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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. Electronic supplementary material The online version of this article (10.1186/s12913-017-2678-1) contains supplementary material, which is available to authorized users.

A description of policies for increasing ART access and improving retention in care by country and date of adoption. (DOCX 28 kb)

The last decade has seen rapid evolution in guidance from the WHO concerning the provision of HIV services along the diagnosis-to-treatment continuum, but the extent to which these recommendations are adopted as national policies in Kenya, and subsequently implemented in health facilities, is not well understood. Identifying gaps in policy coverage and implementation is important for highlighting areas for improving service delivery, leading to better health outcomes. We compared WHO guidance with national policies for HIV testing and counselling, prevention of mother-to-child transmission, HIV treatment and retention in care. We then investigated implementation of these national policies in health facilities in one rural (Kisumu) and one urban (Nairobi) sites in Kenya. Implementation was documented using structured questionnaires that were administered to in-charge staff at 10 health facilities in Nairobi and 34 in Kisumu. Policies were defined as widely implemented if they were reported to occur in > 70% facilities, partially implemented if reported to occur in 30–70% facilities, and having limited implementation if reported to occur in