Antiretroviral Drugs as Emerging Environmental Contaminants in South African Water Resources

1.1. The Issue of Pharmaceutical Pollution

Pharmaceutical contamination of aquatic environments is a growing global concern, but ARVs present distinct challenges that set them apart from other pharmaceutical compounds. In South Africa, home to the world’s largest ARV treatment program, the scale, diversity, and persistence of ARVs in the environment are unmatched. ARVs are typically administered as part of combination therapy regimens, meaning multiple compounds such as efavirenz, lamivudine/emtricitabine, and tenofovir are consumed simultaneously. These drugs often have different physicochemical properties (e.g., solubility, polarity, persistence), which influence their environmental behaviour and toxicity. Moreover, many ARVs are only partially metabolized by the human body and are excreted in active or bioactive forms, including their metabolites (Milburn et al., 2017; Ngumba et al., 2016). For example, dolutegravir, darunavir, and tenofovir are excreted up to 94 and 80% of the parent drugs, respectively, without biotransformation (Kim et al., 2017; Riska et al., 1999). Tipranavir is excreted at 80%, and nevirapine at 2.7% via urine. Assuming a mean of 30% excretion to sewage via urine and faeces, it was estimated that about 159 000 kg of ARVs could reach the aquatic systems of South Africa every year (Swanepoel et al., 2015). This means that ARVs inevitably end up in rivers, lakes, and even drinking water supplies, potentially causing significant environmental harm and contributing to the development of pharmaceutical-resistant microorganisms.

Another concern is the formation of TPs during wastewater treatment, which may possess unknown or increased toxicity. These TPs are rarely monitored, leading to potential underestimation of environmental risks. Research has shown that lamivudine and tenofovir degradation products can inhibit bacterial and algal growth at concentrations as low as 10–50 ng/L (Souza-Silva et al., 2025a). Similarly, preliminary evidence suggests that exposure of Raphidocelis subcapitata to acyclovir and its TPs, carboxy-acyclovir and COFA (secondary TP), for 72 hours showed that COFA exerted the strongest inhibitory effect, significantly reducing algal yield and growth rate, with EC₁₀ and EC₅₀ values of 4.12 mg/L and 18.15 mg/L, respectively. Reported laboratory studies within South Africa reported that in Daphnia magna exposed for 21 days, carboxy-acyclovir significantly reduced reproduction and population growth by 39.9% and 22.4%, respectively, indicating higher toxicity than the parent compound. In contrast, COFA TP exhibited no significant toxicity in Daphnia. Further, no acute fish toxicity for acyclovir and both TPs up to ~100 mg/L (Schlüter-Vorberg et al., 2015). Overall, these findings indicate that while COFA poses the greatest risk to algal growth, carboxy-acyclovir exerts more pronounced chronic toxicity in Daphnia, whereas acyclovir and its TPs show minimal acute toxicity to fish, highlighting species-specific sensitivities and differential ecological risks among the compounds.

Although numerous degradation processes for ARVs have been explored (Madikizela, 2025). In the last decade, research on the identification of antiretroviral drugs in water has intensified, especially in developing countries. Concentrations reaching 33 µg/L for efavirenz have been reported in wastewater effluent, which is released into the surface water. Some antiretroviral drugs have been found to possess toxic effects on aquatic organisms and plants. This threatens the sustainability of high-quality vegetables as the water scarcity necessitates the practise of crop irrigation with used or treated water, which is often contaminated with pharmaceuticals. This article reviewed the progress made on the removal of antiretroviral drugs in contaminated water, identified challenges and gaps, while outlining the possible future research directions. It was observed that various degradation processes for antiretroviral drugs have been explored, with limited information on the characterization of the degradation by-products and their toxic effects. The adsorption process is also dominating for removal of antiretroviral drugs in water, while wetland removal and plant uptake are the least explored. An adsorption capacity as high as 833 mg/g has been reported for lopinavir using biochar modified by incorporating layered double hydroxide. Research on the removal of antiretroviral drugs in water is expected to continue with the inclusion of studies focusing on metabolites of these chemicals. Madikizela (Madikizela, 2025), emphasizes that a major challenge remains: the identification and toxicity assessment of their TPs. This difficulty arises from low environmental concentrations, complex matrices, and the need for advanced analytical expertise, typically requiring GC–MS or LC–MS techniques and a strong understanding of organic transformation pathways, highlighting the need for further research on ARV degradation and by-product toxicity. Unlike broader categories of pharmaceuticals, the environmental risks of ARVs are amplified by their chronic, low-level presence in regions with high HIV prevalence and their lack of removal during conventional treatment processes.

