Abstract:
Introduction In many malaria- endemic countries, the
private retail sector is a major source of antimalarial
drugs. However, the rarity of malaria diagnostic testing
in the retail sector leads to overuse of the first- line class
of antimalarial drugs known as artemisinin- combination
therapies (ACTs). The goal of this study was to identify the
combination of malaria rapid diagnostic test (RDT) and ACT
subsidies that maximises the proportion of clients seeking
care in a retail outlet that choose to purchase an RDT (RDT
uptake) and use ACTs appropriately.
Methods 842 clients seeking care in 12 select retail
outlets in western Kenya were recruited and randomised
into 4 arms of different combinations of ACT and RDT
subsidies, with ACT subsidies conditional on a positive RDT.
The outcomes were RDT uptake (primary) and appropriate
and targeted ACT use (secondary). Participants’ familiarity
with RDTs and their confidence in test results were also
evaluated.
Results RDT uptake was high (over 96%) across the study
arms. Testing uptake was 1.025 times higher (98% CI
1.002 to 1.049) in the RDT subsidised arms than in the
unsubsidised groups. Over 98% of clients were aware of
malaria testing, but only 35% had a previous experience
with RDTs. Nonetheless, confidence in the accuracy of
RDTs was high. We found high levels of appropriate use
and targeting of ACTs, with 86% of RDT positives taking
an ACT, and 93.4% of RDT negatives not taking an ACT.
The conditional ACT subsidy did not affect the RDT test
purchasing behaviour (risk ratio: 0.994; 98% CI 0.979 to
1.009).
Conclusion Test dependent ACT subsidies may contribute
to ACT targeting. However, in this context, high confidence
in the accuracy of RDTs and reliable supplies of RDTs and
ACTs likely played a greater role in testing uptake and
adherence to test results.