A programme meant to allow pharmacists and nurses working at private pharmacies to prescribe HIV treatment or anti-HIV pills and jabs is on hold because of a drawn-out court case
Mays Chemist is a bright, bustling pharmacy on Main Road in Melville, Johannesburg. Since July last year, a small revolution has been taking place there — and one that could make a real difference to HIV prevention in South Africa.
With the support of pharmacists and an in-house nurse, 210 people have started getting PrEP (short for pre-exposure prophylaxis) here, which is medication that can protect someone from contracting HIV. PrEP has been available in South Africa since 2016 and over a million people have already started taking it to help protect them against HIV infection.
So, why are the new clients getting their medication from Mays so important?
Because they’re taking part in a project that’s looking at whether letting people get HIV prevention medicines from healthcare facilities that are part of their everyday routines, such as pharmacies that are near to where they work, study or shop, can work. At the moment, people have to go to a government clinic or hospital to get PrEP.
So far, the project has proven popular — over 1 200 people across 10 pharmacies have started PreP.
The medicine is a Schedule 4 drug under the Medicines and Related Substances Act and so a private pharmacy can only give it to someone who has a prescription from a doctor or a specially licensed nurse who works at a state clinic or hospital.
We think that also allowing pharmacists and nurses working at private facilities to prescribe PrEP and other anti-HIV drugs, which are also Schedule 4 medicines, is more than an urgent medical need — it is a human right.
Take your pick — then tell your pharmacist
Around 90 000 women and 50 000 men were infected with HIV in South Africa last year — on top of the 7.8 million who already have HIV. We have to prevent new infections with every tool we have and to do this we have to make it as easy as possible for people to get anti-HIV drugs.
But more than that, we have to give people a choice about how they want to take their medication.
Until now, PrEP has been available only as a daily pill. It contains the two antiretrovirals emtricitabine and tenofovir (drugs that stop the virus from multiplying in your body). It works so well that it lowers your chance of getting HIV through sex to almost zero — but for that level of protection you have to take it diligently every day.
In December, though, an injectable form of the drug cabotegravir, called CAB-LA for short, was approved as PrEP in South Africa. The first two injections are given four weeks apart and then one every two months, which makes it convenient to use because you don’t have to remember to take a pill every day.
Studies have shown that taking the injection virtually wipes out someone’s chance of getting HIV through sex.
CAB-LA will be available from some state health facilities before the end of the year, with the health department also looking to buy more — if the price is right, Bhekisisa reported as part of their coverage of the International Aids Conference in July.
Our project also offers CAB-LA as a PrEP option in a substudy called Axis, which is run at some facilities in Gauteng, under the umbrella of our bigger PrEP project.
We want to see whether people prefer to take the daily tablet or the two-monthly injection and also want to know what people think of the injection and how practical a PrEP option it would be in real life for people in South Africa.
Since we started the Axis study in March, 143 out of the 200 people enrolled chose CAB-LA over the daily PrEP pill and 108 came back for their first follow-up shot a month later.
In in-depth interviews, people told us they prefer the long-acting injectable form of PrEP over the daily pill because it’s convenient, easy to take, more attractive than having to swallow a big pill and they know that they’re protected against infection.
But the prevention pill is still useful to people who are scared of needles and those who are used to taking tablets every day.
Why the focus on private pharmacies?
Participants told us they like private pharmacies because they’re conveniently located at malls and near busy taxi ranks, are open on weekends and the service is fast and efficient. Moreover, people said, they trust the professionalism of the staff and the confidentiality of their relationship and that they faced less scrutiny from other customers.
In our project, people who want to start PrEP speak to a pharmacist, who refers them to an in-house nurse for advice on things like contraception and lowering their HIV risk and to do tests for HIV and other sexually transmitted infections, hepatitis B and kidney function, as set out in the health department’s guidelines.
Once all that is done, people have a phone conversation with a doctor, who then writes the prescription.
If pharmacists and in-house nurses could issue the prescriptions themselves, the process could be cheaper and faster. Although this is a change from the current way things are done, it’s not a radical one.
In South Africa, pharmacists are already part of the process to get people started on treatment for a health condition, give advice on using medicines, check how well someone sticks with their therapy and follow up with clients to make sure that they know what to do in case of a missed dose or how to deal with possible side effects. They also dispense emergency contraceptives without prescriptions.
The South African Pharmacy Council, the regulatory body to which pharmacists belong and which audits practitioners’ service level, backs the Pharmacy Initiated Management of Antiretroviral Therapy (Pimart) course. This programme, which has been part of pharmacy practice since August 2021, trains pharmacists and in-house nurses to prescribe ARVs, HIV prevention medicines (whether taken before or after sex) and tuberculosis treatment.
But Pimart is on hold for now after the Independent Practitioner Association Foundation, a network of general practitioners and dentists, took the pharmacy council to court to stop the programme from running. Even though the Pretoria high court ruled in favour of the council in August last year, the network of doctors and dentists was allowed to appeal and a new court date for that is yet to be set.
Dara Vucevic, a pharmacist at Mays, completed the Pimart training, but because the programme has been stalled, she’s not received a certificate and isn’t allowed to add the tasks to her day-to-day work.
But, she says, with her four-year pharmacy degree, 28 years’ experience and this extra course under her belt, she understands what clients need and that she could put that knowledge and skills to good use when prescribing HIV prevention medicine.
And because she’s able to build up a relationship with clients, she can guide them through starting a new treatment. They can pop in and ask questions, which is often not possible in busy clinics, and she knows immediately if they don’t arrive to pick up a refill.
Excluding the close to 3 600 private pharmacies in South Africa from delivering HIV prevention services will be a wasted chance to halt new infections in the country.
Angela Tembo is a social scientist with extensive experience in implementation research at Ezintsha, a research and policy unit based at the faculty of health sciences at Wits University.
Tsitsi Nyamuzihwa is a pharmacist with experience in clinical trials at Ezintsha.
This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.