1.2. The Impact on Water Resources

The introduction of ARVs into environmental matrices presents considerable risk to both public health and the environment. Even though concentrations detected in aquatic systems are frequently minimal, prolonged exposure, even at trace levels, may lead to detrimental health outcomes. A critical yet often neglected issue is the potential for the development of drug resistance, akin to resistance patterns observed with antibiotics, if ARVs are not effectively eradicated from the environment. Persistent environmental exposure could facilitate the selection of resistant strains of HIV or related viruses, thereby undermining decades of progress in HIV clinical management. Such resistance would pose severe challenges for South Africa, a nation combating the world’s largest HIV epidemic and one that has made extensive financial and infrastructural investments in treatment programs to achieve the World Health Organization’s treatment for all and 95-95-95 objectives. The escalation of ARV usage in alignment with these targets is anticipated to increase drug loads in the environment, thereby heightening this risk. The emergence of resistant strains would undermine the efficacy of first-line and second-line regimes, necessitating more costly and complex treatment regimens, thereby imposing additional burdens on the already overextended healthcare system.

From an ecological perspective, the presence of ARVs in the environment poses significant disruptions to aquatic ecosystems. Empirical research has demonstrated that ARVs interfere with the hormonal systems of fish, consequently altering their reproductive cycles and behaviours (Nibamureke et al., 2019b; Nibamureke and Wagenaar, 2021). These disruptions extend beyond fish populations, cascading through the food web, resulting in bioaccumulation in wildlife and posing risks to human populations dependent on aquatic organisms for nutrition. In the long term, the intersection of ecological and health ramifications of ARV contamination may plausibly lead to biodiversity loss, further destabilization of aquatic ecosystems already burdened by climate change and pollution, and reduced resilience of these systems. Ultimately, without the implementation of effective strategies for the monitoring and removal of ARVs from the environment, the sustainability of both public health initiatives and ecosystem integrity remains at risk.

1.3. Occurrence of ARVs in Aquatic Ecosystems

Recent South African studies have documented the occurrence and persistence of ARVs in surface waters and wastewater effluents, as shown in Fig. (2) and Table S1-S5. For example, (Schoeman et al., 2017) reported that effluent discharged from a wastewater treatment plant in Southern Gauteng contained concentrations ranging between 5 500 to 14 000 ng/L for efavirenz and 92 and 743 ng/L nevirapine, indicating that conventional treatment processes are inadequate for removing these compounds. Similarly, (Nibamureke and Barnhoorn, 2025) screened surface waters in the Vhembe District, Limpopo

Province, and found nevirapine and lopinavir concentrations reaching up to 166 and 42 ng/L, respectively. These levels exceed reported ecotoxicological thresholds for aquatic organisms such as fish and invertebrates, underscoring the need for site-specific risk assessments. (Swanepoel et al., 2015) evaluated the prevalence of ARVs in wastewater, surface water, groundwater, and drinking water across different regions of South Africa. The study reported the presence of 12 ARVs in different environmental compartments. The highest concentrations were reported in Kwa-Zulu Natal Province, attributed to the highest HIV statistics. This further highlights the widespread and persistent nature of ARV contamination.

