Truth is relative; Client report versus provider report, a post-modern analysis of data from a trial in the private...

In malaria-endemic countries, private retail outlets are a major source of antimalarials for individuals experiencing an acute febrile illness. However, there remains a challenge in how the decision to dispense the drugs is made. The lack of malaria diagnostic tools in the retail sector leads to a presumptive approach to diagnosis and overuse of ACTs. The TESTsmART study trained retail outlet attendants to perform malaria rapid diagnostic tests (mRDTs) in conjunction with a mobile application to capture testing and drug dispensing data. Concurrently, febrile clients were randomly selected for exit interviews outside the outlet, and analogous information about testing and drug purchasing was recorded based on self-report. A small subset of clients enrolled in exit interviews were also asked to participate in exit Plasmodium falciparum mRDT testing to confirm the accuracy of mRDTs in the outlet and to estimate malaria positivity amongst untested clients. In this sub-study, comparison of these two concurrent data sources showed the testing rate for eligible participants was slightly lower in the exit interview (42.8%, 2436/5695) than in the app (51.1%, 24,446/49,804). We noted important differences in the experiences of testing and adherence reported by outlets compared to clients; 11.0% of clients had positive mRDT reported in the app (and validated by photo review) compared to 35.3% from exit interviews. Outlets reported that 97% of test-positive clients received a first-line Artemether Combination Therapy (ACT), but only 77% of clients who reported a positive test also reported receiving the first-line ACT in the exit interview. For test-negative clients, 35% received an ACT based on outlet reports compared to 25% by exit interviews. Among 109 clients randomly selected for re-test at exit interview, nearly two-thirds of those who reported a positive test from the outlet had a negative mRDT (64.3%, 9/14) when retested. Contrasting outcomes reported by the provider and the client highlight barriers to improving testing and adherence for malaria as well as challenges for monitoring case management in the retail sector. These include accurate communication of results to the client, poor confidence in a negative result, and reluctance to withhold antimalarials from test-negative clients.