With the coronavirus disease 2019 (COVID-19) pandemic in the United States, a majority of states have instituted “shelter-in-place” policies effectively quarantining individuals—including pregnant persons—in their homes. Given the concern for COVID-19 acquisition in health care settings, pregnant persons with high-risk pregnancies—such as persons living with HIV (PLHIV)—are increasingly investigating the option of a home birth. Although we strongly recommend hospital birth for PLHIV, we discuss our experience and recommendations for counseling and preparation of pregnant PLHIV who may be considering home birth or at risk for unintentional home birth due to the pandemic. We also discuss issues associated with implementing a risk mitigation strategy involving high-risk births occurring at home during a pandemic. Key Points

Background The most recent iteration of the Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations includes language mandating handoff education for trainees and assessments of handoff quality by residency training programs. However, there are a lack of validated tools for the assessment of handoff quality and to utilize for trainee education. Methods Faculty at two sites (University of Chicago and Yale) were recruited to participate in a workshop on handoff education. Video-based scenarios were developed to represent varying levels of performance in the domains of communication, professionalism and setting. Videos were shown in a random order and faculty were instructed to use the Handoff mini-CEX, a paper-based instrument with qualitative anchors defining each level of performance, to rate the handoffs. Results Forty-seven faculty members (14=site 1; 33=site 2) participated in the validation workshops providing a total of 172 observations (of a possible 191 (96%)). Reliability testing revealed a Cronbach’s alpha of 0.81 and Kendall’s coefficient of concordance of 0.59 (>0.6=high reliability). Faculty were able to reliably distinguish the different levels of performance in each domain in a statistically significant fashion (i.e. unsatisfactory professionalism mean 2.42 vs. satisfactory professionalism 4.81 vs. superior professionalism 6.01, p<0.001 trend test). Two-way ANOVA revealed no evidence of rater bias. Conclusions Using standardized video-based scenarios highlighting differing levels of performance, we were able to demonstrate evidence that the Handoff mini-CEX can draw reliable and valid conclusions regarding handoff performance. Future work to validate the tool in clinical settings is warranted.

Objective: The Illinois Perinatal HIV Prevention Act was passed to ensure universal HIV testing once during pregnancy and was extended in 2018 to add third trimester repeat HIV screening. The objectives of this analysis were to describe uptake of, and patient factors associated with, third trimester repeat HIV testing at a high-volume birthing center. Study Design: This is a retrospective cohort study of people who delivered at a single tertiary care hospital in Illinois during 2018. Women who delivered before 27 weeks, had an intrauterine fetal demise, a known diagnosis of HIV, or no HIV test during pregnancy were excluded. Repeat testing was defined as an HIV test at or after 27 weeks’ gestation after an earlier negative HIV test during the same pregnancy. The primary outcome was the proportion of people who received repeat testing prior to delivery. Bivariable analyses were performed to identify patient characteristics associated with documentation of repeat HIV testing. Results: Of 12,053 people eligible for inclusion, 3.4% (N=414) presented without a documented third trimester repeat HIV test. The proportion of people with repeat testing improved from 80% to >99% in the first year. Patient factors were largely not associated with testing performance although multiparous people were more likely to have documented repeat testing. Conclusion: Rapid implementation of third trimester repeat HIV testing was achieved without disparity. Patient factors were largely not associated with testing performance, which reinforces the goal of a universal screen: to test all people equitably and effectively without bias.

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