by R Ramphal
Health Systems Trust: KZN Provincial Manager – Differentiated Models of Care
In South Africa, millions of parcels containing medicine bottles are dispensed every year through the Central Chronic Medicine Dispensing and Distribution (CCMDD) Programme.
Typically, these containers have been seen as simple vessels for life-saving pills. But what if they could do more? What if – alongside supporting a patient's adherence to chronic medicine – they could quietly offer hope and safety to women navigating not only illness, but also sex-based violence (SBV)?
The 'Beyond the Box' initiative challenges pharmaceutical companies to embrace this vision: transforming every medicine bottle into a medium for both health and compassion. Inspired by the Access to Medicine Foundation's Through Her Lens campaign1, this approach recognises that health is never merely about the body: it is about dignity, safety, and community support.
Globally, only about 50% of patients with chronic conditions take their medicines as prescribed, with even lower adherence rates in developing countries.2 In South Africa, this crisis is particularly acute due to the high burden of HIV, hypertension, diabetes, and mental health conditions. The CCMDD Programme was designed to address this by making chronic medicines more accessible, reducing the need for frequent clinic visits and minimising congestion in public health facilities.
However, access alone is not enough. As the country moves towards six-month dispensing (6MMD) for antiretroviral therapy (ART), and mobilises the National Department of Health's '1.1 Million Close the Gap' campaign to bring more people into HIV care3,4, the challenge of adherence becomes even more critical. If we want to be HIV-free, we must address every barrier to taking medicine as prescribed, including those that are hidden, such as violence and fear.
Research shows that sex-based violence is a major, often overlooked barrier to medicine adherence. A landmark study by Lopez, et al. found that women experiencing intimate partner violence had 59% lower odds of optimal ART adherence.5 Cluver, et al. showed that adolescents facing both intimate partner violence and sexual abuse had only a 38% probability of adhering to their medicine, compared to 72% for those not exposed to violence.6 In Kenya, Biomndo, et al. found that violence directly undermines a woman's ability to prioritise her treatment when her safety is at risk.7
This is not just an HIV issue. Bagherzadeh, et al. found that among women with chronic illnesses, intimate partner violence was significantly linked to poor adherence across conditions.8 A 2024 study conducted by South Africa's Human Sciences Research Council revealed that more than one in three women (36%) reported experiencing physical or sexual violence, with 24% experiencing violence from an intimate partner – a reality that has a direct impact on their health behaviours and outcomes.9
Why CCMDD parcels are a unique opportunity
For many women, collecting a CCMDD parcel might be the only moment of privacy in their day. In homes where partners are controlling or abusive, or where HIV-related stigma is high, this brief interaction with the health system is a rare chance for patients to access information safely. By including discreet SBV support information, such as helpline numbers on medicine parcels or bottles, we can offer a lifeline to those in distress.10,11
This isn't just theory. Cohen and Saran demonstrated in Uganda that simple, targeted messages on malaria medicine packaging increased adherence by 9% and reduced untaken pills by 29%.10 The most effective message was direct and supportive: "Malaria is NOT gone until ALL tablets are finished." Imagine the impact if, alongside such messages, we included information on where to get help for violence or abuse.
The CCMDD Programme's focus is on improving access and adherence, but health does not exist in isolation. When survival is uncertain, adherence becomes harder. As healthcare workers, we see that patients are more than just their chronic conditions. They are mothers, daughters, sisters, people whose health is shaped by the safety and stability of their environment.
Including SBV messaging in chronic medicine programmes allows us to do more than dispense medicine; it enables us to dispense compassion, solidarity and safety. Even if this intervention helps only one woman, it is worth it.
The social impact of integrating SBV support into chronic medicine programmes extends well beyond individual patients. With millions of CCMDD parcels distributed annually, even small improvements in help-seeking behaviour could connect thousands of women with potentially life-saving services. The NDoH Command Centre that deals with SBV (0800 428 428)12 and other helplines provide 24-hour support that could be accessed through discreet contact information on the medicine parcel.
