This systematic review and spatiotemporal modelling study mapped the prevalence of *P. falciparum* kelch13 (k13) artemisinin partial resistance (ART-R) mutations — plus mdr1 N86Y and crt K76T partner-drug resistance markers — across 47 African countries from 2012 to 2024, using 185,099 samples from 578 studies and 3,848 distinct surveys.
By 2024, k13 ART-R mutations had formed entrenched regional hot spots across most of Uganda and Rwanda (Northern Province Rwanda peak: 62.2% prevalence, up from 0.2% in 2012, +5.2 percentage points/year) and at the Ethiopia–Eritrea–Sudan border; distinct emergences of R561H (Rwanda), A675V and C469Y (Uganda), and R622I (Ethiopia/Eritrea) were identified. mdr1 N86Y prevalence is declining, but crt K76T remains prevalent in the Horn of Africa.
Sparse and uneven surveillance across Africa limits model precision in many regions (wide credible intervals, e.g., 3.9–98.6% in Rwanda). The analysis is restricted to English-language studies, potentially missing relevant data. Eleven unpublished datasets were privately held, introducing potential selection bias.
Clinicians and public health programs in East Africa — especially Rwanda, Uganda, and the Ethiopia–Eritrea border zone — should treat artemisinin partial resistance as entrenched, not emerging, and prioritise therapeutic efficacy studies and ACT regimen review in these hot spots. Co-occurrence of k13 mutations with crt K76T in the Horn of Africa signals a particular risk to all current ACT partner-drug combinations.
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