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Background: Understanding contradictions between national HIV policies and their implementation in health facilities is essential for improving the effectiveness of national HIV programmes. This study compares national policies on HIV testing, prevention of mother-to-child transmission (PMTCT), antiretroviral therapy and retention in care with survey data from health facilities serving the populations of two South African health and demographic surveillance sites (HDSS) in Agincourt and uMkhanyakude in order to assess implementation of national HIV policies.
Methods: Ten national HIV policy documents published in 2003-2015 were reviewed, with content extracted on implicit or explicit adherence to 54 pre-defined indicators likely to influence service access and retention in care across the HIV cascade.
Purposively-sampled health facilities in Agincourt and uMkhanyakude (N=26) were surveyed in October 2013 to May 2014 using a structured questionnaire covering the same HIV services and indicators. Survey data were analysed descriptively and the findings compared to national policy indicators for each site.
Results: South African HIV policies closely adhered to WHO recommendations despite several gaps, notably in relation to quality of care, with health facilities in both sites reporting high client loads and limited refresher training in HIV testing and ART delivery. In terms of HIV treatment, facilities in both sites were weaker in terms of medical management and PLHIV support than in service coverage and access. There were policy gaps in relation to access to HIV treatment and retention in care, but these were often compensated by practices in the facilities, notably in relation to provision of Option B+ which was provided in 88% of facilities in Agincourt and 22% in uMkhanyakude, despite the its absence from policy.
Conclusions: Despite numerous policy gaps for HIV testing, PMTCT, access to ART and retention in care, we found that implementation within health facilities was broadly similar across these two rural South African sites, and sometimes exceeded national recommendations. Future research should explore factors that facilitate or inhibit policy development and implementation, and assess whether differences in HIV service delivery are reflected in HIV mortality patterns in the two HDSS sites.

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