Imagine buying a powerful weight-loss drug through a simple WhatsApp exchange. No doctor's visit, no awkward conversations – just a quick payment and a mysterious package arrives at your door. Sounds too good to be true? It might be, and it's a growing problem in South Africa. Regulators appear to be struggling to control the booming black market for injectable weight loss medications, leaving people vulnerable to potentially dangerous substances.
Beth Amato's story is a stark example. She bypassed traditional medical routes and purchased a knock-off version of Ozempic, called "Izempic," from a contact circulating among her friends. The package arrived without instructions, containing a white powder and vials of clear liquid that she had to mix herself. Undeterred, she bought needles from a pharmacy and began injecting the concoction into her abdomen.
To her relief, it seemed to work. Her appetite decreased, the side effects were manageable, and the kilograms started to melt away. "It was so much easier not to have to deal with the whole fat-shaming experience," Amato admitted. "But I started to get concerned they would get it wrong. And no one was giving me dosing advice." Eventually, she obtained a legitimate prescription and switched to a regulated product. But here's where it gets controversial: The ease with which Amato obtained an unregistered version of these popular GLP-1 weight loss injections highlights the apparent powerlessness of authorities to effectively combat this illicit market.
These black market jabs, at best, are smuggled versions of genuine medications. At worst, they could contain dangerously high doses, undisclosed ingredients, and harmful contaminants. "I’ve never seen anything like it," says Dr. Wayne May, an endocrinologist and obesity specialist. "We don’t really know what’s in these things." He notes that companies are offering a bewildering array of unregistered products, untested combinations of medicines, and even drugs still undergoing clinical trials, such as Eli Lilly’s retatrutide. And this is the part most people miss: The lack of oversight means consumers are essentially playing Russian roulette with their health.
While precise figures on the size of this illegal trade are unavailable, the blatant promotion of unregistered products is occurring across various platforms, including websites, Facebook pages, WhatsApp groups, gyms, and beauty salons. This brazen activity has deeply alarmed authorities, pharmaceutical companies, and healthcare professionals alike.
GLP-1 agonists work by mimicking the effects of the naturally occurring hormone glucagon-like peptide 1. They help regulate blood sugar by stimulating the pancreas to release insulin after a meal, slow down digestion, and suppress appetite. The hormone also plays a role in the brain's reward system, potentially reducing cravings. Preliminary research even suggests it may reduce the desire for alcohol and drugs. But are these benefits worth the risks associated with unregulated products?
In South Africa, the South African Health Products Regulatory Authority (Sahpra) has approved only three injectable medicines containing GLP-1s: Novo Nordisk’s liraglutide and its successor, semaglutide, and Eli Lilly’s tirzepatide. These medications are marketed under different brand names for both diabetes and weight loss. For example, Novo Nordisk's Ozempic (for diabetes) and Wegovy (for weight loss) contain only GLP-1, while Eli Lilly's Mounjaro (for diabetes) and Zepbound (for weight loss) contain both GLP-1 and a second peptide that mimics the gut-hormone glucose-dependent insulinotropic polypeptide (GIP).
Stavros Nicolaou, head of strategic trade at Aspen Pharmacare, explains that semaglutide and tirzepatide are still under patent. This means that any company importing these peptides or creating copies of them is violating the law. Aspen Pharmacare has a licensing agreement with Eli Lilly to market Mounjaro in South Africa.
South Africa's high obesity rates make it a tempting market for companies selling weight loss medications. In 2016, 41% of South African women were obese, and this figure is projected to reach almost 47% by the end of 2025, according to the World Obesity Federation. While the numbers for men are lower, they are rising rapidly – from 16% to over 23% during the same period.
Despite growing recognition of obesity as a chronic disease and increasing evidence that GLP-1s offer additional benefits, such as improved heart health and reduced risk of renal failure, their high cost makes them inaccessible to most South Africans. The injections are not available through the state sector, and private sector purchases can easily cost R10,000 (approximately $550 USD) per month, according to Wits Ezitsha director Francois Venter. He notes that while those struggling with their weight are typically advised to eat less and exercise more, this approach often fails for obese patients. For these individuals, weekly GLP-1 injections can be truly transformative. "People melt away," he says. "But medical aids would be bankrupt tomorrow if they started to offer them."
While some medical schemes cover GLP-1 shots for diabetes, none currently cover their use for weight loss, forcing patients to pay out-of-pocket. Noluthando Nematswerani, chief clinical officer of Discovery Health, one of South Africa's largest medical scheme administrators, states that "GLP-1 agonists are prohibitively expensive. Significant price reductions will be required for broader access to these medications." Discovery's modeling suggests that the price of GLP-1s would need to fall below R1,000 (approximately $55 USD) per month to be cost-effective for high-risk patients with morbid obesity and multiple chronic conditions. For lower-risk members, the price would need to be considerably lower.
Ozempic gained FDA approval in the US as a treatment for type 2 diabetes in 2017 and quickly gained attention for its unexpected and significant impact on weight. Patients, celebrities, and social media influencers began sharing their experiences, leading to a surge in off-label prescribing for weight loss that Novo Nordisk struggled to meet. The high price and intermittent shortages prompted the FDA to allow pharmacies to compound generic semaglutide to ensure diabetics had access to life-saving supplies. This decision unintentionally fueled the black market boom. Sales of both legitimate and illicitly compounded GLP-1s skyrocketed worldwide.
