title: Spatial heterogeneity can undermine the effectiveness of country-wide test and treat policy for malaria: a case study from Burkina Faso.
abstract: BACKGROUND
  Considerable debate has arisen regarding the appropriateness of the test and treat malaria policy broadly recommended by the World Health Organization. While presumptive treatment has important drawbacks, the effectiveness of the test and treat policy can vary considerably across regions, depending on several factors such as baseline malaria prevalence and rapid diagnostic test (RDT) performance.
  
  
  METHODS
  To compare presumptive treatment with test and treat, generalized linear mixed effects models were fitted to data from 6510 children under five years of age from Burkina Faso's 2010 Demographic and Health Survey.
  
  
  RESULTS
  The statistical model results revealed substantial regional variation in baseline malaria prevalence (i.e., pre-test prevalence) and RDT performance. As a result, a child with a positive RDT result in one region can have the same malaria infection probability as a demographically similar child with a negative RDT result in another region. These findings indicate that a test and treat policy might be reasonable in some settings, but may be undermined in others due to the high proportion of false negatives.
  
  
  CONCLUSIONS
  High spatial variability can substantially reduce the effectiveness of a national level test and treat malaria policy. In these cases, region-specific guidelines for malaria diagnosis and treatment may need to be formulated. Based on the statistical model results, proof-of-concept, web-based tools were created that can aid in the development of these region-specific guidelines and may improve current malaria-related policy in Burkina Faso.
authors.affiliation: School of Forest Resources and Conservation, University of Florida, 136 Newins-Ziegler Hall, Gainesville, FL, 32611, USA. drvalle@ufl.edu.
authors.forename: Denis
authors.identifier: http://orcid.org/0000-0002-9830-8876
authors.initials: D
authors.lastname: Valle
authors.affiliation: School of Forest Resources and Conservation, University of Florida, 136 Newins-Ziegler Hall, Gainesville, FL, 32611, USA.
authors.forename: Justin
authors.initials: J
authors.lastname: Millar
authors.affiliation: School of Forest Resources and Conservation, University of Florida, 136 Newins-Ziegler Hall, Gainesville, FL, 32611, USA.
authors.forename: Punam
authors.initials: P
authors.lastname: Amratia
mesh_terms: D000962:Antimalarials / Q000627:therapeutic use*; D002050:Burkina Faso / Q000453:epidemiology; D002675:Child, Preschool; D003955:Diagnostic Tests, Routine / Q000379:methods*; D005260:Female; D006801:Humans; D007223:Infant; D008288:Malaria / Q000175:diagnosis* / Q000188:drug therapy*; D008297:Male; D015233:Models, Statistical; D015995:Prevalence; D014944:World Health Organization
chemical_list: D000962:Antimalarials
keywords: Malaria diagnostics; Microscopy; Presumptive treatment; RDT; Spatial heterogeneity; Test and treat