How the Pharmaceutical Society of South Africa’s members will transform HIV/AIDS care in South Africa
In this long read feature, we explore how South Africa’s NPA has played a leading role in the push to expand the role of pharmacists in HIV/AIDS treatment as the country tries to achieve 95% treatment coverage
According to UNAIDS, close to 8 million people are living with HIV in South Africa. Along with neighbouring countries like Eswatini and Botswana, the country has one of the highest rates of HIV prevalence in the world.
South Africa has made enormous progress in the fight against HIV infection in the last two decades. From a peak of 540,000 infections in 1999, the number of new infections in South Africa has dropped by almost 70% to well below 200,000 now. New vaccines, such as lenacapavir, which the country’s national government has ambitions to roll out across the country, promise to further reduce new infections.
But no vaccination campaign will change the fact that more than 1 in 10 South Africans today are living with an HIV infection that has the potential to become AIDS without treatment. Even with the medical advances of the last quarter century and a huge reduction in mortality, more than half a million people are thought to have died from AIDS related illness since 2015.
The need to expand access to ART in South Africa
South Africa achieved a 20% decline in AIDS mortality in the 5 years to 2025. Since then, though mortality rates have been declining, the pace of progress has slowed. One of the biggest challenges facing the care of current AIDS patients is access to or proper use of antiretroviral therapy (ART).
Antiretrovirals are a type of drug designed specifically to suppress the presence of retroviruses like HIV – viruses whose method of infection and reproduction makes them immune to conventional antivirals in the body.
Some prevent the virus from infecting white blood cells and turning into AIDS, whilst others prevent the virus from gaining a foothold in the body or continuing to reproduce. ART can suppress the virus to the point where it is no longer harmful to the patient or transmissible to others. ART can also be used as pre-exposure prophylaxis (PrEP), a treatment course that prevents new HIV infection upon exposure when properly followed.
As of 2024, South Africa is still struggling to achieve universal uptake of ART. As many as 1 in 5 HIV patients – over 1.5 million people – may not be undergoing retroviral therapy, according to UNAIDS data. Globally, the World Health Organisation (WHO) and UNAIDS had aimed to achieve a 95% uptake rate for ART among HIV patients as a vital step in ending the pandemic.
Pharmacists as leaders in the fight to tackle HIV
Historically, the administration of ART in South Africa has required a licensed medical doctor to provide a patient with a prescription. Although the country has more doctors than pharmacists in its workforce, community pharmacists in particular are usually more accessible to the general public. Not only do they operate longer hours and open at weekends where clinic facilities are usually closed, but 40% of independent community pharmacies are located in rural communities. Pharmacies are also already established points of access for sexual health services like contraception.
The landscape of South Africa’s health inequalities can be explained in no small part by the legacy of apartheid, the system of racial segregation and discrimination imposed by the South African government until 1994. Decades of urban planning undertaken under the apartheid system have left the country with a health infrastructure that heavily favours historically wealthy white majority areas, whilst leaving many others severely under-resourced.
In 2018, this reality led the South African Pharmacy Council (SAPC), in partnership with the South African HIV Clinicians Society (SAHIVCS), to begin developing recommendations for the empowerment of community pharmacists through comprehensive training to initiate ART without the need for a doctor’s prescription. In partnership with the South African Government, this led to the development of PIMART – Pharmacist Initiated Management of Antiretroviral Therapy.
Designing PIMART
By 2020, training and accreditation pathways for pharmacists to take responsibility for starting and managing ART were developed and in place. Around the same time, new, local academic research showed that community-based interventions in the delivery of ART could play a significant role in reducing both transmission and viral load in infected individuals compared to classic, clinic-based treatments.
Since the conception of PIMART, the Pharmaceutical Society of South Africa (PSSA) – the country’s National Pharmacy Association and a longstanding member of the Commonwealth Pharmacists Association (CPA) – has played a consistent and influential role in supporting its development and implementation. As a national professional body, the PSSA has championed the expansion of pharmacists’ roles in HIV prevention, testing, and treatment, recognising PIMART as a critical intervention to strengthen access to care, especially in underserved communities.
