Posts or Comments 20 July 2024

Monthly Archive for "November 2006"

Treatment Bill Brieger | 27 Nov 2006

Chloroquine is Dead, Long Live Chloroquine

The death knell for chloroquine (CQ), a cheap and relatively long lasting antimalarial drug, have been tolling across the continents in a westerly direction for decades and finally reached West Africa in the 1990s. In southern Africa, Malawi was one of the first countries to officially discontinue use of CQ in 1993. A recent article in the New England Journal of Medicine (NJEM – subscription required) reports that when CQ was no longer available in either the public or private health systems of Malawi, the mutated P. falciparum gene associated with drug resistance disappeared.

The drug is now effective again at treating malaria in parts of Malawi– but before too much excitement develops for the drug that is 1/20th the price of currently recommended artemisinin-based combination therapies (ACTs), the authors of the NJEM article caution that CQ is still available throughout the rest of the continent and will not regain its former strength until it disappears entirely as was the case in Malawi. Only then could CQ be reintroduced, but in combination with other antimalarial drugs to prevent resistance from returning. But what are the chances that CQ will be taken off the shelves any time soon, and what does this say about malaria drug policy in endemic countries?

Nigeria, for example, adopted a new ACT-based drug policy in 2005, which was greeted with the headline “Government bans Chloroquine as first line drug in malaria treatment” in a prominent national daily, which required a response by the Federal Ministry of Health a few days later, “Chloroquine Not Banned, Says Minister”. In this milieu it has been a major challenge to convince state and local government health services to adopt the new national malaria drug policy and use their limited essential drug funds to buy ACTs. Supplies from donors, whether the Global Fund or the World Bank, are not adequate, nor are they intended to cover the ACT needs of the total population.

Not surprisingly, CQ and sulphadoxine-pyramethamine (SP), another cheap antimalarial drug to which parasites are resistant, are available and being used for treatment in local government clinics in the southeastern part of the country, an area where CQ resistance is highest. ACTs are rare or non-existent in these rural settings, even in drug shops whose owners are reluctant to buy these expensive alternatives not knowing whether their customers can pay. It is only in the urban private medicine shops and pharmacies that one sees a plethora of ACTs, and unfortunately also monotherapy artesunate drugs.

So, the pressure remains to buy and sell or dispense CQ. One key factor is education of both public and private providers, many of whom have not heard about the new drug policy. Education will not be enough until, as an accompanying NJEM editorial says, the cost of ACTs is comparable to what people have been paying for CQ and SP.

As a final concern, researchers are finding that CQ may be valuable in the treatment of HIV. HIV and malaria produce some very negative synergies so it is not clear what the practical implications of continued use of CQ for HIV might be, but it does raise the possibility that CQ may not disappear soon, and we may not be able to replicate the Malawi experience after all.

Funding Bill Brieger | 17 Nov 2006

Malaria Proposals Don’t Make the Cut in Round 6

A total of 85 grants were approved in Round 6 of the Global Fund to Fight AIDS, TB and Malaria (GFATM) at it recent Guatemala meeting, but malaria advocates are disappointed that only 19 (22%) of the approved grants were for malaria programs, and only eight will go to high-burden countries in Sub-Saharan Africa. In previous rounds, malaria got up to a third of the total funds. In addition, only 31% of 35 submitted malaria proposals made the cut, compared to 38% for HIV and 62% for TB. This experience raises two important issues. First, does burden of disease play any role in prioritizing grant awards? Secondly, are there specific problems with malaria proposals?


Each of the three diseases is a serious health and development challenge. TB has been neglected by international health programs, HIV is devastating large portions of the productive age population in many countries, and malaria is a major cause of child mortality. In Africa HIV accounts for twice as many deaths overall as malaria, but in children under five years of age, malaria deaths are three times higher than HIV. Arguments in support of the lion’s share consistently allocated to HIV may relate to the cost of interventions, but with Long Lasting Insecticide-treated Nets (LLINs) and Artemisinin-based Combination Therapy (ACT) being recommended for malaria, that argument carries much less weight. Under these circumstances, one would expect relatively equal treatment for the diseases.

