Mays Chemist is a bright and bustling pharmacy on the main street of Melville, a suburb of Johannesburg. Since July last year, a small revolution has been taking place there that could make a real difference to HIV prevention in South Africa.
With the support of pharmacists and a pharmacy nurse, 210 people have started receiving PrEP (short for pre-exposure prophylaxis), a medication that can protect a person from contracting HIV. PrEP has been available in South Africa since 2016, and more than one million people have already started taking it to protect themselves from HIV infection.
So why are new customers receiving their medication at this pharmacy so important? Because they participate in a project that studies whether allowing people to obtain these medications in health centers that are part of their daily routine—such as pharmacies near where they work, study or shop—can work. Now you have to go to a public clinic or hospital to get PrEP. At the moment, the project is being successful: more than 1,200 people in 10 pharmacies have started taking this preventive medication.
Around 90,000 women and 50,000 men became infected with HIV in South Africa last year, on top of the 7.8 million people who already have it.
The medicine is included in Schedule 4 of the Medicines and Related Substances Act, so a private pharmacy can only dispense it to someone who has a prescription from a doctor or a nurse with special authorization who works in a public clinic or hospital. .
We believe that also allowing pharmacists and nurses working in private facilities to prescribe PrEP and other HIV medications is more than an urgent medical need: it is a human right.
Give to choose
Around 90,000 women and 50,000 men became infected with HIV in South Africa last year, on top of the 7.8 million people who already have it. We have to prevent new infections with all the tools at our disposal, and to do so we must facilitate access to medications against the virus as much as possible. What’s more, we have to give people the possibility to choose how they want to take their medication.
Until now, PrEP was only available in daily pill form. It contains the two antiretrovirals emtricitabine and tenofovir. It works so well that it reduces the chances of contracting HIV through sex to almost zero, but to achieve that level of protection you have to take it diligently every day. However, in December, an injectable form of the drug cabotegravir, called CAB-LA, was approved as PrEP in South Africa. The first two injections are given four weeks apart and then one every two months, which makes its use more convenient because you don’t have to remember to take a pill every day. Studies have shown that the injection virtually eliminates the possibility of contracting HIV through sexual intercourse.
Our project also offers CAB-LA in a secondary study taking place in some centers in Gauteng (the province where Johannesburg is located). We want to see if people prefer to take the daily pill or get the bi-monthly injection, and we also want to know what they think of this and to what extent it would be a practical PrEP option for South Africans in real life.
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Since we started the study in March, 143 of the 200 people enrolled chose CAB-LA instead of the daily pill, and 108 returned for their first follow-up injection a month later. In in-depth interviews, people told us they preferred the long-acting injectable form because they found it convenient and easy, and more appealing than having to swallow a large pill. Plus, they know they are protected against infection.
But the preventive pill is still useful for people who are afraid of needles and those who are used to taking pills every day.
The importance of private pharmacies
Participants told us that they like private pharmacies because they are conveniently located in shopping centers and near busy taxi ranks, they are open on weekends, and the service is fast and efficient. Additionally, they trust the professionalism of the staff and the confidentiality of their relationship, and face less scrutiny from other clients.
In our project, people who want to start taking PrEP talk to a pharmacist, who then refers them to a nurse at the pharmacy for advice on topics such as contraception and HIV risk reduction, and to be tested for HIV and other sexually transmitted infections, hepatitis B, and kidney function. Once all this is done, patients have a telephone conversation with a doctor, who then prescribes the medications.
If pharmacists and nurses in pharmacies could issue prescriptions, the process could be cheaper and faster. Although this is a change from the current way of doing things, it is not radical.
In South Africa, pharmacists are already part of the process of starting treatment for a disease, advising on the use of medicines, checking compliance with therapy and following up with patients to ensure they know what to do if they forget. take a dose or in case of possible side effects. They also provide emergency contraceptives without a prescription.
If pharmacists and nurses in pharmacies could issue prescriptions, the process could be cheaper and faster. Although this is a change from the current way of doing things, it is not radical.
The Pharmacy Initiated Antiretroviral Therapy Management (Pimart) course is endorsed by the South African Pharmacy Council, which is the regulatory body to which pharmacists belong. This program, which has been part of pharmacy practice since August 2021, trains pharmacists and intern nurses to prescribe antiretrovirals, HIV prevention medications, and tuberculosis treatment [ya que permitiría, una vez completado, obtener un permiso especial para dispensar medicamentos de la Lista 4].
But the course has been suspended for the moment, after the Independent Doctors Association Foundation, a network of GPs and dentists, took the Pharmacy Council to court to stop it being taught. Although the North Gauteng High Court in Pretoria ruled in favor of the Council in August last year, the network of doctors and dentists was allowed to appeal and no trial date has yet been set.
Dara Vucevic, a Mays pharmacist, completed the Pimart training, but because the program has been put on hold, she has not received the certificate and therefore cannot incorporate the tasks into her daily work. With his four-year degree in Pharmacy, 28 years of experience, and this extra course under his belt, he understands what clients need and can put that knowledge and skills into practice when prescribing HIV prevention medications. And because he is able to build a relationship with clients, he can guide them when starting a new treatment. They can stop by and ask questions, which is often not possible in busy clinics, and you know immediately if they don’t show up to pick up your prescription.
Excluding South Africa’s nearly 3,600 private pharmacies from providing HIV prevention services will be a missed opportunity to curb new infections in the country.
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