The Water Research Commission report (Nyoni et al., 2024) evaluated the removal of contaminants of emerging concern in drinking water and wastewater treatment systems. They reported that, while conventional processes such as coagulation, sedimentation, and chlorination achieved only partial reductions of pharmaceuticals, ARVs were resistant to removal. By contrast, advanced treatment processes such as ozonation, activated carbon adsorption, and membrane technologies demonstrated substantially higher removal efficiencies, although cost and scalability remain major challenges. Complementing these findings, a recent study by the North-West University (NWU) (North West University, 2025) quantified ARV residues in South African water resources and reported concentrations in some cases exceeding acceptable thresholds, posing potential long-term health risks. The study further highlighted the inadequacy of existing wastewater treatment processes and recommended ARV-specific regulatory guidelines, improved treatment infrastructure, and multidisciplinary research to address ecological and human health impacts. Together, these reports underscore both the technological and regulatory gaps that must be bridged to protect water quality and public health in South Africa. The research further highlighted alarming effects on aquatic ecosystems and wastewater management systems. For instance, freshwater snails exposed to ARVs exhibited altered embryonic development (North West University, 2025). Further, concentrations of ARVs ranging from 670 to 34 000 ng/L (influents) and 540 to 34 000 ng/L (effluents) were determined in WWTPs in South Africa compared with Europe. In Europe, reported concentrations ranged from less than the limit of detection (LOD) to 32 ng/L (influents) and less than LOD to 22 ng/L (effluents) (Adeola and Forbes, 2022). These findings emphasize the urgent need for tailored environmental monitoring programs and stronger policy interventions to address the environmental presence of ARVs in South African water systems.

These compounds can affect aquatic organisms at various trophic levels, from primary producers like algae, and consumers like daphnids, to higher consumers such as fish (Choudhury et al., 2024; Ngwenya et al., 2025; Souza-Silva et al., 2025b). However, little is known about their effects on non-target aquatic organisms to draw meaningful conclusions. Furthermore, reported concentration ranges should be interpreted with caution due to differences in analytical methodologies, sample preparation techniques, and limits of detection/quantification across variant studies.

Effects on primary producers (e.g., algae) are particularly concerning, as these organisms form the base of aquatic food webs. Exposure to ARVs has been shown to inhibit photosynthesis and reduce algal growth, which may have cascading effects on the food chain (Gomes et al., 2022; Souza-Silva et al., 2025a). Daphids are also important species in freshwater food chains as primary consumers. Their exposure to ARVs has been reported to cause immobilization, mortality, effects on reproduction, biochemical markers, induce oxidative stress, etc (Mahaye and Musee, 2022; Souza-Silva et al., 2025a). Additionally, secondary consumers, such as fish, which have great economic and dietary importance and subsequently serve as a major doorway to human exposure, have exhibited endocrine disruption, altered reproductive success, and behavioral changes due to ARV exposure (Choudhury et al., 2024; Nibamureke and Wagenaar, 2021). While much of the research focuses on the acute toxicity of ARVs, long-term effects, particularly the chronic exposure of aquatic organisms to sub-lethal concentrations, remain poorly understood. Importantly, current studies contribute to understanding the ecotoxicological impacts of ARVs and highlight the importance of long-term assessments to adequately estimate environmental risks of ARVs.

1.4. Ecotoxicity of ARVs in Aquatic Biota

Over the years, considerable attention has been devoted to the investigation of the toxicity of ARVs in mammalian systems (Carr and Cooper, 2000; Hawkins, 2010). It is only in recent times that research has started to elucidate the ecotoxicity of these pharmaceuticals, a factor that contributes to the limited availability of ecotoxicity data for ARVs (Olabode and Somerset, 2019) The toxicity of ARVs toward aquatic organisms, such as fish, algae, daphnia, and bacteria, is classified among the top ten most toxic categories of pollutants (Sanderson et al., 2004). However, only a limited number of studies have reported toxicity data such as acute and chronic endpoints or sub-lethal effects across different levels of biological organization Table 1. Moreover, existing findings are often inconclusive, largely because most experiments were conducted in synthetic media rather than environmentally relevant conditions. This paucity of hazard characterization underscores an urgent need for systematic ecotoxicological assessments of ARVs in non-target species. Although extensive data exist on the environmental occurrence of ARVs across various matrices (Table S1-S5), there remains no clear risk assessment framework addressing their potential impact on ecosystem integrity or human health through exposure pathways such as food or drinking water. For instance, ARVs have already been detected in drinking water supplies (Wood et al., 2015), yet no regulatory threshold values have been established to guide safety evaluations.

