1. The impact of the Kenya post-election crisis on clinic attendance and medication adherence for HIV-infected children in western Kenya R. Vreeman, W. Nyandiko, S. Ayaya, P. Gisore, C. Tenge, B. Musick, E. Sang, E. Dufort, K. Wooks-Kaloustian, P. Braitstein, S. Bucher, J. Dickerson-Putman, L. Atwoli, S. Wiehe

2. Post-election conflict impact on pediatric adherence Background Currently follows over 55,000 patients at 18 clinic locations throughout western Kenya 11,000 children USAID – Academic Model for the Prevention and Treatment of HIV/AIDS (AMPATH) partnership

3. Post-election conflict impact on pediatric adherence Background Kenya experienced political and humanitarian crises following contested presidential elections on 27 December 2007 800-1,500 people killed Over 300,000 people displaced Western Kenya and Rift Valley experienced disproportionate violence and displacement

4. Post-election conflict impact on pediatric adherence

5. Objectives To describe disruptions in clinical care in the post-conflict period for HIV-infected children cared for within AMPATH To describe medication adherence in the pre- and post-conflict period for HIV-infected children on ART through AMPATH

6. Post-election conflict impact on pediatric adherence Methods Retrospective analysis of prospectively collected data from computerized medical records Population: HIV-infected Younger than 14 Seen in any of 17 AMPATH clinics between 26 October 2007 and 25 December 2007

7. Post-election conflict impact on pediatric adherence Methods 2007 2008 October November December January February MarchApril Election: 27 Dec 2007 Pre-ConflictPost-Conflict 26 Oct15 April Power-Sharing Agreement: 28 Feb 2008

8. Post-election conflict impact on pediatric adherence Methods Outcome Variables Disruption in return to clinical care (No Return) Antiretroviral therapy (ART) adherence No Return: No AMPATH clinic visit in time period from 26 December 2007 to 15 April 2008 ART perfect adherence: Caregiver- or self- report of taking all ART doses in past 7 days

9. Post-election conflict impact on pediatric adherence Analysis Descriptive statistics for cohort pre- and post- conflict Multivariable logistic regression analyses using robust standard errors to assess factors associated with not returning to clinic (No Return) Compared medication adherence rates using paired t-tests

10. Results Pre-conflict (26 Oct-25 Dec 2007) Post-election conflict impact on pediatric adherence

11. Pre-conflict (26 Oct-25 Dec 2007) Results Post-election conflict impact on pediatric adherence Post-conflict (26 Dec 2007- 15 April 2008)

12. Visit During 26 Oct-25 Dec 2006 Comparison Group from 2006 Post-election conflict impact on pediatric adherence Return Visit During 26 Dec 2006- 15 April 2007

13. Post-election conflict impact on pediatric adherence Individual Characteristics of Children Based on Return No Return (N=187) Returned to Clinic (N=2,398) Male 84 (45%)1,198 (50%) On ART* 84 (45%)1,558 (65%) Orphan 60 (33%)880 (37%) Age* Median 4.7 yrs Mean 5.0 yrs Median 5.9 yrs Mean 6.0 yrs *p<.01

14. Tribe Affiliation for No Return vs. Returned Post-election conflict impact on pediatric adherence 13% 15% 14% 25% 12% 18% 87% 85% 86% 75% 88% 82%

15. Post-election conflict impact on pediatric adherence Adjusted Odds of No Return by Patient Characteristics

16. Post-election conflict impact on pediatric adherence Adjusted odds of No Return, including tribe majority

17. Post-election conflict impact on pediatric adherence Decreased ART Adherence Post-Conflict Last visit pre-conflict: 98% (N=1,490) reported perfect adherence 3% data missing

18. Post-election conflict impact on pediatric adherence Decreased ART Adherence Post-Conflict Last visit pre-conflict: 98% (N=1,490) reported perfect adherence 3% data missing First visit post-conflict: 95% (N=1,408) reported perfect adherence –10% data missing

19. Post-election conflict impact on pediatric adherence Decreased ART Adherence Post-Conflict Last visit pre-conflict: 98% (N=1,490) reported perfect adherence 3% data missing First visit post-conflict: 95% (N=1,408) reported perfect adherence –10% data missing Significantly fewer children reported perfect ART adherence post-conflict (p<0.001)

20. Post-election conflict impact on pediatric adherence Conclusions During widespread violence and displacement, this vulnerable, HIV-infected population experienced disruption of clinical care and decreased ART adherence HIV-infected children at risk for viral resistance and increased morbidity after humanitarian crises Those on ART more likely to return to care, possibly reflecting understanding of importance of ART adherence Targeted and minority ethnic groups at highest risk

21. Post-election conflict impact on pediatric adherence Conclusions Immediate, multi-faceted AMPATH response, with provision of comprehensive services to address medical, nutritional, and psychosocial needs, may have decreased disruptions in clinical care Plans to minimize disruption of HIV care services during humanitarian crises important target for existing programs and for relief agencies

22. Acknowledgements Indiana University School of Medicine Moi University School of Medicine Moi Teaching and Referral Hospital This research was supported in part by a grant to the USAID-AMPATH Partnership from the United States Agency for International Development as part of the President’s Emergency Plan for AIDS Relief (PEPFAR). Moi Teaching and Referral Hospital

23. No Return by Clinic Locations Pediatric ART Adherence in Low- and Middle-Income Countries

24. Tribe Distribution at Clinics with Highest No Return Iten (12% No Return) Mt. Elgon (10% No Return) Naitiri (10% No Return) Mosoriot (10% No Return) MTRH (6% No Return) Chulaimbo (6% No Return)

25. Tribe Affiliation for No Return vs. Returned Post-election conflict impact on pediatric adherence

26. Age Distribution for No Return vs. Returned Post-election conflict impact on pediatric adherence

27. Decreased ART Adherence Post-Conflict Excluding those missing data: Pre-crisis perfect adherence: 98% Post-crisis perfect adherence: 94% Significantly fewer had perfect ART adherence post-conflict (p<0.001)

28. Post-election conflict impact on pediatric adherence