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In 2015, the WHO recommended universal antiretroviral therapy (ART) for all people living with HIV after two randomized controlled trials revealed lower rates of mortality and serious illnesses among people living with HIV receiving immediate ART compared with those receiving deferred ART. Many countries in sub-Saharan Africa rapidly adopted this guidance and are implementing ‘test and start’ programs.As this work begins, lessons learned from prevention of mother-to-child transmission Option B+ programs can inform decisions for new universal HIV treatment programs. The Option B+ approach involved initiation of lifelong treatment for all HIV-infected pregnant and breastfeeding women. Since its inception in Malawi in 2011 and WHO endorsement in 2012, widespread scale-up of Option B+ prevention of mother-to-child transmission programs in most resource-limited countries has resulted in a dramatic increase in ART coverage for HIV-infected pregnant and breastfeeding women.Despite the overall success of the Option B+ universal lifelong treatment approach, program and operational research data highlight the need for additional focus on strategies to retain women in care. In this commentary, we highlight program considerations and lessons learned from Option B+ implementation experience in resource-limited countries, which may help guide decisions and enhance the quality of general ‘test and start’ programing.