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Free testing, drug discounts improve use of ACTs for malaria

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July 17, 2018

In western Kenya, a community-based intervention that included free malaria testing and discounts on artemisinin-based combination therapies for patients who tested positive increased the proportion of the first-line antimalarials that were given to people who truly needed them, according to study results.

Writing in PLoS Medicine, Wendy Prudhomme O’Meara, PhD, associate professor of medicine and global health at Duke University School of Medicine, and colleagues noted that artemisinin-based combination therapies (ACTs) are available over the counter in most malaria-endemic countries and can be purchased inexpensively without testing.

“There has been enormous global investment in publicly subsidized ACTs delivered through the private retail sector, but targeting of ACTs to those with a malaria diagnosis remains poor in this context,” they wrote. “Malaria diagnostic testing is largely absent from the retail sector, and as a result, individuals without malaria consume 66% to 80% of ACTs sold over the counter. At the same time, up to 70% of individuals with malaria (but without information about their diagnosis) fail to get an ACT.”

O’Meara and colleagues conducted the study in 32 communities in western Kenya with an estimated population of 160,000. Each community had retail outlets selling ACTs and existing community health worker programs. The communities were randomly assigned to control or intervention cohorts.

In the intervention arm, community health workers were made available to perform malaria rapid diagnostic tests (RDTs) for any person aged at least 1 year who was experiencing malaria-like symptoms. Those who received positive RDT results were given a discount voucher for ACT at a retail outlet. Control participants received standard health education, prevention and referrals.

Random households in the study with reported fever in the prior 4 weeks were surveyed at baseline, 6 months, 12 months and 18 months to determine outcomes. An increase of malaria diagnostic testing at 12 months was the primary outcome.

There were 32,404 participants tested for malaria from July 2015 to May 2017, and 10,870 vouchers were distributed. The researchers surveyed 7,416 study participants with recent fever; 62.9% of recent fevers were in children aged younger than 18 years.

The sex of the children in the study was about even, including 50.2% girls; however, women made up 78% of the adult population.

Baseline statistics revealed that 1,362 participants (67.6%) took an ACT for illness, including 819 (40.3%) who purchased it from a retail outlet.

At 1 year, 50.5% of the intervention cohort and 43.4% of the control cohort received a malaria diagnostic test for recent fever (adjusted risk difference, 9 percentage points). The adjusted RR increased to 1.25 at 18 months.

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There was an increase in rational use of ACTs in the intervention cohort at 18 months, from 41.7% to 59.6%. The increase was 40% higher than that of the control cohort.

O’Meara and colleagues said they were unable to determine the long-term impact of the intervention.

“We demonstrate that it is possible to target ACT subsidies to diagnostically confirmed malaria cases,” they concluded. “Allocation of subsidy dollars between testing and treatment for test-positive individuals may present a better use of programmatic resources than unconditional private sector subsidies.” – by Bruce Thiel

Disclosures: The authors report no relevant financial disclosures.