title: Impact of the Kenya post-election crisis on clinic attendance and medication adherence for HIV-infected children in western Kenya.
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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA. rvreeman@iupui.edu
authors.forename: Rachel C
authors.initials: RC
authors.lastname: Vreeman
authors.forename: Winstone M
authors.initials: WM
authors.lastname: Nyandiko
authors.forename: Edwin
authors.initials: E
authors.lastname: Sang
authors.forename: Beverly S
authors.initials: BS
authors.lastname: Musick
authors.forename: Paula
authors.initials: P
authors.lastname: Braitstein
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Wiehe