Evaluating Outcomes of the Antiretroviral Intervention in South Africa: A Systems Thinking Research Framework

  • Johanna Ledwaba
  • Kambidima Wotela


Background and Significance of the topic: HIV has become one of the most serious health and social development challenges in the world. Sub-Saharan Africa accounts for two-thirds of global HIV infections and almost half of these are in Southern Africa. Within the region, South Africa has the largest number (7.1 million) of people infected with HIV. The antiretroviral treatment intervention aims to reduce HIV transmission, improve the quality of life of people living with HIV, and to prolong life expectancy. To date, 3.4 million HIV-infected people receive antiretroviral treatment in South Africa. Notable literature is available on the outcomes of this intervention at country level and key urban areas. However, there is little, if any, knowledge on the outcomes in rural areas. Ultimately, this research intends to assess the outcomes of the antiretroviral treatment intervention in a South African rural setting called Mankweng in Limpopo Province using data abstracted from medical records to track viral load trends and to identify factors that affect virus suppression. The main focus of this paper is to propose a conceptual framework that should guide such an assessment. Methodology: We apply systems thinking approach to derive the theoretical framework and more importantly the conceptual framework in preparation for an empirical assessment of the antiretroviral intervention (ART) in a South African rural setting. Further, we then rely on summative content analysis to interrogate the academic and non-academic literature. Application/Relevance to systems analysis: The system thinking provides for a general approach that emphasises the product (theoretical and conceptual framework) rather than the process (literature review). More specifically, it allows us to integrate more meaningfully both the physical and academic context to deriving the theoretical and conceptual framework. Policy and/or practice implications: In general, development interventions established elsewhere must be contextualised for the African continent and its sub-regions in order to achieve the best outcomes. Discussion and conclusion: Prominent in our interrogation of literature on outcomes of HIV interventions is the lack of a theory of change when undertaking summative evaluations. More specifically, the outcomes of the antiretroviral treatment interventions in rural areas remain unreported.


HIV Viral load Antiretroviral treatment Knowledge gap Interpretive framework Theoretical framework Conceptual framework 


  1. Angoria (2014, August). Public hospitals in Limpopo discover hicts medical consulting expertise. Retrieved December 30, 2015, from
  2. Ansari, R. (2012). Applications of public health education and health promotion interventions. Bloomington: Trafford Publishing.Google Scholar
  3. Berriet-Solliec, M., Labarthe, P., & Laurent, C. (2014). Goals of evaluation and types of evidence. Evaluation, 20(2), 195–213. Scholar
  4. Bhana, A., & Govender, A. (2010). Evaluating interventions (p. 60). Mental Health: Promoting.Google Scholar
  5. Bonell, C., & Imrie, J. (2001). Behavioural interventions to prevent HIV infection: Rapid evolution, increasing rigour, moderate success. British Medical Bulletin, 58(1), 155–170.CrossRefGoogle Scholar
  6. Bryman, A. (2012). Social research methods. Oxford: Oxford University Press.Google Scholar
  7. Budgell, E. P., Maskew, M., Long, L., Sanne, I., & Fox, M. P. (2015). Brief report: Does most mortality in patients on ART occur in care or after lost to follow-up? Evidence from the Themba Lethu Clinic, South Africa. Journal of Acquired Immune Deficiency Syndromes 70(3), 323.CrossRefGoogle Scholar
  8. Cescon, A. M., Cooper, C., Chan, K., Palmer, A. K., Klein, M. B., Machouf, N., et al. (2011). Factors associated with virological suppression among HIV-positive individuals on highly active antiretroviral therapy in a multi-site Canadian cohort. HIV Medicine, 12(6), 352–360.CrossRefGoogle Scholar