The FDA recently declared the US semaglutide shortage over, effectively ending the permission for compounded sales, except for patients who require doses not commercially available. The Australian Therapeutic Goods Authority has gone even further, banning compounded GLP-1 altogether. But here's where it gets controversial... Sahpra, despite issuing repeated warnings about the dangers of weight loss medications from unregulated sources, has yet to significantly impact the trade in compounded GLP-1s or stop the sales of fake and falsified products. Sahpra CEO Boitumelo Semete-Makokotlela explains that the regulator has faced strong industry opposition to its plans to declare compounded GLP-1s an undesirable practice and lacks the resources, with only 12 inspectors, to scrutinize all businesses advertising these products.
Semete-Makotlotela emphasizes that medicines made by compounding pharmacies do not undergo the same rigorous scrutiny as those made in Sahpra-approved factories, posing multiple risks to patients, including dosing errors and contamination. "We don’t know where the compounders are getting their product from," she says. While Sahpra has approved the finished products made by Novo Nordisk and Eli Lilly, it has not approved any sources for the active pharmaceutical ingredients used in them. Recent seizures by South Africa's port authorities indicate that shipments of unauthorized semaglutide and tirzepatide are being smuggled in from China, concealed within shipments of seemingly harmless products like cat food and calcium, according to Nicolaou. Given Sahpra's limited capacity, pharmaceutical manufacturers are working to raise awareness of the issue with other authorities, including the South African Revenue Service (Sars), customs, the border management authority, SAPS, and the Hawks.
Since semaglutide is still under patent in South Africa and Novo Nordisk has not issued licenses for other companies to import the peptide or create generic copies, all compounded GLP-1s containing this active pharmaceutical ingredient are illegal, according to Jonas Lind Hansen, Novo Nordisk South Africa’s head of legal ethics, compliance, and quality.
Hansen argues that the Medicines Act's provisions for compounding were intended for individual patients with specific needs, not for large-scale production of compounded medicines. "It is being misused by what we believe are criminal organizations…they don’t even know the patients," he says. "Even for specific patients, we think it’s undesirable, because the quality of what we’re seeing is so low that we think it’s dangerous."
Novo Nordisk's attempt to legally stop compounding pharmacy Idexis Pharmaceuticals from using semaglutide remains unresolved in the courts. The company is also actively promoting its products through a partnership with men's health service Androlab, using social media to promote GLP-1s and prescribe its products. Alistair McAlpine, AndroLab CEO, notes that people are often too embarrassed to seek guidance from healthcare professionals and are unaware of the risks of using injectable weight loss drugs without medical supervision. Even when used correctly, GLP-1s can have serious side effects, like bowel obstruction and pancreatitis. McAlpine describes a consultation with a patient who developed large patches of red and inflamed skin after using compounded injectables, stating, "That immediately tells me it’s a contaminated product."
While McAlpine has reported cases like these to Sahpra, he says the associated paperwork discourages many doctors from doing so, leading to an underreporting of adverse events. "At the end of the day, you have an ethical responsibility to make sure that patients aren’t hurt [and] you need to report these things," he says.
Sahpra is particularly concerned about sales of compounded injectables containing multiple ingredients that have not been tested or approved for use in combination, says Semete-Makotlotela. But this is where opinions start to clash. Doctors like Tommie Smook, of the weight loss practice Dr. Smook & Partners managed by RxMe, do not share the regulator's concerns. His practice prescribes compounded medicines containing a "proprietary blend" of amino acids, semaglutide, and tirzepatide, which he says is tailored to each individual’s needs. He expresses confidence in combining the two peptides, despite the lack of clinical research demonstrating the safety of using them together. "There’s no reason why we can’t do what we’re doing," he argues, pointing out that doctors frequently prescribe medicines proven safe and effective on their own but not tested together, such as an antibiotic with cortisone and an anti-inflammatory.
Smook declines to reveal the sources of the semaglutide and tirzepatide contained in the compounded medicines he prescribes, stating only that they come from "reputable pharmaceutical companies all over the world" and are compounded in a "Sahpra-approved" facility. "We’ve treated thousands of patients, and I’ve got more than 15 patients that lost more than 100kg. My biggest loser…lost 170kg. He had a prescription the whole time, and we knew exactly what was in the product," Smook says, while declining to disclose the price of the medicines he prescribes.
Ultimately, market forces may play a role in reducing South Africa's black market for injectable GLP-1s. The patent on semaglutide is set to expire in many countries next year, which will likely lead to the introduction of new generic versions and a decrease in prices. Pharmaceutical companies are also working to develop GLP-1 pills, which are expected to be cheaper and easier to manufacture than injections, making them available to millions more patients.
Amato's experience demonstrates the effectiveness of injectables. Under the guidance of her doctor, she continues to use a registered GLP-1 that has helped her lose 25kg over the past two years. Although the medicine is much more expensive than the black market version and requires her to pay out of pocket, she's willing to make sacrifices to continue her weekly injections. Her weight has stabilized at a healthy 65kg, her cholesterol levels are back to normal, and most importantly, she is no longer controlled by cravings and constant hunger. "I don’t eat differently, I just eat less," she says.
So, what do you think? Is Sahpra doing enough to protect consumers from potentially dangerous black market weight loss injections? Should compounded GLP-1s be banned altogether, even if it limits access for those who can't afford the brand-name drugs? Or do doctors have the right to prescribe compounded medications based on their clinical judgment, even if the combinations haven't been rigorously tested? Share your thoughts in the comments below!
