Abstract
BackgroundKenya 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.MethodsWe 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.ResultsBetween 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.ConclusionDuring 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.
Highlights
Conflicts, population displacement, and the economic consequences of disasters affect children disproportionately.[1]
In the two months before the presidential elections, between 26 October 2007 and 25 December 2007, 2,585 Human Immunodeficiency Virus (HIV)-infected children were seen in the 17 Academic Model Providing Access to Healthcare (AMPATH) clinics operating during that time period
Looking at the adjusted odds ratios, children who were on antiretroviral therapy (ART) were significantly more likely to return to clinic (OR = 1.42, 95%CI: 1.22–1.57)
Summary
Population displacement, and the economic consequences of disasters affect children disproportionately.[1] Children are more vulnerable to communicable diseases and environmental exposures than adults.[2,3] They have special dietary needs for growth and development, and they are generally dependent on their families.[4] Studies have shown that children under five have the highest mortality rates in conflict-affected settings.[5,6] while acute illnesses and injuries are important in humanitarian emergencies, exacerbation of underlying chronic illnesses can lead to significant morbidity and mortality.[7] When these emergencies occur in the setting of pre-existing poverty, low nutritional status, and immune-compromising diseases such as HIV, children face even greater risks.[8,9]. 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
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