title: Adherence to treatment with artemether-lumefantrine for uncomplicated malaria in rural Malawi.
abstract: BACKGROUND
  In 2007, Malawi replaced the first-line medication for uncomplicated malaria, sulfadoxine-pyrimethamine-a single-dose regimen-with artemether-lumefantrine (AL)-a 6-dose, 3-day regimen. Because of concerns about the complex dosing schedule, we assessed patient adherence to AL 2 years after routine implementation.
  
  
  METHODS
  Adults and children with uncomplicated malaria were recruited at 3 health centers. We conducted both pill counts and in-home interviews on medication consumption 72 hours after patients received AL. Complete adherence was defined as correctly taking all 6 AL doses, as assessed by pill count and dose recall. We used logistic regression to identify factors associated with complete adherence.
  
  
  RESULTS
  Of 386 patients, 65% were completely adherent. Patients were significantly more likely to be completely adherent if they received their first dose of AL as directly observed therapy at the health center (odds ratio [OR], 2.4; P < .01), received instructions using the medication package as a visual aid (OR, 2.5; P = .02), and preferred AL over other antimalarials (OR, 2.7; P < .001). In contrast, children <5 years of age were significantly less likely to be adherent (OR, 0.5; P = .05).
  
  
  CONCLUSIONS
  Adherence to AL treatment for uncomplicated malaria was moderate, and children, who are the most likely to die of malaria, were less adherent than adults. Efforts to improve adherence should be focused on this vulnerable group. Interventions including the introduction of child-friendly antimalarial formulations, direct observation of the first dose, use of the AL package as a visual aid for instructions, and enhancing patient preference for AL could potentially increase AL adherence and overall effectiveness.
authors.affiliation: Division of Parasitic Diseases and Malaria, Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA. kmace@cdc.gov
authors.forename: Kimberly E
authors.initials: KE
authors.lastname: Mace
authors.forename: Dyson
authors.initials: D
authors.lastname: Mwandama
authors.forename: James
authors.initials: J
authors.lastname: Jafali
authors.forename: Madalitso
authors.initials: M
authors.lastname: Luka
authors.forename: Scott J
authors.initials: SJ
authors.lastname: Filler
authors.forename: John
authors.initials: J
authors.lastname: Sande
authors.forename: Doreen
authors.initials: D
authors.lastname: Ali
authors.forename: S Patrick
authors.initials: SP
authors.lastname: Kachur
authors.forename: Don P
authors.initials: DP
authors.lastname: Mathanga
authors.forename: Jacek
authors.initials: J
authors.lastname: Skarbinski
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000962:Antimalarials / Q000008:administration & dosage*; D000077611:Artemether, Lumefantrine Drug Combination; D037621:Artemisinins / Q000008:administration & dosage*; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D004338:Drug Combinations; D004983:Ethanolamines / Q000008:administration & dosage*; D005260:Female; D005449:Fluorenes / Q000008:administration & dosage*; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D008288:Malaria / Q000188:drug therapy*; D008295:Malawi / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance / Q000706:statistics & numerical data*; D010961:Plasmodium / Q000187:drug effects*; D011739:Pyrimethamine / Q000008:administration & dosage; D012424:Rural Population; D013413:Sulfadoxine / Q000008:administration & dosage; D055815:Young Adult
chemical_list: D000962:Antimalarials; D000077611:Artemether, Lumefantrine Drug Combination; D037621:Artemisinins; D004338:Drug Combinations; D004983:Ethanolamines; D005449:Fluorenes; C001205:fanasil, pyrimethamine drug combination; D013413:Sulfadoxine; D011739:Pyrimethamine