Background: Understanding the implementation of 2013 World Health Organization (WHO) consolidated guidelines
on the use of antiretroviral drugs for treating and preventing HIV infection at the facility level provides important
lessons for the roll-out of future HIV policies.
Methods: A national policy review was conducted in six sub-Saharan African countries to map the inclusion of the
2013 WHO HIV treatment recommendations. Twenty indicators of policy adoption were selected to measure ART
access (n = 12) and retention (n = 8). Two sequential cross-sectional surveys were conducted in facilities between
2013/2015 (round 1) and 2015/2016 (round 2) from ten health and demographic surveillance sites in Kenya,
Malawi, South Africa, Tanzania, Uganda and Zimbabwe. Using standardised questionnaires, facility managers were
interviewed. Descriptive analyses were used to assess the change in the proportion of facilities that implemented
these policy indicators between rounds.
Results: Although, expansion of ART access was explicitly stated in all countries’ policies, most lacked policies that
enhanced retention. Overall, 145 facilities were included in both rounds. The proportion of facilities that initiated ART at
CD4 counts of 500 or less cells/μL increased between round 1 and 2 from 12 to 68%, and facilities initiating patients on
2013 WHO recommended ART regimen increased from 42 to 87%. There were no changes in the proportion of
facilities reporting stock-outs of first-line ART in the past year (18 to 11%) nor in the provision of three-month supply of
ART (43 to 38%). None of the facilities provided community-based ART delivery.
Conclusion: The increase in ART initiation CD4 threshold in most countries, and substantial improvements made in the
provision of WHO recommended first-line ART regimens demonstrates that rapid adoption of WHO recommendations
is possible. However, improved logistics and resources and/or changes in policy are required to further minimise ART
stock-outs and allow lay cadres to dispense ART in the community. Increased efforts are needed to offer longer
durations between clinic visits, a strategy purported to improve retention. These changes will be important as countries
move to implement the revised 2015 WHO guidelines to initiate all HIV positive people onto ART regardless of their
immune status