PIMART builds on existing schemes in South Africa in place for many years for primary care drugs. Much of the training will be inspired by an existing programme already rolled out to nurses, involving the same kind of expertise in its development. This older system programme – NIMART – has already been shown to have had an impact on quality of care and expanding access to ART. It requires certification, usually after the completion of an exam and a practical work unit, and dozens of hours of focused study. NIMART often includes a mentoring pathway.
In 2020 official guidance was published on the proposed scope of PIMART and the role of the pharmacist in HIV care, with clear respect for safety guidelines and comprehensive training. SAPC’s comprehensive proposal will require pharmacists to be trained in nearly 30 clinical competencies before they are allowed to lead ART-based treatment of HIV/AIDS. This includes not just deciding how and when to initiate ART or how to manage patients on antiretrovirals, but also critical patient safeguards like identifying medication interactions and identifying infections like TB in HIV patients. The training framework was developed by leading experts, including medical doctors.
Crucially, PIMART’s design puts a strong emphasis on pharmacists demonstrating understanding of proper referral pathways and ensuring patients are always directed to the most appropriate clinician for the treatment they require. It is about empowering pharmacists as one part of a multidisciplinary team that includes doctors, nurses and allied healthcare professionals. The importance of referral is emphasised, especially for high-risk groups like pregnant women, people with complex presentations, and those suffering from opportunistic infection.
There are also regulations for pharmacies that want to provide PIMART services. These include adequate consultation space to protect patient privacy as well as rigorous patient record-keeping systems to ensure sound clinical governance both locally and across the scheme’s implementation.
Throughout the multi-year journey, the PSSA consistently served as an advocate, coordinator, and policy leader. It championed modernised scopes of practice, submitted evidence-based motivations to regulators and government, coordinated its sectors to maintain a unified national voice, and supported the development of high-quality training through accredited providers.
Dr Renier Coetzee
President
Pharmaceutical Society of South Africa
“Pharmacists are often the first point of contact for many South Africans, and PIMART unlocks their ability to do even more. By enabling pharmacists to initiate and manage HIV treatment, we bring lifesaving care closer to people, reduce delays, and strengthen the country’s overall HIV response.
“Pharmacies reach deep into cities, small towns, and rural communities. With PIMART, that reach translates into earlier treatment, better adherence, and fewer new HIV infections. It’s a powerful step toward achieving the 95-95-95 goals and making care truly patient-centred.
“With strong collaboration between the public and private sectors, PIMART allows stable patients to access or even start ARVs at their local pharmacy. This eases pressure on clinics, improves continuity of care, and positions the pharmacy profession as a decisive force in ending the HIV pandemic.”
The PSSA and SAPC advocating for patients and underserved communities
Unfortunately, despite PIMART’s rigorous competency framework, the embrace of the full multidisciplinary team did cause concern in some corners of the healthcare system. An association of private general practitioners challenged the competency of pharmacists to deliver PIMART. Commercial concerns also played a role in this challenge, with some doctors concerned that they would be losing a revenue stream to pharmacists who might be able to provide ART more affordably. Some of the objections were also based on a fundamental misconception about the proposals – including suggestions that it would somehow lead to pharmacists performing abortions in the community.
As the voice of the pharmacy profession in South Africa, the PSSA mounted a vigorous defence of the role pharmacists could play in HIV care. They made an evidence-based case to the Ministry of Health on both the competence and expertise of pharmacists as highly trained health professionals, as well as the benefit to underserved patients and communities. In a letter to the Ministry, the PSSA emphasised how vital truly multidisciplinary teams are, not just to achieving more effective patient care and working towards universal health coverage (UHC), but in South Africa’s case, also healing the divisions of the past.
What followed was a protracted legal battle over the clinical expertise and competency of pharmacists that would make its way all the way to the Supreme Court of Appeal. As the legal fight rumbled on, the PSSA had been defending the principle that pharmacists are vital to equitable HIV prevention and treatment, offering guidance to members and strengthening the case for task-sharing within primary healthcare.
