Howard University Capitol Region Telehealth Project
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CCCoP Case Studies

Expand Your Skills

A unique feature of the HU-CCCoP Program is the inclusion of case-based studies in every webinar to enhance the learning experience of clinicians.  Each case study is carefully designed to incorporate the social, cultural and clinical realities that are relevant to the Caribbean context.

Case studies actively engage webinar participants in problem solving and clinical decision making; and help them to apply the knowledge gained through discussion in their own clinical practice.

Clinicians are invited to use the following collection of case studies from HU-CCCoP’s archived webinars as training tools. They serve as excellent resources for teaching medical or nursing students or conducting professional development seminars for clinical staff. 

The following case studies are selected from the HIV-HCV CCCoP collection of archived webinars and focus on scenarios related to clinical considerations when prescribing PrEP (Pre-Exposure Prophylaxis) to patients at risk for HIV infection. To view the archived webinar, click on the link below each topic area. 

Table of Contents


Prescribing Pre-Exposure Prophylaxis (PrEP) for HIV Prevention (July 25, 2019)

Access the corresponding webinar here.

Case Study

Case Study 1

Bobby, a 26-year-old policeman, lives on one island but works on another for three weeks out of every month. He was referred to your STI clinic. Bobby reports having 2 to 3 male sexual partners per month. He engages in oral as well as anal sex and is inconsistent where condom use is concerned. Physical examination is unremarkable, and he has had no chronic medical problems. He reports no prior sexually transmitted infections and, as a matter of fact, three weeks ago his STI testing, including HIV, was negative.

Questions a clinician may want to consider when treating this patient:

Case Study

Case Study 2

Marcus, a 20-year-old male, comes to your primary care clinic today for a follow-up visit and HIV testing. Cherry, his female partner of two months, disclosed her status to Marcus by revealing that she was seen three months ago in the emergency department for fever, chills and a throbbing headache. She thought she had the flu but was diagnosed with acute HIV infection instead. Your medical records for Marcus noted that his last HIV test was two months ago. The result was negative. Marcus confides that he is in love with Cherry and plans to continue the relationship. Although they are not currently sexually active, Marcus revealed to you that he does not use condoms consistently as he finds them to be uncomfortable. The purpose of Marcus’s visit with you today is to discuss how to safeguard his health and not acquire HIV.

Questions a clinician may want to consider when treating this patient:


HIV, HVB, HCV and TB Co-Infection in the Caribbean (August 8, 2019)

Access the corresponding webinar here.

Case Study

Case Study 1

A 48-year-old man from Jamaica presents with a past medical history of hypertension which he is managing by taking herbal products. He is also evaluated for worsening joint pains. A routine HIV test was positive. The patient is concerned about disclosing his status to loved ones. Baseline testing showed the following:

  • Positive anti-HCV antibody test
  • Negative HBsAg and HBsAb tests
  • Positive HBcAb test
  • Routine PPD was positive.

Questions a clinician may want to consider when treating this patient:

Case Study

Case Study 2

A 29-year-old man from Barbados was diagnosed with HIV in 2012 and is on effective ART. His transmission risk is MSM. The patient has no illicit drug use and presents for his routine quarterly visit with the following:

  • CD4 cell count 871, HIV VL<20
  • Immunized against HBV
  • HCV negative in 2017
  • Routine repeat HCV Ab positive

Questions a clinician may want to consider when treating this patient:


HIV and Metabolic Complications: Cardiovascular Diseases and Diabetes (August 22, 2019)

Access the corresponding webinar here.

Case Study

Case Study 1

Patient: A 35- year- old man is diagnosed HIV+ in 2000: PMH: acute hepatitis A with the following:

  • PMH: acute hepatitis A
  • Herpes zoster
  • Peripheral neuropathy
  • Secondary syphilis/Neurosyphilis
  • Asthma
  • Hypertension
  • Hyperlipidemia
  • DVT/recurrent pulmonary embolism
  • Peripheral vascular disease
  • GERD/duodenal ulcer
  • Acute anterior wall myocardial infarction with PCI
  • Congestive heart failure
  • Lymphoma
  • Osteopenia

Questions a clinician may want to consider when treating this patient:

Case Study

Case Study 2

A 40-year-old Caribbean woman with a history of HIV disease, dyslipidemia and diabetes mellitus type 2 comes to the emergency department after she passed out in church. Her medication includes emtricitabine, tenofovir alafenamide, dolutegravir, metformin, and pravastatin sodium. She is obese, diaphoretic and cold, but in no obvious distress. Her vital signs show: Temperature 93?F, pulse 60/minute, respirations 16/minute, and blood pressure 90/65.

Questions a clinician may want to consider when treating this patient:

Case Study

Case Study 3

A 50-year- old HIV positive man comes to your clinic. The patient is taking lamivudine, tenofovir, boosted darunavir, and atorvastatin. His CD4 cell count is 250 cells/mm3, plasma viral load 800 copies/mL, total serum cholesterol 220, triglycerides 180, HDL, 35, and LDL 120. He complains of headache, insomnia, and epigastric upset, nausea, and pain in the deltoid muscle.

Questions a clinician may want to consider when treating this patient:


Strategies to Reduce HIV/HCV among Sexual and Gender Minorities in the Caribbean (September 5, 2019)

Access the corresponding webinar here.

