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A recent court judgment has made it easier for HIV-positive people to get antiretroviral drugs. Picture: 123RF.COM
A recent court judgment has made it easier for HIV-positive people to get antiretroviral drugs. Picture: 123RF.COM

After last week’s ruling by the North Gauteng High Court that gave the go-ahead for pharmacists to prescribe anti-HIV drugs, SA is one step closer to getting everyone diagnosed with HIV on treatment that will prevent them from transmitting the virus.

The court judgment makes it easier for HIV-positive people to get antiretroviral drugs (ARVs) and for those who are HIV-negative to use a daily HIV prevention pill, because they won’t first have to see a doctor. 

When someone with HIV takes their daily ARVs correctly, it becomes virtually impossible for them to infect others through sex, because the medicine suppresses the virus in their bodies to levels too low to transmit it

SA struggles to get enough people who know they have contracted the virus on ARVs. 

The latest figures from Stats SA show 7.94-million people in the country are estimated to have HIV. From this, and using the health department’s data on the proportion of people diagnosed and on treatment, 8.45-million people know they’re infected and 6.11-million of them are on ARVs. This means 2.34-million HIV-positive (both diagnosed and undiagnosed) people are not on treatment. 

The court decision comes after a doctors’ group, the Independent Practitioners Association Foundation (IPAF), took the South African Pharmacy Council (SAPC) to court in 2022 for starting the Pharmacist-Initiated Management of Antiretroviral Treatment (Pimart) programme. Through this programme, pharmacists would be able to, after completing a training course and obtaining a special permit for dispensing schedule 4 drugs, advise clients on taking ARVs and following their treatment. 

Under the Pimart programme, someone can go to a qualifying pharmacy to get HIV prevention drugs, have an HIV test or pick up their ARVs without having to see a doctor first for a prescription

ARVs are classified as schedule 4 medicines according to South African law, and should conventionally only be prescribed by a doctor, says the Medicines and Related Substances Act

The World Health Organisation (WHO) said that widening the circle when it comes to managing patients’ primary healthcare — such as for treating or preventing HIV infections — is a good idea. 

Why? Because the easier it is for people to get ARVs, the closer we’ll be to ending the epidemic by 2030. 

To do this, the Joint UN Programme on HIV/Aids (UNAIDS) wants all member countries to reach something known as the 95-95-95 goals by 2025. That means governments, including that in SA, would need to have, by 2025, 95% of people with HIV diagnosed, get 95% of diagnosed people on ARVs and get 95% of those on treatment to have viral levels so low they can’t infect someone else (called viral suppression).

According to figures from the health department, we’re far behind on the second 95, namely getting people who know they have HIV to initiate treatment. 

Knowing our numbers 

By May, 95% of people with HIV in SA knew they were infected. But only 77% of them were on ARVs. Of those, only 92% were virally suppressed. 

“We’re not satisfied with where we’re at,” said Thato Chidarikire, the health department’s acting chief director for HIV, when asked about the country’s progress on the 95-95-95 goals.  

New guidelines from the WHO, released in July, could help to change the picture.

Generally, when there are fewer than 20 copies of the virus in a millilitre of blood, someone is said to have an undetectable viral load (that is, the amount of virus in the body) and the virus is virtually untransmittable. This idea is called U=U: undetectable equals untransmittable.  

The WHO said if someone has a viral load anywhere below 1,000 copies per millilitre — which will be picked up by a test — the infection is controlled enough that there’s an “almost zero or negligible risk” of passing on HIV to a sexual partner.  

Treatment gap

Why does SA struggle to get diagnosed people on treatment, and help them to stick to it? 

Francois Venter, executive director of the Ezintsha research centre at Wits, said: “People may be in denial [after being diagnosed], feel stigmatised or be scared. Or the health services may be unfriendly or inaccessible.”  

To keep viral levels suppressed, someone with HIV has to stick to their treatment, meaning taking ARVs for the rest of their life. But, said Venter, this is hard, despite “vanishingly rare” side effects of the medication.