  9. Cheever, L. W. (2007). Engaging HIV-infected patients in care: their lives depend on it. Clinical Infectious Diseases, 44(11), 1500–1502.CrossRefGoogle Scholar
  10. Cohen, M. S., Chen, Y. Q., McCauley, M., Gamble, T., Hosseinipour, M. C., Kumarasamy, N., et al. (2011). Prevention of HIV-1 infection with early antiretroviral therapy. New England Journal of Medicine, 365(6), 493–505.CrossRefGoogle Scholar
  11. Connell, J. P., & Kubisch, A. C. (1998). Applying a theory of change approach to the evaluation of comprehensive community initiatives: progress, prospects, and problems. New Approaches to Evaluating Community Initiatives, 2(15–44). Retrieved from
  12. Cornell, M., Grimsrud, A., Fairall, L., Fox, M. P., van Cutsem, G., Giddy, J., et al. (2010). Temporal changes in programme outcomes among adult patients initiating antiretroviral therapy across South Africa, 2002–2007. AIDS (London, England), 24(14), 2263.CrossRefGoogle Scholar
  13. Das, M., Chu, P. L., Santos, G.-M., Scheer, S., Vittinghoff, E., McFarland, W., et al. (2010). Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco. PLoS ONE, 5(6), e11068.CrossRefGoogle Scholar
  14. Denning, P., & DiNenno, E. (2010). Communities in crisis: Is there a generalized HIV epidemic in impoverished urban areas of the United States. Presented at the XVIII international AIDS conference.Google Scholar
  15. Department of Health. (2003). Operational plan for comprehensive HIV and AIDS care, management and treatment for South Africa. Retrieved May 15, 2015 from
  16. Department of Health. (2004). Monitoring and Evaluation Framework for Comprehensive HIV and AIDS Care, Management and Treatment Plan for South Africa. Retrieved March 30, 2016 from
  17. Doshi, R. K., Milberg, J., Isenberg, D., Matthews, T., Malitz, F., Matosky, M., Cheever, L. W. et al. (2014). High rates of retention and viral suppression in United States HIV safety net system: HIV care continuum in the Ryan White HIV/AIDS Program, 2011. Clinical Infectious Diseases, ciu722.Google Scholar
  18. Drimie, S. (2002). The impact of HIV/AIDS on rural households and land issues in Southern and Eastern Africa. A Background Paper Prepared for the Food and Agricultural Organization, Sub-Regional Office for Southern and Eastern Africa. Pretoria, South Africa: Human Sciences Research Council.Google Scholar
  19. Edgington, N. (2010). Let’s take a step back in the outcomes debate. Retrieved January 10, 2016 from
  20. Fatti, G., Grimwood, A., & Bock, P. (2010). Better antiretroviral therapy outcomes at primary healthcare facilities: an evaluation of three tiers of ART services in four South African provinces. PLoS ONE, 5(9), e12888.CrossRefGoogle Scholar
  21. Fielding, K. L., Charalambous, S., Stenson, A. L., Pemba, L. F., Martin, D. J., Wood, R., et al. (2008). Risk factors for poor virological outcome at 12 months in a workplace-based antiretroviral therapy programme in South Africa: a cohort study. BMC Infectious Diseases, 8(1), 93.CrossRefGoogle Scholar
  22. Fox, M. P., Shearer, K., Maskew, M., Macleod, W., Majuba, P., Macphail, P., et al. (2012a). Treatment Outcomes after Seven Years of Public-sector HIV treatment at the Themba Lethu Clinic in Johannesburg, South Africa. AIDS (London, England), 26(14), 1823.CrossRefGoogle Scholar
  23. Fox, M. P., Van Cutsem, G., Van Cutsem, J., Maskew, M., Keiser, O., Prozesky, H., et al. (2012b). Rates and predictors of failure of first-line antiretroviral therapy and switch to second-line ART in South Africa. Journal of Acquired Immune Deficiency Syndromes (1999), 60(4), 428.CrossRefGoogle Scholar
  24. Funnell, S. C., & Rogers, P. J. (2011). Purposeful program theory: Effective use of theories of change and logic models (Vol. 31). New York: Wiley.Google Scholar
  25. Gargani, J., & Donaldson, S. I. (2011). What works for whom, where, why, for what, and when? Using evaluation evidence to take action in local contexts. New Directions for Evaluation, 2011(130), 17–30.CrossRefGoogle Scholar
  26. Ghanotakis, E., Peacock, D., & Wilcher, R. (2012). The importance of addressing gender inequality in efforts to end vertical transmission of HIV. Journal of the International AIDS Society, 15(Suppl 2).Google Scholar