Ecotoxicity data in Table 1 reveal highly variable responses of aquatic organisms to ARVs. Toxicity ranged from non-toxic to highly toxic effects and was compound-, organism-, and exposure duration-dependent. For example, acyclovir and abacavir generally showed low to moderate toxicity, with EC₅₀ values often >50 mg/L and in several cases >100 mg/L. However, acyclovir transformation products (e.g., carboxy-ACV) exhibited increased toxicity at chronic exposures (e.g., reduced Daphnia reproduction). In contrast, efavirenz, ritonavir, and lopinavir demonstrated higher toxicity, with sub-lethal effects (e.g., oxidative stress, developmental abnormalities) and EC₅₀/LC₅₀ values in the low mg/L to µg/L range. Dolutegravir showed time-dependent toxicity, increasing with prolonged exposure, particularly in cyanobacteria. Lamivudine and tenofovir generally displayed low toxicity, with several studies reporting no significant effects at environmentally relevant concentrations. However, acute effects were observed in Daphnia magna and Brachionus calyciflorus at prolonged exposures. Nevirapine showed limited acute toxicity but caused developmental inhibition in echinoderm larvae. Transformation products posed differential risks, with some, such as carboxy-ACV, being more toxic than their parent compounds. Overall, toxicity trends in Table 1 suggest species-specific sensitivities, with microalgae, rotifers, and early developmental life stages often being the most vulnerable, particularly to efavirenz, ritonavir, and dolutegravir.

Almeida et al., (Almeida et al., 2021) found that efavirenz exhibited an EC₅₀ and NOEC of 0.026 mg/L and 0.016 mg/L, respectively, when exposed to Ceriodaphnia dubia over eight days, illustrating that efavirenz is extremely toxic to C. dubia. Robson et al., (Robson et al., 2017) discovered that an exposure of 0.0103 µg/L of efavirenz resulted in severe hepatic damage and concomitantly reduced long-chain triglyceride (LCT) levels in Oreochromis mossambicus after 96 hours of exposure, an effect mirroring effects observed in humans (Blas-García et al., 2010). Similarly, chronic toxicity evaluations over 28 days by Pitso (Pitso, 2020) identified marked renal and hepatic toxicity in O. mossambicus. Omotola et al., (Omotola et al., 2021) illustrated that lamivudine is highly toxic to Daphnia magna, with a 100% mortality rate observed at 0.1 mg/L following 48 hours of exposure (Omotola et al., 2021). Additionally, chronic toxicity spanning eight days, conducted using lamivudine on C. dubia yielded an EC₅₀ of 1.345 mg/L and a NOEC of 0.625 mg/L, highlighting the toxicity of the drug to Daphnia (Almeida et al., 2021). Minguez et al., (Minguez et al., 2016) exposed abacavir to D. magna and Pseudokirchneriella subcapitata for 48 and 72 hours, respectively, finding EC₅₀s of >100 mg/L and 57.32 mg/L, thereby indicating non-harmful and harmful toxicity, respectively. Conversely, zidovudine, was also categorized as toxic to daphnia (C. dubia) with an EC₅₀ of 5.671 mg/L (Almeida et al., 2021).

