Methods for determining the Impact of Global HIV/AIDS investment on the health systems of low income countries: A case study from Uganda

The US President's Emergency Plan for AIDS Relief (PEPFAR) has invested more than $30 billion in the care, treatment and prevention of HIV/AIDS. While many studies show the impact of this program in successfully controlling the HIV epidemic in many low-resource settings, there is a growing interest in understanding the collateral impact of large disease-specific programs on services for other diseases and the country's health system. For example, has the focus on HIV/AIDS helped to improve the competency of health workers in other disease areas? Conversely, has PEPFAR investment shifted health care workers away from care of patients with non-HIV conditions? Using the case study of Uganda, we explore how PEPFAR investments affected utilization of other health services and the broader health system. We collected qualitative and quantitative data from 112 health district offices and 336 health facilities across Uganda, looking for changes in the health system between 2005 (when PEPFAR investments began) and the current time. We describe the variation in PEPFAR investments by district, and associated utilization changes in non-HIV services, especially outpatient, maternity and newborn care. We controlled for confounders and effect modifiers. Findings from this study can inform how future investments in disease-specific interventions can simultaneously strengthen the whole health system.