Access to HIV prophylaxis at pharmacies not as easy it seems

First published by Daily Maverick 168 weekly newspaper

Maverick Citizen, using a pseudonym, emailed and phoned 31 pharmacies across the country, asking them whether they were able to assist with access to post-exposure prophylaxis (PEP) counselling and antiretroviral medication.

These pharmacies were selected because they are listed on the #4EachOther website, or websites promoted by various organisations, including the HIV Clinicians Experts website, as pharmacies that participate in the PEP and pre-exposure prophylaxis (PrEP) programme for HIV prevention. Fifty-eight percent of these pharmacies did not respond to our email query. While 61% answered the phone, only 32% said they were able to assist.

#4EachOther is spearheaded by Expanding Access to PrEP and ARVs Innovation Consortium (EPIC). EPIC is led and managed by the Southern African HIV Clinicians Society (SAHCS), in partnership with consortium members the Independent Community Pharmacy Association (ICPA), Ezintsha, Digital Health Cape Town and Vula Mobile.

The aim of #4EachOther and EPIC is to “bring HIV information, services, prevention and treatment options into pharmacies to give people all the support they need to stay HIV free”.

Part of their commitment to realising an HIV-free future has been to make PrEP more available in mainstream and community pharmacies.

HIV in South Africa

The latest Thembisa Model suggests that 7.7 million people (19% of the adult population) currently live with HIV. KwaZulu-Natal sits at the centre of the HIV epidemic; despite the steep incidence decline, it remained the province with the highest HIV prevalence, with nearly 26% of the adult population being diagnosed with the disease.



Incidence rates are highest in the Eastern Cape (1.1%), North West (1.06%) and Mpumalanga (1.04%), and are lowest in the Western Cape (0.4%).



PEP and PrEP play a crucial role in not only reducing the number of people who contract the disease but also in the goal to eliminate the virus completely.

PEP medications are used to prevent infection after possible HIV exposure such as unprotected sex and rape. PEP should be used only in emergency situations and must be started within 72 hours after possible exposure to HIV.



Are pharmacies equipped?

Natalie Martyn from the SAHCS says that the pharmacies listed on the #4EachOther website were “self-selected”.

“Dis-Chem, Clicks and Pick n Pay opted to be part of the programme. We also have smaller independent retail pharmacies [that] are members of the ICPA and when the programme rolled out, the ICPA ... invited pharmacy owners to be part of ... EPIC...”

Of the email correspondences, 58% did not respond, while a third of participating pharmacies said they did not offer the programme, despite the pharmacies being listed as participating outlets.

Telephonic and email responses ranged from “May I ask how you got my email address” to “We have the medication, but you must get a prescription from a doctor.”

Thirty-two percent of pharmacies said they were able to assist and most were educated on the topic. Of the 29% of pharmacies that said they did not offer PEP counselling, only one pharmacy (in North West province) provided an alternative, saying: “While we regrettably no longer stock the medication or offer counselling, you can go to your nearest clinic and get the medication ... free.”

The cost of PEP and PrEP counselling and medications vary widely across the country, even among giant retail chains. Overall, the cost of PEP medication varied across the country from R291 to R400 and consultations from R150 to R200.

Martyn says that some pharmacies have not completed all nine steps to become “permit ready” and that the South African Pharmacy Council has not completely signed off on the permits required to offer the services.

The permit in question is Section 22A (15) of the Medicines and Related Substances Act, 1965. A nurse in possession of a Section 22A (15) concession may acquire, use and supply Schedule 1 and 2 medicines without a prescription. Pharmacies mostly use nurses to conduct the counselling before the medication can be dispensed.

Martyn says all the participating pharmacies are waiting for their permits. What is concerning, however, is if a person living in a rural area travels to one of these listed pharmacies, only to be turned away as they either do not offer these HIV prevention programmes or because they require the individual to consult with a doctor first.

PEP access to rape victims

In cases of rape, SA’s sexual offences legislation guarantees survivors the right to PEP to prevent HIV infection. Unfortunately, institutional and practical challenges hinder access and adherence to this treatment within the crucial 72-hour time limit, especially in rural areas, explains gender-based violence expert Lisa Vetten. She says that in cases of rape, victims should not go to pharmacies for assistance, as they are not equipped to provide the “right support. I would not encourage the use of pharmacies. Victims can go to any hospital or clinic, without having to report the rape, to access PEP medication and counselling. The treatment is completely free,” says Vetten.

She adds that while there are many things that the government does not do well, the PEP programme is “one of the few instances where the government has put in some effort to try to make this work. Yes, there are problems of accessibility. But that often has to do with follow-up and adherence... There is a ... bigger problem around supporting women to continue and complete a PEP regimen, rather than necessarily to get access to it.”

She says that individuals requiring PEP, especially rape victims, require trained professionals who can offer adequate support. With regard to pharmacies offering general PEP counselling (for instances not involving rape), Vetten says the effectiveness of such services needs to be monitored closely.

“I would strongly encourage this service to remain with the government. There are more than 280 facilities in the country designated to provide PEP and support after rape, regardless of whether you report it to the police,” says Vetten.

Lauren Jankelowitz, CEO of the SAHCS, later contacted DM168 with an update that since being alerted to the problem they had started adjusting the list of the pharmacies on the website.

“I wanted to thank you for alerting us to an issue in our programme and on our website. We are busy adjusting the list of pharmacies to include a trained nurse or pharmacist to make it more user-friendly as not all pharmacy staff are trained. Many thanks also for publicising this new service. We hope many more people will now be able to access PEP, PrEP and 1st line therapy,” said Jankelowitz. DM168