A call to action: The role of Pharma and policy
The evidence is clear: simple packaging interventions can significantly improve medicine adherence while providing critical support to vulnerable populations.8,10 Regulation 10 of the South African Health Products Regulatory Authority (SAHPRA) allows for the inclusion of special information on medicine labels, so the regulatory pathway exists.13 The technology is available. The business case is compelling.
Pharmaceutical companies now have an unprecedented opportunity to show that their commitment to health equity is more than a slogan. Every medicine bottle offers a platform to improve lives, not only through the pills inside, but through the hope, support and empowerment it can provide through information on SBV services.
The question is not whether pharmaceutical companies can make this transformation, but whether they will choose to lead this revolutionary approach to patient care. The answer lies in seeing patients not merely as consumers, but as whole human beings deserving of comprehensive support in their journey toward health and safety.
As South Africa's Close the Gap campaign and six-month dispensing policies expand, let's ensure that every step forward in access is matched by a step forward in compassion and safety. The 'Beyond the Box' initiative challenges the industry to lead this change.
The time for action is now.
To achieve an HIV-free society, we must try to solve every adherence challenge, even if it helps only one woman. That is enough. That is everything.
References
1. Access to Medicine Foundation. Health Equity Through Her Lens. Amsterdam, 2025.
URL: https://accesstomedicinefoundation.org/health-equity-through-her-lens
2. Cutler RL, Fernandez-Llimos F, Frommer M, Benrimoj C, Garcia-Cardenas V. 2018. Economic impact of medication non-adherence by disease groups: a systematic review. BMJ Open, 2018; 8:1, e016982.
3. Joint United Nations Programme on HIV/AIDS (UNAIDS). Bold new initiative to put an additional 1.1 million people living with HIV on treatment. Geneva: UNAIDS; 2025. URL: https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2025/february/20250225_1-1-million-people-treatment-south-africa
4. World Health Organization. South Africa launches 1.1 million HIV campaign to close treatment gap. Geneva: WHO; 2025.
URL: https://www.afro.who.int/countries/south-africa/news/south-africa-launches-11-million-hiv-campaign-close-treatment-gap-0
5. Lopez EJ, Jones DL, Villar-Loubet OM, Arheart KL, Weiss SM. 2010. Violence, coping, and consistent medication adherence in HIV-positive couples. AIDS Educ Prev, 2010; 22:1, 61─68.
6. Cluver LD, Zhou S, Orkin M, Rudgard W, Meinck F, Langwenya N, Vicari M, Edun O, Sherr L, Toska E. Impacts of intimate partner violence and sexual abuse on antiretroviral adherence among adolescents living with HIV in South Africa. AIDS, 2023; 37:3, 503─511.
7. Biomndo BC, Bergmann A, Lahmann N, Atwoli L. Intimate partner violence is a barrier to antiretroviral therapy adherence among HIV-positive women: Evidence from government facilities in Kenya. PLoS One, 2021; 16:4, e0249813.
DOI: 10.1371/journal.pone.0249813.
8. Bagherzadeh R, Sayad Nik A, Gharibi T, Vahedparast H. The predictive role of intimate partner violence in treatment adherence among women with chronic illness: A cross-sectional study. Chronic Illn, 2024; 20:1, 76─85.
9. Human Rights Watch. Confronting South Africa's Crisis of Gender-Based Violence. 2024. URL: https://www.hrw.org/news/2024/11/25/confronting-south-africas-crisis-gender-based-violence
10. Cohen J, Saran I. The impact of packaging and messaging on adherence to malaria treatment: evidence from a randomized controlled trial in Uganda. J Dev Econ, 2018; 134, 68─95.
11. 1000 Women Trust. Gender-based violence resources and support. Cape Town, 2024. URL: https://www.1000women.co.za
12. Department of Justice and Constitutional Development. Gender-based Violence Command Centre (GBVCC): Emergency Line number – 0800 428 428.
URL: https://www.justice.gov.za/vg/GBV.html
13. South African Health Products Regulatory Authority (SAHPRA). Medicines and Related Substances Act 101 of 1965: General Regulations, Regulation 10: Labelling of medicines intended for human use. 2017.
URL: https://www.sahpra.org.za/wp-content/uploads/2022/07/General-Regulations-Medicines-and-Related-Substances-Act-25-Aug-2017-Gazetted.pdf