Eight months after the Supreme Court of Appeal gave the green light for specially trained pharmacists to dispense antiretrovirals without a script from a doctor, the programme remains stuck in the starting blocks. With enabling permits now seemingly on the horizon, Angela Tembo and Dr Deanne Johnston ask if there has been sufficient planning to make the initiative a success.
On 9 October 2025, the Supreme Court of Appeal upheld the Pharmacist-Initiated Management of Antiretroviral Therapy programme, better known as PIMART, bringing an end to a four-year legal battle led by a doctors' group and signalling a major shift in how HIV services can be delivered in South Africa.
For the first time, trained and accredited pharmacists can prescribe and manage antiretroviral drugs (ARVs), including treatment for people living with HIV, as well as prevention options like pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), without needing to first consult a doctor.
As Professor Renier Coetzee, President of the Pharmaceutical Society of South Africa, has put it, PIMART is a "real game-changer" for the profession.
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Pharmacists are already among the most accessible healthcare workers in the country, with more than 4 000 community pharmacies located in shopping malls and neighbourhoods, many of which operate extended hours. "Pharmacists are often the most accessible health professionals in the country," notes Jackie Maimam, CEO of the Independent Community Pharmacy Association (ICPA), underscoring the potential reach of PIMART into people's daily lives. (Maimam provided comment to us by e-mail.)
The significance of the ruling extends beyond South Africa. In an e-mail to us, Paul Sinclair, President of the International Pharmaceutical Federation (FIP), describes its global importance:
"South Africa's new HIV and Aids pharmacy-based services, PIMART, are a pharmacist-driven solution to supporting people living with HIV and Aids. This new service highlights pharmacists' vital role in the battle against infectious diseases, as they contribute at the frontline through prevention, screening, and management strategies, and FIP hope to see this service expanded to countries with similar challenges as South Africa."
Yet, eight months after the court's decision, PIMART permits have not been issued, and the implementation process remains unclear. A recent Spotlight article unpacked reasons for this delay and outlined the possible path forward of issuing permits with a limited scope of practice to pharmacists who have already completed the Southern African HIV Clinicians Society's (SAHCS) PIMART training course, allowing them to provide oral PrEP and PEP in the interim. However, this process hinges on a decision by the Director-General of the Department of Health.
With permits expected to unlock a new era of pharmacy-based HIV prevention and treatment, pharmacists will need to hit the ground running when implementation finally moves forward. Three "P's" need to be prioritised for PIMART to work in practice: the Pharmacist, the Pharmacy, and the People they serve.
The first P - training and supporting pharmacists
Under Board Notice 101 of 2021, PIMART can only be provided by pharmacists who have completed specialised training through a provider approved by the South African Pharmacy Council (SAPC). SAHCS was initially approved in 2019 to offer PIMART training as a continuing professional development (CPD) course, but legal challenges put the training on hold. No new provider has been approved since, and SAHCS has confirmed that its updated course is currently under evaluation by the SAPC.
More than 1 000 pharmacists completed the original PIMART course with SAHCS. Before they can offer the full range of PIMART services, these pharmacists will need to complete a refresher or bridging course. The SAPC has asked the Director-General of Health to issue limited-scope permits in the meantime, for these pharmacists to provide limited services, specifically PrEP and PEP. A phased approach could allow prevention services to become available while broader training and permitting arrangements are finalised.
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Training can equip pharmacists with the necessary knowledge, but the realities of day-to-day clinical practice can still be daunting. South Africa has the largest HIV programme globally, with many well-trained healthcare professionals with years of experience providing HIV care who could step into mentoring roles. Several NGOs also have deep experience in establishing and supporting HIV service delivery, and are well placed to offer valuable support.
PIMART-trained pharmacists may also learn from colleagues who offer primary healthcare services under the Primary Care Drug Therapy (PCDT) programme. Following specific training, PCDT pharmacists can examine patients, diagnose common illnesses, and prescribe medicines according to a specific list of conditions. Looking at how PCDT pharmacists operate offers a useful precedent for expanded pharmacy-based care programmes. Professional networks and peer support structures will be critical. For example, the South African Association of Community Pharmacists has a special interest group for PCDT pharmacists. A similar mechanism could help PIMART providers share experiences, standardise good practice, and access ongoing support.
The second P - get it right at pharmacies
PIMART services could be especially valuable in under resourced rural and urban areas. With over 4 000 community pharmacies distributed across the country, the potential reach is significant. However, pharmacists should not assume that clients will be queuing for these services as soon as they become available.
Before offering PIMART, pharmacies would benefit from basic market research. Existing dispensing and sales data, such as contraceptive and ARV usage, sales of HIV self-test kits, and condom purchases, can help gauge local demand and needs. Understanding the community being served is just as important as having the clinical skills to serve them. Pharmacies should consider when services are offered; extended and weekend hours may be critical in reaching people who cannot take time off work to visit a clinic.
Preparation is non-negotiable. Pharmacies offering PIMART services will need to meet clear minimum standards. A private consultation area is required, as are robust record-keeping systems to support client retention. Most community pharmacies already have consultation rooms, often used by nurses for screening and immunisation services. However, these nurses cannot provide PIMART services, so careful planning is required to ensure that pharmacist-led and nurse-led services work alongside each other in shared spaces without compromising privacy and safety.