  27. Gharajedaghi, J. (2006). Systems thinking: Managing chaos and complexity: A platform for designing business architecture. Amsterdam: Elsevier Inc.CrossRefGoogle Scholar
  28. Görgens-Albino, M., & Kusek, J. Z. (2009). Making monitoring and evaluation systems work: a capacity development toolkit. World Bank Publications.Google Scholar
  29. Gregson, S., Nyamukapa, C. A., Garnett, G. P., Mason, P. R., Zhuwau, T., Caraël, M., et al. (2002). Sexual mixing patterns and sex-differentials in teenage exposure to HIV infection in rural Zimbabwe. The Lancet, 359(9321), 1896–1903.CrossRefGoogle Scholar
  30. Guerra-López, I. (2012). The monitoring and impact evaluation process: A Systemic approach to improving performance and impact. International Journal of Environmental Science and Engineering Research, 3(3), 80–85.Google Scholar
  31. Guerra-López, I., & Hicks, K. (2015). The participatory design of a performance oriented monitoring and evaluation system in an international development environment. Evaluation and Program Planning, 48, 21–30.CrossRefGoogle Scholar
  32. Hanson, S., & Hanson, C. (2008). HIV control in low-income countries in sub-Saharan Africa: are the right things done? Global Health Action, 1.CrossRefGoogle Scholar
  33. Holvoet, N., & Inberg, L. (2014). Taking stock of monitoring and evaluation systems in the health sector: findings from Rwanda and Uganda. Health Policy and Planning, 29(4), 506–516.CrossRefGoogle Scholar
  34. Hsieh, H., & Shannon, S. (2005). Three approaches to qualitative content analysis. Qualitative health Research, 15(9),1277–88.CrossRefGoogle Scholar
  35. Jobanputra, K., Parker, L. A., Azih, C., Okello, V., Maphalala, G., Kershberger, B., et al. (2015). Factors Associated with Virological Failure and Suppression after Enhanced Adherence Counselling, in Children, Adolescents and Adults on Antiretroviral Therapy for HIV in Swaziland. PLoS ONE, 10(2). Retrieved from Scholar
  36. Johnson, L. F., Estill, J., Keiser, O., Cornell, M., Moolla, H., Schomaker, M., Boulle, A. (2014). Do increasing rates of loss to follow-up in antiretroviral treatment programs imply deteriorating patient retention? American Journal of Epidemiology, kwu295.Google Scholar
  37. Johnson, L. F., Mossong, J., Dorrington, R. E., Schomaker, M., Hoffmann, C. J., Keiser, O., et al. (2013). Life expectancies of South African adults starting antiretroviral treatment: collaborative analysis of cohort studies. PLoS Medicine, 10(4), e1001418.CrossRefGoogle Scholar
  38. Joint United Nations Programme on HIV/AIDS (UNAIDS). (2010). Combination HIV prevention: tailoring and coordinating biomedical, behavioural and structural strategies to reduce new HIV infections. Geneva: UNAIDS.Google Scholar
  39. Joint United Nations Programme on HIV/AIDS. (2016). Global AIDS Update 2016. Retrieved March 16, 2017, from
  40. Joint United Nations Programme on HIV/AIDS (UNAIDS). (2017). UNAIDS DATA 2017. Retrieved September 06, 2017, from
  41. Kaul, R., Makadzange, T., & Rowland-Jones, S. (2000). AIDS in Africa: a disaster no longer waiting to happen. Nature Immunology, 1(4), 267–270.CrossRefGoogle Scholar
  42. Kawonga, M., Blaauw, D., & Fonn, S. (2012). Aligning vertical interventions to health systems: A case study of the HIV monitoring and evaluation system in South Africa. Health Res Policy Syst, 10(2), 10–1186.Google Scholar
  43. Kinsey-Steele, D. (2012). Effects of Psychosocial Issues on Medication Adherence Among HIV/AIDS Patients. FEDERAL PRACTITIONER.Google Scholar
  44. Kumar, R. (2014). Research Methodology: A Step-by-Step Guide for Beginners. Los Angeles: Sage Publications.Google Scholar
  45. Kusek, J. Z., & Rist, R. C. (2004). Ten steps to a results-based monitoring and evaluation system: a handbook for development practitioners. World Bank Publications. Retrieved from
  46. Langen, T. T. (2007). Gender power imbalance on women\’s capacity to negotiate self-protection against HIV/AIDS in Botswana and South Africa. African Health Sciences, 5(3), 188–197.Google Scholar
