The extensive use of antiretroviral drugs (ARVs) for HIV/AIDS treatment in South Africa has generated a new class of persistent contaminants within the aquatic environment. This review consolidates current evidence on the occurrence, transformation products, ecotoxicological effects, and removal efficiencies of ARVs in South Africa’s water resources. Measured concentrations of compounds such as efavirenz, nevirapine, and lamivudine frequently exceed international ecotoxicological thresholds, reflecting the limitations of conventional wastewater treatment systems designed primarily for nutrient and organic load removal. Because ARVs are only partially metabolized in humans and exhibit high polarity and chemical stability, they persist in effluents, surface waters, and occasionally in drinking water. Chronic exposure studies indicate potential adverse effects on aquatic organisms across trophic levels, including oxidative stress, endocrine disruption, developmental abnormalities, and altered enzymatic activity. The review critically evaluates advanced treatment approaches such as photocatalytic advanced oxidation processes (AOPs), highlighting their efficiencies, scalability, and cost implications for South African contexts. Major research and policy gaps include limited long-term ecotoxicological data, inadequate nationwide monitoring, and the absence of ARV-specific water quality thresholds. The study proposes the integration of ARV monitoring into South Africa’s Green Drop framework, the adoption of visible-light-driven photocatalysis for energy-efficient remediation, and alignment of national water policies with the UN Sustainable Development Goals. By explicitly linking environmental contamination with public health resilience and equity, this review underscores the urgent need for coordinated interventions to ensure that the life-saving benefits of antiretroviral therapy do not compromise aquatic ecosystem integrity.
Mahaye et al. (Wed,) studied this question.