“New drugs have far fewer side effects, to the point that almost all patients tolerate their drug combinations extremely well. We also see far less [drug] resistance. There’s more forgiveness for the occasional lapse in adherence. Treatment really is so much easier than before,” he said 

Why the difficulty in keeping people on their pills?

Venter said: “It’s all social. The chaos of everyday life. Changing jobs, provinces, moving house, stresses. You name it. There are so many reasons for interrupting therapy, and the system doesn’t make it easy to move clinics or to come back after you’ve stopped your treatment. The healthcare workers routinely yell at you. It’s a huge disincentive to come back.”

How to get to the finish line 

Chidarikire agreed. To help people get, and stay on, treatment, we have to make access to medication easier. SA already follows a differentiated service delivery model, she said, as recommended by the WHO. This means instead of having a one-size-trying-to-fit-all approach to HIV treatment, the way people get tested and treated for HIV is adapted to fit their circumstances. 

“We may have reached the first 95, but the second and third still need a lot of effort, both on the demand and supply side,” she said.

Enter Pimart. Under this programme, someone can go to a qualifying pharmacy (one that has a section 22A(15) permit) to get HIV prevention drugs, have an HIV test or pick up their ARVs without having to see a doctor first for a prescription. If this is close to where they live or work, and if the process is fast and efficient, it will be easier for people to stay on treatment or protect themselves from getting infected in the first place. 

In the case of treatment, pharmacists will only be allowed to issue first-line ARVs (the first type of regimen  in the form of a three-in-one daily pill  on which a newly diagnosed person is put). 

But getting your HIV treatment from a private pharmacy won’t be free. Pharmacists will be able to charge the single exit price for the medicine plus a professional fee, as set by the SAPC. The cost of treatment in the private sector, therefore, could be a barrier to people who use government facilities, said Andy Gray, senior lecturer in pharmacology at the University of KwaZulu-Natal (UKZN). 

“PREP [pre-exposure prophylaxis in the form of a daily HIV prevention pill] may be a more affordable option and may be more widely used by key populations [groups who have a bigger chance of getting HIV than the general population, such as sex workers and men who have sex with men] and who are being missed by the public sector now.” 

But, said Gray, someone who doesn’t want to use the public health system can choose to go to a private pharmacy instead, even if they have to pay for the pills themselves or claim from their medical aid.  

Despite having to pay for the medicine, Natalie Schellack, a professor in pharmacology at the University of Pretoria (UP), said at an SAPC press briefing last week that the hidden expenses of getting treatment, such as travelling to a government facility and waiting in line, add considerable cost to treatment, which could make getting pills at a private pharmacy attractive. 

Studies show that having HIV services like testing and medicine collection at a private pharmacy ups the demand for these. Moreover, clients who choose to have a trained pharmacist follow the progress of their ARV treatment get to viral suppression just as well as patients who are treated by a doctor. 

Gray said Pimart also offers an opportunity for the government programme to expand access to ARVs by potentially supplying free state stock to these pharmacies, in the same way as getting childhood vaccines or contraceptives via a private facility, even when the pharmacy can charge a service fee. 

The health department has not yet announced whether it will have such partnerships with private pharmacies. Bhekisisa has asked the health department for a response and we will update the story once they have responded.

In July, the WHO also said using a spot sample of dry blood for a viral load test at a clinic can help to check how well people are doing on their medication, especially in rural areas where it might be difficult to get liquid samples to a lab. For this, someone’s finger is pricked and a drop of blood is dabbed onto a special paper card which is then analysed. 

Will these plans get us to our 95-95-95 goals in the next year-and-a-half?

“It’s complex,” said Venter. 

“We’ve done the easy stuff. The last 20%-30% will take far more effort to work out. I suspect making both testing and getting on treatment easier will go some way in getting us there, but not all the way.”

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

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