South Africa is on the brink of allowing pharmacists holding the required permits to prescribe and initiate HIV medicines without people first having to get scripts from doctors or nurses.
The initiative, known as Pharmacist-Initiated Management of ART or PIMART, seeks to improve linkage to HIV treatment and prevention therapy among under-reached and underserved groups and communities. South Africa’s PIMART programme will be the first of its kind globally – potentially paving the way for other countries to follow suit.
Linking men to treatment earlier
South Africa has the largest HIV antiretroviral treatment (ART) programme in the world. Over seven million people in the country are living with HIV – over five million of whom are on ART.
South Africa’s success in scaling up ART to treat millions is partly due to the introduction of Nurse-Initiated Management of ART, or NIMART, in 2010 – which allowed for the screening and initiation of HIV-positive people onto ART by nurses at primary health care clinics across the country. Prior to the introduction of NIMART, initiation of ART could only be done by clinicians and was largely hospital-based.
While NIMART has allowed for the massive expansion of South Africa’s public ART treatment programme, many people still only get diagnosed and started on treatment very late after they have experienced HIV-related illnesses and are at risk of dying of opportunistic infections. According to data from Thembisa (the leading mathematical model for HIV in South Africa), around a quarter of adults who started ART in 2019 had CD4 counts below 200 – meaning their immune systems had already been severely compromised, among others making them vulnerable to tuberculosis (TB).
Men in particular tend to wait too long before testing and starting treatment. This is one group that pharmacists and HIV clinicians hope can be better reached through PIMART, which will allow pharmacists to initiate HIV-positive men onto ART at pharmacies.
Francois Venter, an infectious diseases professor at the University of the Witwatersrand, explains that private pharmacies are a first port of call for many people seeking health services in South Africa, including men seeking treatment for sexually transmitted infections (STIs). Venter adds that each of these visits provides an opportunity to offer men HIV testing services and initiate HIV-positive men onto ART, or offer PrEP (medicines to prevent HIV infection) to men who test negative.
“We have men coming in [to pharmacies] for chronic medicine, we have men coming in for libido boosters who don’t go to doctors,” says Jackie Maimin, CEO of the Independent Community Pharmacy Association (ICPA). “We have men coming in for all sorts of over-the-counter stuff. Men don’t like to go to clinics and don’t like to go and see the doctor, but they will pop into the pharmacy,” says Maimin.
“Pharmacies are really in the communities, they are even pharmacies in the most rural of areas.” She adds that because men come in for a whole range of services, from collecting chronic medicines to buying shaving cream, there is little stigma around visiting pharmacies, and they can provide a high level of anonymity to men who are reluctant to visit primary health care clinics in their communities.
Venter adds, “Unlike primary clinics and GPs, pharmacies are open after hours and on weekends.”