In addition to the dearth of individual drug toxicity data, the combined effects of parent drugs and their TPs may exhibit even higher toxicity towards aquatic life (Gosset et al., 2021; Kumar et al., 2021). However, such investigations are significantly lacking, despite the extensive use of these drugs in sub-Saharan Africa. This underscores the imperative for systematic investigations into the toxicity of ARVs across different levels of biological organization. Considering the high costs and time-intensive nature of quantifying the environmental risks associated with pollutants, such as the multitude of ARVs, modelling approaches are essential to estimate, for instance, their predicted environmental concentrations (PECs) to quantify exposure levels (Keller, 2006; Keller et al., 2014). Furthermore, models can be employed to estimate the aquatic toxicity of most ARVs utilizing the Ecological Structure Activity Relationships (ECOSAR) software, thereby facilitating the calculation of predicted no-effect concentration (PNEC) values necessary for risk assessment.

1.5. Ecological Risk Assessment

The frequent detection of ARVs such as EFV, NVP, 3TC, TDF, and AZT in WWTP influent and effluent in South Africa, as well as in the associated receiving surface waters, represents an increasing ecotoxicological concern. To evaluate the plausible risk posed by these pharmaceuticals in environmental matrices, the risk quotient method (Equation 1) was employed. The ECOSAR and NORMAN models were utilized to estimate the predicted no-effect concentrations (PNECs), as shown in Fig. (3), while measured environmental concentrations (MECs) reported in the literature were used. The risk categorization was conducted using the framework proposed by (Hernando et al., 2006). According to this framework, an RQ < 0.01 indicates no ecological risk, ARV drugs with 0.01 ≤ RQ < 0.1 present low risk, those with 0.1 ≤ RQ < 1 present minimal risk, and pollutants with an RQ ≥ 1 present a high ecological risk.

For instance, the MEC of EFV, reaching up to 140.4 µg/L in influents and 37.3 µg/L in effluents, as well as 3TC concentrations of up to 20.9 µg/L, significantly surpass the PNECs for aquatic organisms, notably algae, daphnia, and fish. This potential exceedance under high risk condition suggests the potential for both acute and chronic ecological risks (Abafe et al., 2018; Wood et al., 2015). The persistence of these compounds through conventional treatment processes, along with their presence in surface waters, underscores the inefficacy of removal methods and the potential for bioaccumulation and trophic transfer within aquatic ecosystems.

Notably, EFV emerges as the compound with the highest environmental risk among the ARVs detected in South African water matrices. Utilizing the surface-water concentration of 38.45 µg/L and a conservative PNEC of 0.20 µg/L (NORMAN, 2025; US EPA, 2015), the RQ of 192.3 indicates a significant ecological risk (Almeida et al., 2021). Comparable observations have been documented globally, where EFV's low biodegradability and pronounced hydrophobicity contribute to its persistence and toxicity in aquatic environments (Ngwenya and Musee, 2023). Chronic exposure investigations further corroborate EFV's capability to induce oxidative stress, reproductive impairments, and developmental toxicity in Daphnia magna and fish species (Mahaye and Musee, 2022). These findings underscore that even at ecologically relevant concentrations, EFV poses a considerable threat to aquatic biota.

Similar to EFV, NVP, and LPV also present moderate to high ecological risks, regardless of low effluent concentrations recorded up to 1.9 μg/L and 3.8 μg/L, respectively. These compounds manifest chronic toxicity to Daphnia magna and fish, even at sub-microgram levels (PNECs < 0.1 μg/L), suggesting that their persistence in aquatic environments could adversely affect reproductive and growth functions in aquatic organisms (Souza-Silva et al., 2025a). Other ARVs, including TDF and 3TC, exhibited lower numerical RQs but remain a concern due to their persistence and chronic effects. For NVP and TDF, RQs of 0.065 and 2.8 × 10⁻⁴ were derived using surface-water concentrations of 2.8 µg/L and 0.25 µg/L with PNECs of 43 µg/L and 900 µg/L, respectively, indicating a low acute risk. Nonetheless, chronic toxicity has been documented in Daphnia magna and fish at sub-microgram levels, indicating potential long-term ecological damage (Souza-Silva et al., 2025a). Similarly, 3TC exhibited a low calculated RQ of 0.034, though literature suggests that laboratory-derived PNECs may be substantially lower than regulatory values, implying a potential underestimation of risk (K’oreje et al., 2020; Ngwenya and Musee, 2023).

