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Long-term effects of increased adoption of artemisinin combination therapies in Burkina Faso

Artemisinin combination therapies (ACTs) are the WHO-recommended first-line therapies for uncomplicated Plasmodium falciparum malaria. The emergence and spread of artemisinin-resistant genotypes is a major global public health concern. To explore how the increased adoption of ACTs may affect the high-burden high-impact malaria setting of Burkina Faso, we added spatial structure to a validated individual-based stochastic model of P. falciparum transmission and evaluated long-term effects of increased ACT use. We explored how de novo emergence of artemisinin-resistant genotypes may occur under scenarios in which private-market drugs are eliminated or multiple first-line therapies (MFT) are deployed. We found that elimination of private market drugs would reduce the long-run treatment failures. An MFT policy with equal deployment of artemether-lumefantrine (AL) and dihydroartemisinin-piperaquine (DHA-PPQ) may accelerate near-term drug resistance and treatment failure rates, due to early failure and substantially reduced treatment efficacy resulting from piperaquine-resistant genotypes. A rebalanced MFT approach (90% AL, 10% DHA-PPQ) results in better long-term outcomes than using AL alone but may be difficult to implement in practice.