Indicator-focussed technical assistance in South Africa’s HIV programme: a stepped-wedge evaluation
Open accessAbstract
Background: There is a lack of research on technical assistance (TA) interventions in low- and middle-income countries. Variation in local contexts requires tailor-made approaches to TA that are structured and replicable across intervention sites whilst retaining the flexibility to adapt to local contexts. We developed a systematic process of TA using multidisciplinary roving teams to provide support across the various elements comprising local HIV services. Objectives: To examine the effectiveness of targeting specific HIV and TB programme indicators for improvement using roving teams. Method: We conducted a cluster-randomised stepped-wedge evaluation of a TA support package focussing on clinical, managerial and pharmacy services in the Mopani district of the Limpopo province, South Africa (SA). Three roving teams delivered the intervention. Seventeen primary and community healthcare centres that had 400–600 patients on antiretroviral therapy (ART) were selected for inclusion. The TA package was implemented for six consecutive months across facilities until all had received the same level of support. Data were collected from the relevant health management information systems for 11 routine indicators. Results: The mean proportion of PLWH screened for tuberculosis (TB) at ART initiation increased from 85.2% to 87.2% ( P = 0.65). Rates of retention in care improved, with the mean proportion of patients retained in care at three months post-ART initiation increasing from 79.9% to 87.4% ( P < 0.001) and from 70.3% to 77.7% ( P < 0.01) after six months. Finally, the mean proportion of patients with TB who completed their treatment increased from 80.6% to 82.1% ( P = 0.75). Conclusion: Tailored TA interventions in SA using a standardised structure and process led to a significant improvement in retention-in-care rates and to non-significant improvements in the proportion of PLWH screened for TB and of those who completed their treatment.
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Jobson et al. (2021) included 20 clusters (parishes).
“20”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [52]
The Methods (Study design) define each healthcare facility as a cluster, and Methods (Sampling) state that 17 facilities were included. The source therefore reports 17 facility clusters, not 20 parishes. (LLM, conf=0.94)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredJobson et al. (2021) drew a sample of 4,372 adults aged 25-70 years from 3,689 randomly selected households across 80 villages in the 20 parishes, designed to provide adequate power to detect changes in CVD risk factors.
“A sample of 4,372 adults aged 25–70 years was drawn from 3,689 randomly selected households across 80 villages in the 20 parishes. The sample size was designed to provide adequate power to detect changes in CVD risk factors through the intervention”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [52]
Methods > Sampling (page unavailable) says the study selected 17 healthcare facilities, not adults from households across villages. Methods > Data analysis (page unavailable) identifies HIV and TB outcomes, not changes in CVD risk factors. (LLM, conf=0.90)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredJobson et al. (2021) randomly assigned 20 parishes to the order in which they would receive the intervention.
“The parishes were randomly assigned to the order in which they would receive the intervention. The randomization ensured that all parishes eventually received the intervention while allowing for a staggered rollout”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [52]
The Methods (Study design) describe random allocation of clusters to intervention times, with a staggered rollout until all received support. But Methods (Sampling) says the study included 17 healthcare facilities, not 20 parishes. (LLM, conf=0.90)
Experimental — accuracy not yet measuredJobson et al. (2021) used multiple steps, with each parish transitioning to the intervention phase at different times.
“Multiple steps, with each parish transitioning to the intervention phase at different times”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [52]
The Methods (Study design) describe a stepped-wedge evaluation in which clusters crossed from control to intervention at different allocated times. The clusters were healthcare facilities, however, not parishes; the Sampling section identifies 17 facilities in the study. (LLM, conf=0.88)
Experimental — accuracy not yet measuredSome stepped-wedge interventions aimed to strengthen healthcare infrastructure and systems to improve service delivery and patient outcomes.
“Some interventions aimed to strengthen healthcare infrastructure and systems to improve service delivery and patient outcomes (27, 49, 52, 54, 56–58, 60, 62, 65, 66, 68, 70, 72, 74, 77, 79, 84–88, 90, 91, 93–96).”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [52]
The Methods and intervention description identify a stepped-wedge technical-assistance programme aimed at improving HIV and TB service delivery through clinical mentoring, data-quality work and drug-supply management. The Discussion reports improvement in retention in care. Although the Introduction names poor physical infrastructure as a health-system challenge, the described intervention does not show an aim to strengthen physical infrastructure. (LLM, conf=0.82)
Experimental — accuracy not yet measured
Jobson et al. (2021) chose a stepped wedge design to accommodate logistical and practical considerations for rolling out the intervention in a resource-constrained setting.
“This design also accommodated logistical and practical considerations for rolling out the intervention in a resource-constrained setting”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [52]
Primary care facilities were often chosen as clusters in low-resource settings.
“Primary care facilities were often chosen as clusters in low-resource settings (37, 52, 55, 56, 62, 70, 91, 92, 101, 108).”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [52]
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Self-citation
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- Authors
- Jobson, G. A., Railton, J., Mutasa, B., Ranoto, L., Maluleke, C., McIntyre, J., Struthers, H., & Peters, R.
- Affiliations
- Anova Health Institute (ZA)
- University of Cape Town (ZA)
- Corresponding author
- Jobson, Geoffrey A.
- Venue
- Southern African Journal of HIV Medicine
- Publisher
- AOSIS
- Published
- 2021-06-15
- Volume
- 22
- Issue
- 1
- Pages
- 1229-1229
- ISSN
- 1608-9693 (ISSN-L)
- 2078-6751
- PMC
- PMC8252139
- OpenAlex
- W3170487647
- Cited by
- 4
- References
- 14
- Citations by year
- 2026: 1 · 2025: 1 · 2024: 2
- FWCI
- 0.16
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- Southern African Journal of HIV Medicine (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- UpSpace Institutional Repository (University of Pretoria) (submittedVersion, cc-by)
- Funders
- United States Agency for International Development (674-A-12-00015)
- U.S. President’s Emergency Plan for AIDS Relief (Cooperative Agreement number 674-A-12-00015, 674-A-12-00015)
- Anova Health Institute
- Topics
- Health Sciences › Medicine › Infectious Diseases › HIV/AIDS Research and Interventions
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › HIV/AIDS Impact and Responses
- Keywords
- technical assistance, retention in care, tuberculosis screening, TB treatment completion, antiretroviral therapy, health management information systems, South Africa
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