In addition to direct toxicological effects, the persistent environmental presence of ARVs introduces a supplementary, indirect risk by potentially fostering the development of antiviral drug resistance among environmental microorganisms. Analogous to the effects observed with antibiotics, chronic low-level exposure to ARVs can exert selective pressure on microbial communities, promoting the horizontal gene transfer of resistance determinants to pathogenic strains (Apetroaei et al., 2024). This phenomenon could compromise the efficacy of HIV treatment initiatives, endangering the substantial national investments directed toward HIV management and precipitating novel public health challenges through the establishment of environmental reservoirs of resistance.

In summary, the findings suggest that while certain ARVs, such as 3TC and TDF, exhibit low ecological risk under current conditions, compounds like EFV and LPV remain of significant concern due to their persistence, potential for bioaccumulation, and toxicity even at trace concentrations. The observed elevated RQs underscore the necessity for ongoing environmental monitoring, more stringent regulatory controls, and enhanced wastewater treatment technologies capable of effectively removing ARVs. Moreover, the reliance on ECOSAR predictions, limited chronic toxicity data for South African species, and the need for refining local PNECs and integrating both chronic and mixture toxicity assessments are essential for a more precise evaluation of ecological risk in South African aquatic systems.

1.6. Remediation of Antiretroviral Drugs in Wastewater

The prevalence of ARV drug compounds in South African wastewater underscores the limitations of conventional wastewater treatment methodologies, predominantly based on biological and sedimentation processes. Specific compounds such as EFV, NVP, and lamivudine (3TC) persist post-treatment and are commonly detected in effluent and receiving water bodies at concentrations that pose significant ecological hazards (Ncube et al., 2025). The inherent chemical stability, low biodegradability, and polar nature of these compounds impede their microbial degradation and adsorption, necessitating the implementation of advanced remediation strategies to alleviate both ecological and public health risks.

Advanced Oxidation Processes (AOPs), as depicted in Table 2, including photocatalysis and UV/H₂O₂ treatment, have demonstrated superior efficacy in the degradation of ARVs (Ngwenya et al., 2025; Ruziwa et al., 2023; Zhang et al., 2023). Photocatalytic systems utilizing P25 titanium dioxide (TiO₂) for 3TC and graphene oxide-titanium dioxide (GO-TiO₂) for abacavir (ABC) have achieved removal efficiencies exceeding 95% under moderate ultraviolet (UV) irradiation conditions (An et al., 2011; Evgenidou et al., 2023). Similarly, compounds such as acyclovir (ACV), AZT, and protease inhibitors, including LPV and ritonavir (RTV), can be effectively degraded using nanocomposites such as TiO₂ nanoparticles-multiwalled carbon nanotubes (TNPs-MWCNTs), graphite carbon nitride/titanium dioxide (g-CN/TiO₂), bismuth vanadate chloride (Bi₄VO₈Cl), and silver-silver bromide layered double hydroxide (Ag-AgBr-LDH) under UV or visible light, achieving removal efficiencies exceeding 98% (Cheng et al., 2014; Hu et al., 2014; Li et al., 2016; Tabana et al., 2023).

Previous work has proven that these processes facilitate non-selective oxidation, ensuring near-total mineralization without the formation of persistent metabolites (Dagnew et al., 2025; Yang et al., 2021). AOPs have shown superiority to conventional water and wastewater treatment processes due to the production of reactive radicals capable of degrading chemically stable ARVs, which conventional biological processes fail to efficiently eliminate (Aziz et al., 2025; Xiangyu et al., 2025). Furthermore, the modular design of photocatalytic reactors allows for seamless integration into existing WWTPs with minimal infrastructural modification, such as the retrofitting of UV lamps or immobilized catalysts within secondary treatment stages. This integration is cost-effective and scalable for deployment within existing South African facilities where comprehensive upgrades may be economically restrictive.

