LAUSR

The introduction of effective antiretroviral therapy (ART) led to substantially improved survival in people living with HIV (PLHIV), through reduction in AIDSrelated complications. This has resulted in an ageing population of PLHIV, with 46% of the estimated 25 000 PLHIV in Australia aged over 50 years. PLHIV are at increased risk of age-related non-communicable diseases. With shifting demographics and increasingly complex comorbidities in PLHIV, medical practitioners must adjust to the evolving needs of PLHIV for support with advance care planning (ACP). ACP is a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care to help ensure that people receive care consistent with these values and preferences during serious and chronic illness. ACP improves end of life care, patient and family satisfaction, and reduces stress, anxiety and depression in surviving relatives. There are limited studies on ACP in PLHIV and international HIV guidelines are yet to provide guidance on this important issue. Alfred Health is the Victorian state-wide service for HIV care, and manages approximately 1000 PLHIV annually. It became apparent that very few PLHIV admitted to Alfred Health’s HIV subacute facility for management of complex medical and psychosocial issues had ACP in place. To address this deficit, a pilot ACP educational intervention for healthcare workers (HCW) (medical, nursing and allied health) comprising tutorials, and written information was undertaken over a 2-month period in 2017. A questionnaire evaluating HCW understanding of the principles and practice of ACP was completed before and after this intervention. An audit of ACP prevalence in PLHIV admitted to the subacute inpatient service was also performed, covering a 6-month period before and after the educational intervention (Table 1). Questionnaires were completed by 31 HCW before the intervention and 18 afterward. The majority of HCW stated that knowledge about ACP was important for their role (94% preand post-intervention, respectively). ACP knowledge improved after the educational intervention (71% self-assessing their knowledge as good or average prior to the intervention and 95% afterwards; 67% of respondents felt their knowledge improved after the intervention). Respondents’ confidence in discussing ACP with patients improved from 26% prior to and 67% after the intervention respectively. Barriers to completing ACP with PLHIV cited by HCW included having a new relationship with the patient (50%) and limited time (39%). Although there was increased knowledge and comfort discussing ACP, this did not translate into significantly greater numbers of PLHIV admitted with ACP in place. The results of this audit are consistent with a recent review of ACP in PLHIV which reported a low prevalence of advance care directives (8–47%); three studies assessed physician barriers to ACP reported by physicians, citing major barriers as limited time, energy and preparation. The reduced response rate to the post-intervention survey is likely due to staff rotation post-intervention, reflecting the high turnover of medical staff in inpatient medicine. Our sample size was too small for any statistical analysis. This pragmatic pilot study demonstrated that an educational intervention can improve self-reported knowledge of ACP in HCW. It also demonstrated key limitations to instituting ACP during hospital admissions, including high turnover of HCW and limited pre-existing relationships with patients. Primary care and specialist outpatient settings are likely to involve a more consistent group of HCW with longer term relationships with PLHIV and should be the primary target for future ACP educational interventions, which ideally will involve repeated education intervention and audit cycles to determine the impact on clinical practice. More research is needed to assess the translation of HCW knowledge into patient outcomes and create ACP guidelines for HCW managing PLHIV. Table 1 Audit of subacute inpatient admissions of PLHIV before and after an advance care planning educational intervention