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The communications challenges of introducing test and treat

Burgess COMMENTARY

Peter Burgess

The communications challenges of introducing test and treat

Today, RDTs allow health workers to quickly test for malaria. Photo: PATH

MalariaCare, a USAID/PMI program led by PATH, recently hosted a webinar on the importance of formally and carefully introducing the relatively new case management policy to “test, treat, and track” all suspected malaria cases. Before malaria diagnostic tools became widely available, treating presumptively—providing malaria drugs to all patients with malaria-like symptoms in high-risk areas—was the only option. Rapid diagnostic tests (RDTs) were not until relatively recently, so an accurate diagnosis by microscopy could have meant waiting precious days for a distant laboratory to analyze the patient’s blood. Such delays would mean more deaths, especially in children, and longer periods of illness.

The problem with presumptive diagnosis of malaria based on clinical presentation is that many diseases cause the symptoms that also are characteristic of malaria. Under presumptive treatment, a proportion of patients were given drugs for a disease they didn’t have. Further, there is evidence that the overuse of antimalarial drugs contributed to the development of drug resistance, drastically reducing their effectiveness for those suffering from malaria.

Following the advent of RDTs, the WHO called for testing all suspected malaria cases before administering treatment. This new mandate requires significant behavior change among governmental and non-governmental health workers and their clients, including community leaders—changes that have not always gone smoothly, and still have not been implemented everywhere.

Generations of health workers were trained to treat fevers presumptively with malaria drugs; they have done so during their entire careers. And community members are used to receiving drugs after a visit to the health worker, and may continue to request them regardless of their RDT diagnosis. Further complicating the situation is that in some places both health workers and communities have expressed distrust of the relatively new technology.

A poster from the Test on Day One awareness campaign in Uganda. Photo: PMI/Uganda Ministry of Health. A poster from the The Power of Day One awareness campaign in Uganda. Photo: PMI/Uganda Ministry of Health.

Sometimes, these challenges have straightforward solutions: a recent study in Senegal showed that health workers were more likely to trust RDTs after seeing that the tests yielded both negative and positive results, so introducing the devices during a high transmission period (when there will be many positives) could be a simple way to help convince end users that the tests work. On the demand side, campaigns convincing community members of the value of testing before treatment, and urging them to demand test services, would put pressure on health care providers to adhere to the new guidance.

During the MalariaCare webinar panelists shared lessons learned from their experiences improving the knowledge, skills and behaviors of health providers to ensure high-quality malaria case management. Presentations included diverse country experiences across the public and private health sectors, and at community level. This event was moderated by MalariaCare’s Dr. Jamie Eliades with panelists Mr. Scott Wittet, MalariaCare, USA; Dr. Raphael Ntumy, MalariaCare, Ghana; Mr. Kafula Silumbe, MACEPA, Zambia; and Dr. Hnin Su Su Khin, PSI, Burma.