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  • 1 USAID Bureau for Africa

The publication of this supplement in the American Journal of Tropical Medicine and Hygiene is a critical step in disseminating the important public health findings from a very successful trial of insecticide-treated bed nets (ITNs) in western Kenya. The decision to undertake a large-scale applied research project in western Kenya was spurred by the 1992 Ministerial Conference on Malaria, which called for a renewed international effort to reduce the burden of malaria.

In the early 1990s, it was not clear that the impressive results from trials of ITNs in areas of low or seasonal malaria transmission could be replicated in areas of high perennial transmission. This gap in the evidence hampered development of a solid strategy for promoting ITNs. The United States Agency for International Development (USAID) and other partners sought further evidence to develop plans for deployment of this key intervention. Should ITN promotion be site-specific? If ITNs were not effective in areas of high perennial malaria transmission, their promotion in these areas would be a waste of limited resources, and targeting areas of low and seasonal transmission would be the most technically and economically rational strategy.

The question of ITN efficacy in areas of high perennial malaria transmission needed an answer. A partnership of the Kenya Medical Research Institute (KEMRI), the Centers for Disease Control and Prevention (CDC), and USAID’s Bureau for Africa was formed and funded to answer this question. The community-based research infrastructure developed to examine the efficacy of ITNs provided a platform for research into other health priorities for the community, notably HIV/AIDS and the nature and consequences of malaria and HIV co-infection. As a result, the trial and its associated studies (some of which are published separately from this supplement) produced a much greater return on investment than originally expected.

The success of the western Kenya ITN trial is largely attributable to the factors listed below. Underpinning all was an obvious prerequisite, a common commitment to quality research coupled with the resources needed to conduct such research.

Capacity development.

Partner commitment to capacity development was central to the implementation of this project. Opportunities for scientific training and practical research experience were abundant, enabling many Kenyan and international students to engage in meaningful research leading to advanced degrees. Many of these young scientists are authors and co-authors of the papers contained in this supplement. In addition, and equally important, the project provided an opportunity for members of the local community to obtain skills and experience in the use of information technologies, management, logistics, social mobilization, and communications.

Community involvement.

Significant efforts were made by the research team to engage and partner with the communities involved. From the outset, the Kenyan and CDC investigators met with local leaders, communities, and families to discuss reasons and plans for the study. Through repeated visits to households in the community, the investigators and families became well known to each other. And, perhaps most importantly, when analysis of the study results was complete, the investigators presented their detailed findings to the community before discussing the results with the outside world. One of the possible benefits of all this is that daily use of ITNs in the community remains high more than two years after the end of the study.

Meaningful partnership.

The effective relationships established among the partners were also an important element of success. All of the core partners (KEMRI, CDC, USAID, and the Kenyan Ministry of Health) were engaged in the day-today work as well as the major decisions affecting the trial. In addition, the western Kenya ITN trial team engaged many other partners, notably the United States Embassy in Nairobi, The Netherlands Foundation for the Advancement of Tropical Research (WOTRO), the World Health Organization/TDR, and academic institutions in Kenya, Europe, and North America. There was constant communication among the partners, frequent face-to-face meetings in western Kenya, and briefings on progress to the partner organizations’ offices in Nairobi, Atlanta, and Washington, DC. This level of engagement paid off in extremely rapid problem solving, and continuous informed support at all levels of the partner institutions.

We have learned a great deal from the western Kenya ITN trial: both about partnership and about ITNs. The lessons in partnership have influenced USAID’s thinking on how the Roll Back Malaria partnership can best function, both for operationally relevant research and for programmatic implementation. The lessons about delivery, use, and impact of ITNs that are described in detail in this supplement have informed the Roll Back Malaria partnership and strengthened USAID’s commitment to the Roll Back Malaria strategic framework for scaling up insecticide-treated netting programs in Africa.