The Supreme Court of Appeal ultimately ruled decisively in favour of the pharmacy profession and authorised the rollout of PIMART in late 2025, concluding that SAPC’s proposed training process was “rigorous and thorough” and that ideal treatment management was already “a collaborative effort involving various health professionals”, putting PIMART in the spirit of best practice. The Court found no evidence that PIMART would impair or undermine the unique role of doctors in HIV care.
Empowered pharmacists saving lives and transforming patient outcomes
With the legal obstacle to PIMART’s implementation cleared, a new era in multidisciplinary collaboration is about to begin in South Africa. Around 1,000 pharmacists have already completed training aligned to SAPC’s competency framework, and steps are now being taken to secure their legal accreditation and, if necessary, refresher training. SAPC is working with potential training providers to accredit new courses and support the rollout of PIMART. Some regulatory steps remain, like agreeing the fee schedule for PIMART treatment.
The PSSA and SAPC hope, however, that by early 2026, the first local PIMART initiatives will be in place as pharmacists who have already completed training secure the accreditation they need. As pharmacists begin to qualify to prescribe and dispense ART to patients without the need for a doctor’s prescription, they hope that the programme will begin to reach “untested, untreated and hard-to-reach populations” and “bring access to those South Africans who were, for various reasons, unable to access lifesaving treatment and HIV-prevention services”, as an SAPC media statement described the profession’s goal.
The case of PIMART in South Africa illustrates the vital role that National Pharmacy Associations and pharmacy regulators, like the PSSA and SAPC, have to play in promoting advancements in UHC and patient care through their advocacy work. The design of the PIMART programme shows the unique, transformative role pharmacists can play in improving patient outcomes and especially in reaching diverse communities who face structural barriers to accessing life-saving medicines. The strengthening of involvement for the whole multidisciplinary team only stands to benefit patients.
The story of the struggle to realise PIMART’s implementation also shows the opposition that pharmacists can face in taking on expanded clinical roles for patient benefit. The PSSA is working collaboratively with representative bodies of other healthcare professions to build understanding of, and support for, the expanded role of pharmacists. CPA’s own international and high-impact AMR programmes have shown the enormous benefit to patients when pharmacists, doctors, nurses and other health professionals work together with respect for each other’s expertise.
Collaboration between professions – which CPA embodies on a global scale through our work holding the Chair of the Commonwealth Health Professions and Partners Alliance that unites representative bodies for all health and social care professions across the Commonwealth – is vital at every level of every healthcare system, especially in countries struggling to achieve UHC where pharmacists can play a crucial role in expanding access to life-saving medicines.
South Africa’s experience is also part of a wider global story of pharmacists stepping into more and more significant leadership roles within healthcare systems. In the UK, for example, nearly 2 million people every year are already seeing pharmacists for prescriptions for more than half a dozen common ailments under the new ‘Pharmacy First’ scheme, with experts saying millions more people could be safely redirected from their GP to their pharmacist in the years to come.
CPA members turning policy into practice
The implementation of PIMART in the coming months and years may well be a critical intervention in South Africa’s drive to push ART coverage to its 95% target. Thanks to the skill and expertise of pharmacists, HIV/AIDS treatment will be more accessible than ever before to South Africans and especially to those still disadvantaged by the legacy of apartheid. The design of PIMART offers a model for how pharmacists can be equipped and empowered to be leaders in the fight against diseases like HIV/AIDS in a way that makes the most of their role as experts in the safe, effective use of medicines.
The PSSA continues to play a key enabling role, promoting pharmacist uptake, supporting integration into the national HIV response, and advocating for sustainable, community-centred HIV services that bring care closer to the people who need it most. Its consistent leadership has helped position pharmacists as accessible, competent, and trusted frontline providers capable of expanding treatment coverage.
The PSSA’s experience offers a powerful lesson that when national pharmacy bodies take a proactive leadership role, backed by evidence, coordinated advocacy, professional unity, and strong partnerships, pharmacists can successfully expand into clinical roles that transform public health. The PIMART journey shows that an expanded scope is not only possible but also essential for countries with high disease burdens and communities far from traditional health facilities.