Artemisinin-based combination therapies in Africa: efficacy, adherence, and future directions

Abstract

Artemisinin-based combination therapies (ACTs) have become the cornerstone of malaria treatment across Africa, substantially reducing morbidity and mortality caused by Plasmodium falciparum . Their combination of a fast-acting artemisinin derivative with a longer-acting partner drug ensures rapid parasite clearance and sustained therapeutic effects, which have contributed to significant declines in malaria burden over the past two decades. Despite their proven efficacy, maintaining the effectiveness of ACTs requires addressing various implementation challenges specific to African settings. One of the primary barriers to optimal ACT effectiveness is patient adherence. Factors such as complex dosing regimens, side effects, limited access to medication, and sociocultural beliefs often result in incomplete treatment courses. Poor adherence not only jeopardizes individual treatment outcomes but also facilitates the emergence and spread of drug-resistant parasites. Additionally, the recent emergence of artemisinin resistance in Southeast Asia raises concerns about potential threats to African malaria control programs, necessitating vigilant surveillance and adaptive treatment policies. This review explores the current evidence on ACT efficacy in Africa, highlights challenges related to treatment adherence, and examines the threat posed by drug resistance. It also discusses future directions, including the development of novel therapies, improved diagnostic tools, and community-based adherence interventions, which are critical for sustaining ACT effectiveness and advancing toward malaria elimination on the continent.