The application of photocatalysts activated by visible light and low-power UV systems enhances their suitability within the context of South Africa. Compounds such as CuO@Ag@Bi₂S₆ and CuSm_0.06Fe_1.94O₄@g-C₃N₄ demonstrate effective degradation of ARV agents such as AZT, STV, and LPV at reduced catalyst concentrations under moderate irradiation conditions (Ayodhya, 2022; Hojamberdiev et al., 2022; Masunga et al., 2022). These systems effectively decrease operational expenses and energy consumption while maintaining high efficiencies in ARV removal, thereby supporting decentralized or resource-constrained treatment facilities and minimizing the release of residual catalysts. While advanced treatment technologies show promising removal efficiencies in the cited studies, most data originate from laboratory or pilot-scale experiments conducted under controlled conditions, mostly outside South Africa. Direct transferability to full-scale South African WWTPs (with variable influent composition, infrastructure, and operational constraints) should therefore be interpreted with caution.

1.7. Gaps in Research and Policy

Consistent with prior reports (Department of Water and Sanitation, 2023; Nyoni et al., 2024), and as highlighted in the occurrence data, risk assessment, and the North West University (North West University, 2025), the absence of regulatory thresholds for ARVs emphasized the need for long-term ecological and human health impact studies. To guide future action, Table 3 summarizes research priorities crucial for informing risk assessments and policy development in South Africa.

1.8. Challenges in Addressing the Issue

There are several factors involved in managing pharmaceutical pollution in water resources. Wastewater treatment plants in South Africa, especially in rural areas, are not designed to remove pharmaceutical residues. Most wastewater treatment processes focus on biological and chemical pollutants. Furthermore, monitoring and detecting ARV contamination in water resources is a difficult task. Standard water testing methods may not be sufficient to identify specific pharmaceutical compounds present. The lack of widespread research on the impact of ARVs in South Africa makes it difficult to fully understand the scope of the problem. There is also limited data on concentration levels of ARVs in water systems, making it challenging to assess risks to public health and the environment. The lack of public awareness regarding the presence of ARVs in water resources is another challenge. South Africa has made significant progress in addressing HIV/AIDS through widespread access to ARVs. However, the public is not aware of the environmental implications of their use. Without greater public education on how pharmaceuticals affect water systems, efforts to mitigate pollution may be insufficient.

1.9. Societal, Ecological, and Health Implications

The persistence of ARVs in South Africa’s water resources has far-reaching consequences that extend beyond ecology into public health and social equity. Ecologically, ARVs disrupt aquatic food webs, reduce biodiversity, and alter ecosystem services such as nutrient cycling and water purification. Bioaccumulation in aquatic organisms poses additional risks to wildlife and to humans who consume fish or other aquatic species.

From a health perspective, chronic low-level exposure to ARVs through contaminated drinking water remains a concern, particularly for vulnerable groups such as children, the elderly, and immunocompromised individuals. Prolonged exposure may also foster the emergence of drug-resistant pathogens, potentially undermining the gains of South Africa’s HIV/AIDS treatment programme.

Socially and economically, unmanaged ARV pollution may exacerbate inequities, as disadvantaged communities dependent on untreated or poorly treated water sources face disproportionate risks. Rising water treatment costs and impacts on livelihoods reliant on aquatic ecosystems further illustrate the societal burden of pharmaceutical pollution.

Addressing ARV contamination is therefore not only an environmental and public health priority but also a development challenge. It directly aligns with the United Nations Sustainable Development Goals (SDGs 3, 6, and 14), underscoring the urgent need for integrated solutions that combine technological innovation, stronger policy frameworks, and community engagement. By recognizing the interconnected ecological, health, and social dimensions of this crisis, South Africa can advance sustainable water management while safeguarding public health and social equity.

1.10. Future Directions and Recommendations