Radical Cure (RC) With Tafenoquine or Primaquine After Semi-quantitative G6PD Testing: A Feasibility Study in Peru

The goal of this study is to evaluate the operational feasibility of using a new treatment algorithm for Malaria Vivax in Peru.

The implementation package includes the following interventions:

* A revised vivax treatment algorithm that incorporates new Radical Cure tools (G6PD test + Tafenoquine or Primaquine)
* The training of Health Care Providers ( HCPs) in the revised algorithm and the use of the new RC tools
* Patient counselling
* A follow-up visit at Day 3 \[+2 days\] for patients after treatment start
* Accompanying supporting measures: job aids, strengthening of supervision and PV processes

The goal of this study is to evaluate the operational feasibility of providing Tafenoquine and Primaquine after semi-quantitative G6PD testing at different levels of the health services, in order to inform potential policy change, malaria strategy, and introduction planning.

This implementation research study will be carried out in Peru among 40 Health Care Providers ( HCPs) each treating a minimum of 15 patients with P. vivax malaria. The study will be conducted in Loreto Region (Loreto, Maynas and Ramon Castilla provinces), an area which is endemic for P. vivax.

A total of 30 health facilities will be included: 6 in the first phase and 12 will be added in the second phase. An additional 12 health facilities have been selected as backup in case the malaria case load is low, and this is needed in order to meet the sample size.

All relevant HCP working in study facilities will be trained on the relevant aspects of performing the G6PD testing, interpreting its result, evaluating patient's eligibility for Radical Cure and choosing the appropriate treatment as per their role accordingly.

HCP knowledge and skills regarding semi-quantitative G6PD testing and RC treatment will be assessed through standardized competency assessment (including self-assessments).

Adherence to the revised algorithm will be evaluated as follows. At each HF included in the study, the ideal patient case management cascade will be defined a priori. Individual HCP adherence to each step of the case management will be assessed against this cascade. By indexing each step in the patient care cascade to a specific HCP, the study will be able to consider feasibility at multiple levels, analysing adherence to specific steps of the case management algorithm.

A specific process will be put in place for patient counselling and standard tools such as a counselling checklist will be developed to assist HCPs. In addition, patient materials will be developed which will give explanations on the new Radical Cure tools, emphasize the need to come for a follow-up visit and outline the potential side effects that can be elicited by 8-AQ. Patients will be instructed to come back or call the facilities in case they experience those events.

The study will be carried out in following phases:

1. A formative research and baseline phase ( approx. 3 months) : this phase is meant to collect baseline information from the selected study facilities prior to introduction of the implementation package. This phase will also be important to field-test and validate study tools, such as the training material and documents and data collection tools (e.g. qualitative research questionnaires and interview guides). Finally, during this formative research phase, the supervision processes and tools will be revised.
2. A higher-level facilities phase ( approx. 8 months) : in this phase the implementation package will only be rolled out in selected higher-level facilities.

   An interim analysis will be conducted prior to rolling out the implementation package to lower-level facilities. The data cut-off point for this interim analysis will be once 50 patients have been treated with the revised algorithm. During this interim analysis, enrolment in Higher-level HF will continue.
3. An All-level facilities phase ( approx.14 months) : in this phase the implementation package will be rolled out to the lower-level facilities.

Final analysis will be performed at study end and results will be shared with the Peru National Malaria Control Program (NMCP) to make informed decisions on revisions to national malaria treatment policies.

The study aims to achieve the following specific objectives:

1. Assess HCP adherence to a revised case management algorithm for vivax malaria that involves providing RC treatment after semi-quantitative G6PD testing and a follow-up visit. This will be assessed at the provider, patient, and health facility (HF) level.
2. Determine the ability of HCP to safely implement RC treatment after semi-quantitative G6PD testing
3. Evaluate the quality and effectiveness of training and supervision strategies to support the implementation of semi-quantitative G6PD testing before RC treatment
4. Explore barriers and facilitators at the patient, provider, and facility level that mediate effective use of RC treatment with semi-quantitative G6PD testing. 5. Determine the costs associated with introducing semi-quantitative G6PD testing before RC treatment as part of routine care

Eligibility Criteria:
Inclusion Criteria Health Care Providers:

• All HCPs working in the selected facilities who are involved in the management of vivax patients.

Inclusion criteria patients:

* All patients aged 6 months onward, who have a confirmed P. vivax infection and who are treated in a study Health Facilities
* Pregnant and lactating women, who have a contra-indication to both Primaquine and Tafenoquine, but for whom correct case management will be evaluated as part of the primary endpoints.
* Patients providing informed consent and/or informed assent

Exclusion criteria patients:

• Patients with signs of severe infection