Subsidies for combination treatments in countries where malaria is endemic are urgently needed to forestall drug resistance and save lives, warns a paper published this week.
A subsidy of only $100m (£57m; €83m) to $200m for artemisinin based combination drugs might be needed, said Ramanan Laxminarayan, from Resources for the Future, a non-profit, independent organisation based in Washington, DC, and the paper's lead author.
He said that if such a subsidy programme was implemented within three months, up to 25 000 lives a month could be saved (Health Affairs2006;25:325-36).
Dr Laxminarayan, whose coauthors are from the World Bank and the US National Institutes of Health, said, “Providing the subsidies is probably the most important thing the world can do for malaria today. I can't think of another public health program that could be deployed so rapidly and would save as many lives. One and a half million people die in Africa every year from malaria, mostly children under five … We have a small window of opportunity to do this. Already there are reports of artemisinin resistance.” (See News Extra, bmj.com)
Artemisinin based combinations are the best choice of malaria treatment to reduce the risk of resistance, the report argues. If artemisinin is used as a single treatment, resistance can soon develop. However, using artemisinin in combination with other drugs reduces the ability of the malaria parasite to develop resistance.
Combination treatments using artemisinin are too expensive in most countries where malaria is endemic, so subsidies from international organisations or donor countries are needed, the report advises. “Subsidising the drug is quite different from just paying for the drug,” Dr Laxminarayan said. Subsidising encourages people to buy the more effective drug rather than others on the market, he explained.
Subsidies leading to wide use of the combination treatment would eventually encourage resistance although more slowly than if artemisinin was used on its own. However, the problem could be lessened or postponed if subsidies made the combination more attractive than use of artemisinin or other drugs alone. The report concludes that partial subsidies of two combination treatments, artemisinin combined with either of two partner drugs [amodiaquine or sulfadoxine-pyrimethamine], would reduce mortality from malaria more and would cost less than subsidising a single combination treatment. A three drug combination might be even more effective.
Delaying subsidy programmes would be the worst choice, leading to more deaths and higher costs, the authors argue. A delay of even two years in a partial subsidy for artemisinin based combination treatment would increase resistance caused by the use of artemisinin alone or other drugs alone.
Given the worldwide problem of malaria, using the same artemisinin based combination treatment everywhere might lead to resistance in one country that then spreads to other areas, so at least two combinations are needed, the report concludes.