BACKGROUND
In resource-poor settings, treatment adherence is a major determinant of response to anti-malarial drugs as most are taken at home without medical supervision. Evidence on adherence to artemisinin-based combination therapy (ACT) is limited. The study aimed to measure adherence and identify reasons for non-adherence to a 3-day, fixed-dose combination (FDC) of artesunate-amodiaquine (ASAQ), the first-line treatment for uncomplicated malaria in the Médecins Sans Frontières project in the Shabunda Health Zone, South Kivu, Democratic Republic of Congo, a highly malarious and conflict-affected area.

METHODS
The study took place in the health centres/outpatient departments of the Shabunda general hospital, the quarter Mbangayo, and participant households. Patients prescribed FDC ASAQ were visited at home on the day after their regimen finished and asked to complete an adherence questionnaire. Patients/caretakers were also interviewed when exiting the outpatient department to understand their attitude towards FDC ASAQ and assess the quality of the prescribing process.

RESULTS
148 patients/caretakers completed the adherence questionnaire: 11.5 % (17/148, 95 % CI 7-17) had ≥1 tablet left at the time of the home visit and were defined as certainly non-adherent; 13.5 % (20/148, 95 % CI 8-19) were probably non-adherent; thus total non-adherence was 25.0 % (37/148, 95 % CI 18-32). 75 % (111/148, 95 % CI 68-82) were defined as probably adherent. In exit interviews, 87.5 % (105/120) knew they had malaria or could name the correct signs/symptoms. 89 % (107/120) could identify FDC ASAQ as anti-malarials among all tablets given and correctly repeat the intake instructions given at the outpatient department.

CONCLUSIONS
This is the first study to assess adherence to an FDC of ACT under real treatment conditions in a context of high instability. High quality prescribing of anti-malarials at health centre level and patient adherence to the correct intake of ACT were possible in this setting. Adherence to treatment regimen requires careful and constant monitoring which might be better guaranteed at health centre rather than community level. It could, nevertheless, be a precondition to the successful introduction of home- or community based management of malaria.

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High adherence to malaria treatment: promising results of an adherence study in South Kivu, Democratic Republic of the Congo