May 18, 2010
There has been quiet but substantive progress through the Affordable Medicines Facility for malaria (AMFm), a novel financing mechanism for artemisinin-based combination therapies (ACTs) housed at the Global Fund to Fight AIDS, TB and Malaria. Although AMFm will significantly expand access to effective antimalarials, save lives, and delay resistance to ACTs, some worry that making this class of drugs widely available through the private sector could lead to overuse, waste of AMFm resources, and more rapid development of resistance. I have written on this topic in the past. The deployment of rapid diagnostic tests (RDTs), so that only those with malaria receive treatment, has also been discussed previously. Unfortunately, such deployment is easier said than done. For one, most malaria treatment in African countries occurs in the private sector where RDTs are rarely found. Even in clinics in the formal sector where there are likely to be medically trained providers, there is mixed evidence on whether RDTs influence prescribing behavior.
In a recent study published in the British Medical Journal, Ansah and colleagues identified four clinics in western Ghana where microscopy was already used and three where patients were diagnosed on the basis of clinical symptoms alone. They then randomized the 9236 patients into groups that either received an RDT or were diagnosed using the pre-intervention method (microscopy or clinical diagnosis). They also took research slides so that they knew which of the patients actually had malaria. Interestingly, they found that those who were given RDTs in the clinical setting were more likely to be given antimalarials and antibiotics appropriately compared to those in the microscopy setting. Their hypothesis is that prescribers who have not become used to ignoring microscopy results because microscopy is not available may be much more likely to use rapid diagnostic tests to guide diagnosis and treatment.
The observation that experience with previous technologies influences adoption of new ones could apply to other settings both within and outside the health sector. Imagine a farmer who was given seeds by the agricultural extension station that failed to work for another. How open will that farmer be to adopting a new seed technology? Elsewhere, however, an overall positive experience with cell phone technologies is helping ensure that this mode of communication will become the mainstay for those want to find crop prices, send money to relatives back home, and a do host of other things that rely on broad trust in communications technology. These might be inappropriately broad conclusions to draw from this one study, but within the malaria field, it seems to indicate that RDTs are likely to make an impact in places with no microscopy. Given the great lamenting about the lack of trained microscopists in Africa, there is surely an opportunity to figure out creative ways to introduce RDTs in public sector clinics across malaria-endemic parts of the world. Dealing with the private sector may be much more of a challenge.
Image Credit: WHO