  47. Magadi, M. A. (2011). Understanding the gender disparity in HIV infection across countries in sub-Saharan Africa: Evidence from the demographic and health surveys. Sociology of Health & Illness, 33(4), 522–539.CrossRefGoogle Scholar
  48. Mantell, J. E., Di Vittis, A. T., & Auerbach, M. I. (1997). Evaluating HIV prevention interventions. Berlin: Springer Science & Business Media.CrossRefGoogle Scholar
  49. Margoluis, R., Stem, C., Swaminathan, V., Brown, M., Johnson, A., Placci, G., et al. (2013). Results chains: A tool for conservation action design, management, and evaluation. Ecology and Society, 18(3), 22.CrossRefGoogle Scholar
  50. Marks, G., Crepaz, N., & Janssen, R. S. (2006). Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. Aids, 20(10), 1447–1450.CrossRefGoogle Scholar
  51. Mbirimtengerenji, N. D. (2007). Is HIV/AIDS epidemic outcome of poverty in Sub-Saharan Africa? Croatian Medical Journal, 48(5), 605.Google Scholar
  52. McMahon, J. H., Elliott, J. H., Bertagnolio, S., Kubiak, R., & Jordan, M. R. (2013). Viral suppression after 12 months of antiretroviral therapy in low-and middle-income countries: a systematic review. Bulletin of the World Health Organization, 91(5), 377–385.CrossRefGoogle Scholar
  53. Mugavero, M. J., Amico, K. R., Westfall, A. O., Crane, H. M., Zinski, A., Willig, J. H., et al. (2012). Early retention in HIV care and viral load suppression: implications for a test and treat approach to HIV prevention. Journal of Acquired Immune Deficiency Syndromes, 59(1), 86.CrossRefGoogle Scholar
  54. Munro, S., Lewin, S., Swart, T., & Volmink, J. (2007). A review of health behaviour theories: how useful are these for developing interventions to promote long-term medication adherence for TB and HIV/AIDS? BMC Public Health, 7(1), 104.CrossRefGoogle Scholar
  55. Nachega, J. B., Nguyen, H., Dowdy, D. W., Chaisson, R. E., Regensberg, L., Maartens, G., et al. (2009). Antiretroviral therapy adherence, virologic and immunologic outcomes in adolescents compared with adults in southern Africa. Journal of Acquired Immune Deficiency Syndromes (1999), 51(1), 65.CrossRefGoogle Scholar
  56. Nakrošis, V. (2014). Theory-based evaluation of capacity-building interventions. Evaluation, 20(1), 134–150.CrossRefGoogle Scholar
  57. Nattrass, N. (2008). AIDS and the scientific governance of medicine in post-apartheid South Africa. African Affairs, 107(427), 157–176.CrossRefGoogle Scholar
  58. Nglazi, M. D., Lawn, S. D., Kaplan, R., Kranzer, K., Orrell, C., Wood, R., et al. (2011). Changes in programmatic outcomes during 7 years of scale-up at a community-based antiretroviral treatment service in South Africa. Journal of Acquired Immune Deficiency Syndromes, 56(1), e1.CrossRefGoogle Scholar
  59. Nguyen, D. B., Do, N. T., Shiraishi, R. W., Le, Y. N., Tran, Q. H., Nguyen, H. H., et al. (2013). Outcomes of antiretroviral therapy in Vietnam: Results from a national evaluation. PloS ONE, 8(2), e55750.CrossRefGoogle Scholar
  60. Nutbeam, D., Harris, E., & Wise, W. (2010). Theory in a nutshell: A practical guide to health promotion theories. New York: McGraw-Hill.Google Scholar
  61. Nyindo, M. (2005). Complementary factors contributing to the rapid spread of HIV-I in Sub-Saharan Africa: A review. East African Medical Journal, 82(1), 40–46.CrossRefGoogle Scholar
  62. Palella, F. J., Deloria-Knoll, M., Chmiel, J. S., Moorman, A. C., Wood, K. C., Greenberg, A. E., et al. (2003). Survival benefit of initiating antiretroviral therapy in HIV-infected persons in different CD4+ cell strata. Annals of Internal Medicine, 138(8), 620–626.CrossRefGoogle Scholar
  63. Parkhurst, J. O. (2010). Understanding the correlations between wealth, poverty and human immunodeficiency virus infection in African countries. Bulletin of the World Health Organization, 88(7), 519–526.CrossRefGoogle Scholar
  64. Patton, M. Q. (2008). Utilization-focused evaluation. Thousand Oaks: SAGE.Google Scholar
  65. Portfolio Committee for Health. (2011). Report of the Portfolio Committee on Health on the oversight visit to Mankweng, Louis Trichardt Hospitals and Madombidza Clinic in the Limpopo Province from 10–12 August 2011. Retrieved September 28, 2015, from
