and 6) procurement of condoms, lubricants, and other commodities essential to core HIV services for SWs.

Activities marked as Key Population: SW will now be required to provide additional information on activities.

Teams should select all that apply and must select at least one tick-box if there is funding in this crosscutting attribution.

Please include the amount of the budget allocated to SW activities and check all of the following boxes that apply:

• Implementation of core HIV prevention interventions for SWs consistent with PEPFAR guidance on sexual prevention
• Training of health workers and community outreach workers
• Collection and use of SI on SWs and clients
• Conducting epidemiological, social science, and operational research among SWs, their partners, and clients
• Monitoring and evaluation of SW programs
• Procurement of condoms, lubricants, and other commodities essential to core HIV services for SWs

Motor Vehicles: Leased / Motor Vehicles: Purchased

Countries need to provide the total amount of funding by Implementing Mechanism, which can be attributed to the purchase and/or lease of motor vehicle (s) under an implementing mechanism. The term Motor Vehicle refers to motorcycles, cars, trucks, vans, ambulances, mopeds, buses, boats, etc. that are used to support a PEPFAR Implementing Mechanism overseas.

Public Health Evaluation

Public Health Evaluations (PHEs) were implemented in the 2009 COP cycle and ultimately removed to be funded centrally for the COP 2010 cycle. Per the COP 2010 guidance, the purpose of the PHEs were as follows:

Emphasis will be placed on addressing strategic priority questions of global significance that can inform and improve PEPFAR programming broadly, that PEPFAR is uniquely poised to address, that are of sufficient scale and scientific rigor, that can be addressed in a timely and efficient manner and that take advantage of central coordination and support where appropriate. While we expect that most priority questions will fall into the category of global significance, there may be some exceptions. Therefore, it is recognized that there is a need to allocate some funding to country-specific priority questions that respond to requests of host governments or address locally specific implementation challenges.

• PHEs of global significance are those studies that can inform and change how PEPFAR delivers programs globally and that PEFPAR is uniquely poised to address. The majority of funds will be allocated to these projects, which should be of sufficient scale and scientific rigor and reflect the diversity of PEPFAR programs and populations served, in order that the findings might be globally relevant. Where appropriate, these studies will be conducted across countries. The selection process will be competitive. Emphasis will be given to projects that address identified PEPFAR strategic priority questions, build capacity locally and across countries, and are implemented in settings that reflect PEPFAR‘s diversity. All country programs, regardless of PEPFAR funding levels, can propose and participate in these competitive PHEs of global significance.
• Country-priority PHEs are those studies that respond to specific requests for the host government, address specific local implementation challenges and provide capacity-building opportunities for local researchers and local partner organizations, but do not necessarily rise to the potential of global significance. As with PHEs of global significance, the selection process will be competitive and country-priority PHE activities may only be approved if judged of sufficient scientific and technical merit.

Renovation

See Construction/Renovation above

Water

Countries should estimate the total amount of funding from their country budgets, not including central funds, which can be attributed to safe water. Activities include support for availability, access, and use of products to treat and properly store drinking water at the household level or other point-of-use, and promotion of hand washing with soap.