During a period of widespread violence and displacement of people in western Kenya, some vulnerable, HIV-infected children experienced a breech in clinical care and ART adherence. However, these disruptions were less than had been expected given the intensity of the crisis in the region. While the disruptions in return to clinic and ART provide evidence that HIV-infected children may be at risk for viral resistance, opportunistic infections, and decreased nutrition after humanitarian crises, they also suggest that a comprehensive, responsive HIV care system can mitigate and minimize these disruptions. Children on ART were more likely to return to clinic, possibly reflecting an understanding of the importance of ART adherence. This may highlight the strength of adherence education and support efforts within the AMPATH pediatric clinics. Much of the violence and forcible displacement were reported to occur along lines of tribal affiliation, and, in our clinical data, targeted minority ethnic groups were at highest risk of not returning to clinic.
Although HIV-infected children in western Kenya did face disruptions in clinical care and medication adherence after the presidential elections, the rates of clinical care disruption were lower than what might be expected for a resource-limited setting facing conflict and population displacement. Although outside the scope of this analysis to conclude, it is possible the immediate, multi-faceted AMPATH response to the conflict period decreased the disruptions in clinical care. The AMPATH response was built on an infrastructure of clinics, [18–20] food and medical distribution services, networks of community health workers, and a comprehensive electronic medical record system. The unified attitude and commitment of AMPATH personnel to provide care for all patients were also cited by healthcare providers as key factors enabling an effective response. The combination of existing infrastructure, cohesive and positive staff attitudes, and responsive efforts to find and care for patients may have improved continuity of clinical care and ART.
This study has several limitations that merit consideration. First, while the 3% drop in reported ART adherence was a statistically significant difference, it is difficult to know the clinical significance in a setting where viral loads and resistance testing are not routine. The AMPATH pediatric population generally reports very high levels adherence, particularly when monitored over a short period of time. Thus, even a relatively small drop in ART adherence may have clinical significance when contrasted to the very high rates of adherence routinely reported. Furthermore, this was a very conservative measure of nonadherence that may have missed early episodes of nonadherence prior to the patient's return to clinic. Second, even with relatively high estimates of return to clinic and medication adherence, the data likely underestimate the extent to which patients received clinical care. In the first weeks after the election, many of the patients who made it to a clinic were given medication refills for themselves and even their entire families without any record-keeping. Paper encounter forms may not have been filled out, or data entry may have been incomplete. The increase in missing data in the post-election period may reflect both staff shortages and shifting care priorities in the clinic system during the crisis period. Some patients also had an excess drug supply over the holiday season. Moreover, data from visits done by AMPATH teams in the camps or other impromptu sites, as well as data from unaffiliated HIV programs are not included. However, our analyses do include a long follow-up period that would likely extend beyond the first visits and the extra medication supplies. Furthermore, since few other clinical sites in western Kenya provide free ART, the other options for patients to obtain medications were somewhat limited. AMPATH has ongoing initiatives to find patients lost to follow-up from the clinic system. These data were also limited to the information populated in the pediatric electronic medical record. Thus, we could not assess additional, potentially important variables if they were not collected on the routine clinical encounter forms, such as displacement from homes. Assessing these additional contextual factors affecting children remains an important target for the AMPATH clinical system. The key informant interviews provided information about the crisis impact from the perspective of the healthcare providers, but not necessarily from the perspective of families and children. In-depth exploration of the longer-term psychological and social impact of the election conflict on individual children is still needed and is ongoing within the AMPATH clinical care system. Still, this qualitative analysis does provide insight into the factors impacting medication adherence and return to clinical care from the personnel who were the care system's first responders during the time of crisis and thus reflects the immediate experiences within the care system. Finally, both the quantitative and qualitative data rely on the experiences of subjects in a very particular part of the world and in a unique political situation, limiting the generalizability of the results. AMPATH is considered a model of care in under-resourced settings,[19, 31] so return to clinic and ART adherence may be much more impacted in care systems that do not provide similar comprehensive, responsive services. Furthermore, the barriers to return to clinic and adherence are consistent with those identified in research from other conflict settings. Because only limited data are available to describe the impact of crises and conflicts on pediatric HIV care, these data from Kenya provide an important addition to understanding how HIV care systems and humanitarian aid organizations can meet the needs of HIV-infected children in future crises.