Abstract:
Background: Kenya experienced a political and humanitarian crisis following presidential elections on 27
December 2007. Over 1,200 people were killed and 300,000 displaced, with disproportionate violence in
western Kenya. We sought to describe the immediate impact of this conflict on return to clinic and
medication adherence for HIV-infected children cared for within the USAID-Academic Model Providing
Access to Healthcare (AMPATH) in western Kenya.
Methods: We conducted a mixed methods analysis that included a retrospective cohort analysis, as well
as key informant interviews with pediatric healthcare providers. Eligible patients were HIV-infected
children, less than 14 years of age, seen in the AMPATH HIV clinic system between 26 October 2007 and
25 December 2007. We extracted demographic and clinical data, generating descriptive statistics for pre-
and post-conflict antiretroviral therapy (ART) adherence and post-election return to clinic for this cohort.
ART adherence was derived from caregiver-report of taking all ART doses in past 7 days. We used
multivariable logistic regression to assess factors associated with not returning to clinic. Interview dialogue
from was analyzed using constant comparison, progressive coding and triangulation.
Results: Between 26 October 2007 and 25 December 2007, 2,585 HIV-infected children (including 1,642
on ART) were seen. During 26 December 2007 to 15 April 2008, 93% (N = 2,398) returned to care. At
their first visit after the election, 95% of children on ART (N = 1,408) reported perfect ART adherence,
a significant drop from 98% pre-election (p < 0.001). Children on ART were significantly more likely to
return to clinic than those not on ART. Members of tribes targeted by violence and members of minority
tribes were less likely to return. In qualitative analysis of 9 key informant interviews, prominent barriers
to return to clinic and adherence included concerns for personal safety, shortages of resources, hanging
priorities, and hopelessness.
Conclusion: During a period of humanitarian crisis, the vulnerable, HIV-infected pediatric population had
disruptions in clinical care and in medication adherence, putting children at risk for viral resistance and
increased morbidity. However, unique program strengths may have minimized these disruptions.