Same-day initiation of ARVs is central to the PIMART model. For patients starting treatment, baseline blood tests are needed. Some pharmacies already partner with external phlebotomy companies, and pharmacy nurses are permitted to draw blood. Where such services are not available, patients will need to be referred to nearby facilities. This is a real concern, particularly for those paying out of pocket, who may not follow through on a referral.
Integration between systems will also be important. Community pharmacies operate primarily in the private sector, but some have experience working with the public sector, for example, distributing medicines through government's Centralised Chronic Medicines Dispensing and Distribution (CCMDD) programme and administering state-stock childhood vaccines and contraceptives. These partnerships vary significantly from province to province, and there is no coherent national plan for integrating community pharmacies into the broader public health system.
DELAYED AGAIN | Seven months after a Supreme Court of Appeal ruling allowed for specially trained pharmacists to dispense antiretroviral medicines without a doctor's script, no pharmacists are yet providing these services. Spotlight explores why.
www.spotlightnsp.co.za/2026/06/02/w...
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PIMART has not been explicitly incorporated into the National Strategic Plan for HIV, TB and STIs (2023-2028), even though retail pharmacies are mentioned as partners in service delivery. For PIMART to work at scale, important conversations still need to happen about access to state commodities such as HIV test kits and ARVs, as well as laboratory services and data reporting.
Professor Kenneth Ngure, from the School of Public Health at Jomo Kenyatta University of Agriculture and Technology (JKUAT) in Nairobi, emphasises this point from a regional perspective: "For scale-up, it will be critical for the Ministry of Health to support this pharmacy PrEP model with drugs and HIV test kits." His observation resonates strongly in South Africa, where similar questions about commodity supply and health system support remain unresolved.
Importantly, the scope of practice for PIMART pharmacists includes guidance on referrals to general practitioners and/or primary healthcare clinics. It is essential that pharmacists are recognised as part of the broader care team, with well-defined referral pathways, so that patients experience an integrated service rather than a parallel system they must navigate on their own.
Make it affordable. The SAPC has set the consultation fee for PIMART services at R348 (including VAT), excluding the cost of ARVs. People will pay either out of pocket or through their medical aid. This fee is not set in stone, and pharmacists will need to think carefully about what is affordable for the community they serve.
Medical aids have not yet confirmed whether, and at what rate, they will reimburse pharmacists for PIMART services. Some medical aids have published reimbursement guidelines for PCDT services, which give pharmacists reason to be cautiously optimistic, but concrete commitments are lacking.
The affordability question is not just about price; it is about who gets left out. Without meaningful public-private partnerships and mechanisms to subsidise or cover care for uninsured clients, PIMART risks becoming a service for the insured few rather than the many who need it most. Getting the financing and reimbursement model right is arguably the programme's most important challenge.
The third P - people rather than patients
PIMART offers something genuinely new to communities, and people need to know it exists. Demand creation will be critical, but this will require careful compliance with the SAPC's advertising standards. These standards require that, for example, adverts should not mislead the public and must be factual and promote professional services. Creative, community-sensitive communication strategies will be needed to create awareness.
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Building trust between pharmacists and the people they serve is not incidental. Research on PrEP services delivered through community pharmacies has found that people value the non-clinical environment of these services. Findings still to be published from Ezintsha's PPrEPP-SA study similarly found that participants valued the convenience, accessibility, and discreet nature of pharmacy-based care. These findings highlight the potential of PIMART to reach people who may not otherwise access clinic-based HIV services. People accessing PrEP and PEP are often not sick; they are healthy individuals making proactive choices about their health. Many will not want to be labelled or treated as "patients".
Pharmacies that recognise this distinction, and design their services accordingly, from the language staff use to the layout of consultation spaces, will be far more effective. The goal is not to recreate the clinical experience but to offer person-centred services that are accessible and stigma-free.
Successful HIV programmes have always emphasised follow-up and adherence support. Many pharmacies have invested in loyalty programmes and automated refill reminders for chronic medications, and these tools show real promise. However, HIV prevention and treatment are not quite like managing blood pressure or diabetes. Stigma, relationship dynamics, and life circumstances mean that people may stop and start PrEP, miss ART visits, or disengage from care. Additional measures, such as peer support and telephonic or digital counselling, should be considered to keep people engaged over the long term.
So, what's the plan...
Pharmacists are trusted healthcare providers. Community pharmacies are convenient, familiar, and are often open when clinics are not. PIMART is built on these advantages, but they are not enough on their own.
None of the challenges outlined here are insurmountable. There are clear, actionable steps for pharmacists in all spheres. A coordinated response is essential; pharmacy associations, regulators, and both the public and private sectors all have critical roles to play now. If these three priorities, the pharmacist, the pharmacy, and the people, are taken seriously, PIMART could become not only a legal milestone but a scalable public health advance.
The question that remains is: with permits potentially on the horizon, is sufficient planning actually taking place?
*Tembo is Director of Pharmacy Health at Ezintsha, Faculty of Health Sciences at the University of the Witwatersrand. Johnston is a Senior Lecturer in Pharmacy Practice at the University of KwaZulu-Natal.
Note: Spotlight aims to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.
