07 November 2012

Malaria Woes: Rising Resistance and the Future of AMFm

The development of artemisinin-based drugs to treat malaria proved to be one of the most important advancements in stopping malaria. Malaria deaths are down from 1 million in 2000 to 650,000 in 2010 due in part to medical advancements, greater coverage of insecticide treated bed nets and improved coordination. However, evidence of resistance to artemisinin-based drugs is popping up in southeast Asia.

What further complicates the problem is the location of the resistance. Experts are observing resistance on the Thai border with Myanmar and Cambodia as well as in Vietnam. "Resistance to chloroquine and pyrimethamine started here," said Arjen Dondorp, director of malaria research at the Mahidol-Oxford Tropical Medicine Research Unit in Bangkok, to NPR. "Those two were very important drugs until recently. Very cheap, good drugs. We've lost them to resistance, especially here in the region. And then it has spread from here to the rest of the world."

Evidence of resistance first cropped up in 2009 and the WHO has taken steps to work towards preventing its spread from the region, bu encouraging countries to improve monitoring efforts. "Antimalarial drug resistance is like a cancer, it must be fought at every level – affected countries need to be in the frontline in combating the emergence of drug resistance. WHO should be empowered and supported to take a strong lead. It is crucial to protect ACTs as they are the best treatments for millions of people against malaria," said Professor Nicholas J White, of the Mahidol-Oxford Research Unit in Bangkok, Thailand in 2010.

Data Confirms Growing Resistance

A study published in April edition of the British medical journal The Lancet provided a longitudinal approach to artemisinin resistance in western Cambodia. From 2001 to 2010, the researchers tested the efficacy of treatments on patients with malaria ranging from mefloquine to doxycycline. They observed an increase in the time it took for patients to recover from malaria when using ACTs, regardless of the age of the person.

The researchers found that resistance was spreading west from Cambodia and called for a review of the present containment strategies. "Increasing the availability of artemisinin combination therapies in southeast Asia will reduce the incidence of malaria but provides a selection pressure driving artemisinin resistance. The development of strategies to reduce the selection and spread of artemisinin-resistant Plasmodium falciparum while continuing to drive down the incidence of malaria is of the highest priority," concluded the authors.

Global Partners Seek Solutions

The Roll Back Malaria Partnership issued a report earlier this month on the state of malaria around the world. “Anti-malarial drug resistance is one of the greatest challenges to continued success in controlling and eliminating malaria in the Asia-Pacific,” said the Director of the Global Malaria Programme of the UN World Health Organization (WHO), Dr. Robert Newman, at the launch of the report.

It included a section on the problem of resistance faced by southeast Asia calling for further investments in drug monitoring, increased access to quality diagnostics, the scale-up of prevention methods, new government regulations and programs that target migrant populations. "Asia accounts for the second highest burden of malaria, second only to Africa. In the face of persistent economic uncertainty and profound changes in the landscape of global development aid, the region needs strong political leadership. It also needs to develop financing strategies that include substantive and sustained domestic investment, traditional multilateral and bilateral aid and truly innovative sources of funding," said RBM Executive Director, Dr Fatoumata Nafo-Traoré.

All Eyes on AMFm

The Global Fund will soon hold its board meeting and the Affordable Medicines Facility for Malaria (AMFm) program is on the chopping block. AMFm is a pilot program that attempts to leverage the private sector as a way to increase the supply of antimalarial drugs, especially high quality ACTs.

Oxfam published a report recommending the Global Fund to stop hosting the AMFm. Oxfam said in its report that AMFm created a higher demand for ACTs in countries with low malaria prevalence.  More importantly it provided an incentive for untrained retailers and pharmacists to sell ACTs without taking the proper diagnostic measures to determine if a person had malaria. 

Finally, the report said that there is no evidence that ACTs were reaching more vulnerable populations. AMFm successfully reduced the price and inceased the availability of quality malaria drugs, but it matters little, argues Oxfam, if it does not reach the people who need it most.

The report makes three recommendations to the Global Fund:
  • The Global Fund should take a decision at their November board meeting to cease hosting the AMFm;
  • UNITAID and the UK Department for International Development (the AMFm‟s main funders) should discontinue funding beyond current commitments (the end of 2012);
  • If pilot countries wish to continue providing ACT via the private sector, they should do so through normal Global Fund or other donor grants.
Oxfam senior health policy advisor, Dr Mohga Kamal Yanni, told the BBC, "It is dangerous to put the lives of sick children in the hands of a shopkeeper with no medical training, and to pursue a scheme that doesn't help those people who need it the most.

The Global Fund disagrees with Oxfam’s claim. It issued a statement saying, "Some Western aid groups oppose a pragmatic approach that includes any involvement of the private sector. But the reality of this programme is that it is getting life-saving medicine to people who need it most from the private sector outlets where they already seek treatment. Before the launch of AMFm, life-saving malaria treatments cost up to 20 times as much. An extensive study has shown that AMFm has increased availability and reduced prices for high quality anti-malarial drugs."

Victoria Fan of the Center for Global Development took a more cautious approach in regards to the study findings. She was more optimistic than Oxfam and pointed out the problems caused by suddenly terminating the program writing, "Regardless of the precise merits of the evaluation, the evaluation alone does not represent all that the Board will need to consider in its decision. For one, it should be obvious that the sudden termination of a $225M supply-side market intervention would (again) distort the market and likely for the worse. If only for this reason, AMFm should continue, potentially with modification, in the pilot countries where an attributable effect is believed to be seen. But in Niger and Madagascar, where no effect was seen in the evaluation and implementation was somewhat limited, careful decisions are needed to determine whether to “resume”, “suspend” or “terminate.”"

Note: A version of this originally appeared on the PSI Impact blog.