Prudhomme O'Meara Wendy, Mohanan Manoj, Laktabai Jeremiah, Lesser Adriane, Platt Alyssa, Maffioli Elisa, Turner Elizabeth L, Menya Diana
Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA.
Duke Global Health Institute, Duke University, Durham, North Carolina, USA.
BMJ Glob Health. 2016 Sep 28;1(2):e000101. doi: 10.1136/bmjgh-2016-000101. eCollection 2016.
There is an urgent need to understand how to improve targeting of artemisinin combination therapy (ACT) to patients with confirmed malaria infection, including subsidised ACTs sold over-the-counter. We hypothesised that offering an antimalarial subsidy conditional on a positive malaria rapid diagnostic test (RDT) would increase uptake of testing and improve rational use of ACTs.
We designed a 2×2 factorial randomised experiment evaluating 2 levels of subsidy for RDTs and ACTs. Between July 2014 and June 2015, 444 individuals with a malaria-like illness who had not sought treatment were recruited from their homes. We used scratch cards to allocate participants into 4 groups in a ratio of 1:1:1:1. Participants were eligible for an unsubsidised or fully subsidised RDT and 1 of 2 levels of ACT subsidy (current retail price or an additional subsidy conditional on a positive RDT). Treatment decisions were documented 1 week later. Our primary outcome was uptake of malaria testing. Secondary outcomes evaluated ACT consumption among those with a negative test, a positive test or no test.
Offering a free RDT increased the probability of testing by 18.6 percentage points (adjusted probability difference (APD), 95% CI 5.9 to 31.3). An offer of a conditional ACT subsidy did not have an additional effect on the probability of malaria testing when the RDT was free (APD=2.7; 95% CI -8.6 to 14.1). However, receiving the conditional ACT subsidy increased the probability of taking an ACT following a positive RDT by 19.5 percentage points (APD, 95% CI 2.2 to 36.8). Overall, the proportion who took ACT following a negative test was lower than those who took ACT without being tested, indicated improved targeting among those who were tested.
Both subsidies improved appropriate fever management, demonstrating the impact of these costs on decision making. However, the conditional ACT subsidy did not increase testing. We conclude that each of the subsidies primarily impacts the most immediate decision.
NCT02199977.
迫切需要了解如何更好地将青蒿素联合疗法（ACT）应用于确诊的疟疾感染患者，包括非处方销售的补贴ACT。我们假设，以疟疾快速诊断检测（RDT）呈阳性为条件提供抗疟补贴会增加检测的接受度，并改善ACT的合理使用。
我们设计了一项2×2析因随机试验，评估RDT和ACT的2个补贴水平。2014年7月至2015年6月期间，从家中招募了444名患有疟疾样疾病但未寻求治疗的个体。我们使用刮刮卡以1:1:1:1的比例将参与者分为4组。参与者有资格获得无补贴或全额补贴的RDT以及2种ACT补贴水平之一（当前零售价或RDT呈阳性时的额外补贴）。1周后记录治疗决策。我们的主要结果是疟疾检测的接受度。次要结果评估检测结果为阴性、阳性或未检测者的ACT使用情况。
提供免费RDT使检测概率提高了18.6个百分点（调整概率差异（APD），95%可信区间5.9至31.3）。当RDT免费时，提供有条件的ACT补贴对疟疾检测概率没有额外影响（APD = 2.7；95%可信区间 -8.6至14.1）。然而，获得有条件的ACT补贴使RDT呈阳性后服用ACT的概率提高了19.5个百分点（APD，95%可信区间2.2至36.8）。总体而言，检测结果为阴性后服用ACT的比例低于未检测就服用ACT的比例，这表明在接受检测者中靶向性有所改善。
两种补贴都改善了对发热的合理处理，表明这些费用对决策的影响。然而，有条件的ACT补贴并未增加检测。我们得出结论，每种补贴主要影响最直接的决策。
NCT02199977。
