Combination therapy for malaria in Africa: hype or hope?

The development of resistance to drugs poses one of the greatest th reals t o malaria control, In Africa, the efficacy of readily affordable antimalari al drugs is declining rapidly, while highly efficacious drugs tend to be to o expensive. Cost-effective strategies are needed to extend the useful life spans of antimalarial drugs. Observations in South-East Asia on combinatio n therapy with artemisinin derivatives and mefloquine indicate that the dev elopment of resistance to both components is slowed down. This suggests the possibility of a solution to the problem of drug resistance in Africa, whe re, however, there are major obstacles in the way of deploying combination therapy effectively. The rates of transmission are relatively high, a large proportion of asymptomatic infection occurs in semi-immune persons, the us e of drugs is frequently inappropriate and ill-informed, there is a general lack of laboratory diagnoses, and public health systems in sub-Saharan Afr ica are generally weak. Furthermore, the cost of combination therapy is com paratively high. We review combination therapy as used in South-East Asia a nd outline the problems that have to be overcome in order to adopt it succe ssfully in sub-Saharan Africa.