  66. Ras, G., Simson, I., Anderson, R., Prozesky, O., & Hamersma, T. (1983). Acquired immunodeficiency syndrome. South African Medical Journal, 64, 140–142.Google Scholar
  67. Rossi, P. H., Lipsey, M. W., & Freeman, H. E. (2003). Evaluation: A systematic approach. Thousand Oaks: SAGE.Google Scholar
  68. Saka, B., Landoh, D. E., Patassi, A., d’Almeida, S., Singo, A., Gessner, B. D., & Pitché, P. V. (2014). Loss of HIV-infected patients on potent antiretroviral therapy programs in Togo: risk factors and the fate of these patients. Pan African Medical Journal, 15(1).Google Scholar
  69. Sherman, G., Lilian, R., Bhardwaj, S., Candy, S., & Barron, P. (2014). Laboratory information system data demonstrate successful implementation of the prevention of mother-to-child transmission programme in South Africa. SAMJ. South African Medical Journal, 104(3), 235–238.CrossRefGoogle Scholar
  70. Shisana, O., Rehle, T., Simbayi, L., Zuma, K., Jooste, S., Zungu, N., Ramlagan, S. (2014). South African national HIV prevalence, incidence and behaviour survey, 2012. Cape Town.Google Scholar
  71. Statistics of South Africa. (2011). Mankweng. Retrieved January 12, 2016, from
  72. Statistics of South Africa. (2017). Poverty trends in South Africa. An examination of absolute poverty between 2012 and 2015. Retrieved Sempember 08, 2017, from
  73. Stoller, E. J., & Rutherford, G. W. (1989). Evaluation of AIDS prevention and control programs. AIDS, 3(1), S289–S296.CrossRefGoogle Scholar
  74. Stoltzfus, R. J., & Pillai, G. (2002). Measuring performance: A strategy to improve programs. The Journal of Nutrition, 132(4), 845S–848S.CrossRefGoogle Scholar
  75. Taraphdar, P., Guha, R. T., Haldar, D., Chatterjee, A., Dasgupta, A., Saha, B., et al. (2011). Socioeconomic consequences of HIV/AIDS in the family system. Nigerian Medical Journal: Journal of the Nigeria Medical Association, 52(4), 250.CrossRefGoogle Scholar
  76. Tsui, J., Hearn, S., & Young, J. (2014). Monitoring and evaluation of policy influence and advocacy. Working Paper 395, London: Overseas Development Institute.Google Scholar
  77. United Nations Development Programme. (2011). Outcome level evaluation: A companion guide to the handbook of planning monitoring and evaluating for development for development results for programme units and evaluators. Retrieved on 20 December 2015 from
  78. Wandeler, G., Keiser, O., Pfeiffer, K., Pestilli, S., Fritz, C., Labhardt, N. D., et al. (2012). Outcomes of antiretroviral treatment programs in rural Southern Africa. Journal of Acquired Immune Deficiency Syndromes, 59(2), e9.CrossRefGoogle Scholar
  79. Weiss, C. H. (1997). Theory-based evaluation: Past, present, and future. New Directions for Evaluation, (76), 41–55.CrossRefGoogle Scholar
  80. White, H. (2006). Impact evaluation: the experience of the Independent Evaluation Group of the World Bank.Google Scholar
  81. World Health Organisation. (2005). National AIDS Programmes: A guide to indicators for monitoring and evaluating National AIDS Programmes. Retrieved December 24, 2015, from
  82. World Health Organisation. (2010). Priority interventions. Retrieved December 20, 2015 from
  83. World Health Organisation. (2015). Consolidated strategic information guidelines for HIV in the health sector. Retrieved December 30, 2015, from
  84. Wotela, K. (2016). Towards a systematic approach to reviewing literature for interpreting public and business management research results. Electronic Journal of Business Research Methods, 14(2), 83–97.Google Scholar
  85. Wotela, K. (2017). Conceptualising conceptual frameworks in public and business management research: Paper presented at the 16th European Conference on Research Methodology for Business and Management Studies. Dublin Institute of Technology. June 22–23, 2017. Reading: Academic Conferences and Publishing International Limited.Google Scholar

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Authors and Affiliations

  1. 1.WITS Graduate School of GovernanceUniversity of the Witwatersrand (WITS)JohannesburgSouth Africa

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