Possibly the problem rests in the quality of malaria proposals. This would be ironic since during proposal writing time, donors join together to help countries develop them , even when there is uncertain capacity on the ground to carry out a grant if it is awarded. Another factor in judging a new proposal is performance of existing grants. GFATM prides itself in being a performance based organization, and no one would ever wish for less accountability when it comes to international grants. What could be happening is that Round 6 malaria proposals were denied due to poor performance of their predecessors.

Poor performance can be due to basic lack of capacity and competence, but also due to unrealistic goal setting in the early grants. Many projects underestimated the time it would take to get set up and running – the need to address customs and drug registrations, the ability of M&E systems to report, etc. Thus, projects promised unrealistic progress on indicators and may have been penalized in Rounds 5 and 6 for this. Instead of penalties, technical assistance (TA) to overcome the problems would be more helpful and result in saving more lives from malaria deaths. The reality though is that the GFATM is strictly a financial agency and does not provide TA. Donors flock around during the grant writing process, but where are they when the grants begin to falter?

So far in-course TA for the malaria grants has been provided through regional workshops by the RBM Partnership, and recently the US Government made TA services available if CCMs or PRs would apply. Unfortunately few of the eligible countries/projects availed themselves of this TA, and even among those who did, few were malaria grantees.

Announcements for Round 7 and 8 also came out of the 14th GFATM Board Meeting. It is crucial for partners to plan now not just to help write new malaria grants, but to get on board in making the existing malaria grants perform up to expectations.

IPTp &Malaria in Pregnancy &Treatment Bill Brieger | 08 Nov 2006

Dispel the Myths; Preventing Malaria in Pregnancy is a Priority!

Pregnant women are particularly vulnerable to malaria, which can cause life-threatening anemia, low-birth weight, and even death for the infant. Yet the international public health community seems to be overlooking the risks pregnant women and their unborn children face when infected with malaria. And myths and misperceptions at the country level also hamper effective control of malaria in pregnancy (MIP).

Take a look at the WHO’s Global Malaria Program (GMP) website and you will find that intermittent preventive treatment (IPT) for pregnant women has been replaced by indoor-residual spraying (IRS). Specifically in reference to a new publication on IRS, the website states, “IRS is now one of THREE main interventions promoted by WHO to control malaria,” and a closer reading of that document shows that IPT has been dropped in favor of IRS. Obviously WHO is not dropping MIP interventions, but the fall from grace for IPT in pregnancy is disconcerting when MIP is responsible for morbidity and mortality in both mothers and newborns. This is particularly discouraging since IPT and ITNs for pregnant women have been shown to be highly effective, and are delivered through established ante-natal services, making them an obvious choice for high impact at low cost.

In addition to benign neglect by international health officials, various myths have emerged about MIP interventions at the country level. Front line health workers and mothers in many countries still believe that the drug of choice, sulfadoxine-pyrimethamine (SP), is either unsafe or too strong for pregnant women. A second myth surrounds SP as an appropriate treatment – the news about preventing further drug resistance in the general population by not using SP for curative care has not been heard or heeded, especially when the alternatives, artemisinin-based combination therapy (ACT), is so expensive.

Another myth is that since SP is relatively cheap, there is little need to focus major donor attention on strengthening IPT programming. Finally there is the myth that insecticide-treated nets (ITNs) will certainly reach pregnant women if community campaigns are conducted. Aside from the normal problems of leakage and poor documentation, separating ITN distribution from antenatal care removes an important incentive for women to safeguard their pregnancies through timely prenatal visits.

Recently the Roll Back Malaria Working Group on MIP held its seventh meeting in Abuja, Nigeria. A key recommendation was greater involvement, if not full leadership by the reproductive health (RH) community in the battle against malaria in pregnancy. The close integration of RH and malaria control programs can make sure IPT remains a priority intervention necessary to meet the goals detailed in the Abuja Declaration from 2000.