1907. Barriers at the Last Hurdle: Implementing Advance Care Planning for People Living with HIV

Abstract

Background. Advance care planning (ACP) is an increasingly relevant clinical practice as the HIV epidemic ages. In addition to a "graying" cohort of stable people living with HIV (PLHIV), late presentations predominate among newly-diagnosed older people in Singapore. Despite the availability of antiretroviral therapy (ART), prognosis remains guarded in these late presenters and PLHIV with poor adherence for whom ACP is more urgently needed. We sought to evaluate ACP implementation using a cascade-of-care model and determine barriers to its completion among PLHIV receiving care in an HIV specialty clinic. Methods. Eligible PLHIV were identified during multidisciplinary meetings of the National University Hospital's HIV care team from January 2016 to December 2017. Eligibility was based on any of the following: age >=55; current CD4 <200; ART nonadherence; or comorbidities potentially contributing to reduced life expectancy. ACP was offered to eligible PLHIV by their primary HIV doctor. If accepted, trained ACP facilitators continued the process of communication between PLHIV, doctors and loved ones. The process was completed with documentation of an agreed plan for future medical decisions, incorporating patient's personal beliefs and goals, and with a nominated healthcare spokesperson. Results. Among 432 PLHIV screened, 127 (29.4%) were eligible for ACP. Of these, 70 (55.1%) were offered, 47 (37.0%) accepted, and 12 (9.4%) completed ACP. Majority (38, 80.9%) who accepted ACP were >=55 years old. Most were male (43, 91.4%) and of Chinese ethnicity (72%). We found no significant differences between those who were offered, accepted and completed ACP. Barriers were examined via root cause analysis. Social stigma surrounding death (cultural beliefs) and HIV (isolation, fear of disclosure, lack of a potential spokesperson) were the major patient-centered barriers to ACP. Time constraint was the main healthcare provider-centered factor. Conclusion. Fewer than 10% of eligible PLHIV completed ACP. Interventions to address barriers along the cascade are urgently needed to ensure that the increased life expectancy of PLHIV translates into increased opportunities for ACP. All healthcare providers should dedicate time, address stigma and correct misconceptions by incorporating ACP discussions into the routine care of PLHIV. (Figure Presented).