Case Study

Case Study 1

Marvin, a 19-year-old male, presented at your clinic today complaining of a yellowish discharge from the penis. He reported having sex with multiple partners in the past three months. Initially, he had only reported having sex with women. However, on further review, he hesitantly admitted to having sex with both men and women. Marvin does not report consistent condom use. In fact, he reported not using them frequently because he “hates the way they feel.” His primary concern during sex with his female partners is to not get them pregnant because he is not ready for a family. Therefore, he tries to use condoms most of the time with them. He does not see the need to use condoms consistently with his male partners because “men can’t get pregnant.” He also indicated that he is not worried about getting HIV because he is “the man” (top/insertive partner) whenever he is intimate with another man.

Questions a clinician may want to consider when treating this patient:

Case Study

Case Study 2

Sasha, a 20-year-old transgender female, comes to see you in your primary clinic today for a follow-up visit and HIV testing. Her male partner of four weeks disclosed his status to her by revealing that he was seen three months ago in the emergency department and was diagnosed with acute HIV infection. Your medical records for Sasha noted that her last HIV test was three months ago, and the results were negative. She says that she is “in love” with this young man and would like to continue the relationship. Although they are not currently sexually active, Sasha revealed to you that she does not use condoms consistently as she finds them to be uncomfortable. She is in your office today to discuss possible options that may prevent her from acquiring HIV.

Questions a clinician may want to consider when treating this patient:


Understanding the Associations between Mental Health and HIV (October 3, 2019)

Access the corresponding webinar here.

Case Study

Case Study 1

A 36-year-old woman presents at the clinic complaining of an inability to sleep, low mood, and isolative behavior.  She admits that she is unhappy in her relationship but feels that no other man will want her because she is HIV positive. She has not disclosed her HIV status to any of her other friends or family, including her adolescent daughter.

Questions a clinician may want to consider when treating this patient:

Case Study

Case Study 2

A 34-year-old man is brought to the Emergency Department after being found by EMS naked in the street, talking to himself.  The patient is under-weight with dry oral mucosa. He denies past medical history, including past psychiatric history. His HIV test taken in the Emergency Department is positive and the patient states that he remembers another hospital told him that before. The patient is not aware of the date, or his current location. He states that he owns the hospital and is a news anchor.

Questions a clinician may want to consider when treating this patient:


Intimate Partner Violence and HIV:  Identifying the Link (October 17, 2019)

Access the corresponding webinar here.

Case Study

Case Study 1

Three months into her marriage, Anita, a senior nurse at a private care facility in Trinidad, was working on her computer at home trying to catch up on some office work when her husband, John, angrily shut it down. He was upset that she was bringing her work at home and neglecting him. He indicated in the past that once she was at home all work-related matters should be left at the office. To prevent an argument Anita tried to leave the room, but he blocked the door. He grabbed her, threw her down and took her car keys. Later that night when John went out with his friends, Anita called her mother to discuss the situation.

Her mother stated that he probably had a stressful week, and she should not worry about the situation, he is a good husband and provider and once he cooled down everything will be okay. Anita was concerned because his anger was increasing. She had participated in trainings on recognizing the signs of domestic abuse among patients. She was worried that John’s behavior would escalate, and she could be seriously hurt. However, she felt that she could not talk to her colleagues or seek outside help. Who would believe her? After all, as a police officer, John was a well-respected member of their community! She convinced herself that this was a one- time situation and her fault. She would be a good wife and cater to her husband’s needs and everything would be okay.

Since the first event 2 years ago, a physically and emotionally scarred Anita finally left John, and has filed a restraining order. However, John continues to stalk and harass her stating that if he can’t have her no one else will. Anita continues to live in fear. Anita feels a sense of guilt at the dissolution of her marriage. She experiences long periods of depression, isolation and utter despair. Anita has since left her job and moved to the USVI. She feels it is only a matter of time before John finds her new location. He has told her family and friends that he has changed since he joined a church and would like a second chance.

Questions a clinician may want to consider when addressing cases of intimate ­partner violence?

Case Study

Case Study 2

Betty lives with her husband Wayne and their two children. The son and daughter are aged 14 and 11, respectively. The couple have been married for 15 years. Betty met her husband Wayne when she was a teenager, he was a few years older. She had not completed high school when she became pregnant with their first child. She works in retail, and Wayne is a self-employed mechanic and runs a garage with his two brothers. From the start of their relationship, Wayne was violent and abusive towards Betty. He would accuse Betty of showing interest in her male co-workers and struck and verbally abused her as punishment.

Over the years, he has routinely punched, slapped and kicked her even during both pregnancies. Having gained a couple pounds after her pregnancies, he would call her fat and ugly. Betty suffered in silence and never told her family, friends, or police about the abuse she endured at home. She dressed in a way that would cover any marks and bruises on her body (and because she had been made to feel so ashamed of her body); and when that wasn’t possible, she gave another explanation for her injuries.

Not wanting her children to continue to grow up in this lifestyle, Betty decided to leave Wayne but was conflicted. She believed that her religious teachings had taught her to work out her problems and not abandon her relationship. On the other hand, she did not want her children to think that abusive behavior was normal. Focused on acting in the best interest of the children, she left Wayne. Wayne was allowed to visit with the children, however, his violent behavior continued. Feeling stronger and more in control of her life, Betty made a report to the police and Wayne was arrested and briefly incarcerated.

Questions a clinician may want to consider when addressing cases of intimate partner violence?


HIV and Substance Use in the Caribbean: An Overview (October 31, 2019)

Access the corresponding webinar here.

Case Study

Case Study 1

A 36-year-old woman who has been living with HIV for 6 years presents for a routine visit. She is married with a 12- year- old son who does not have HIV and her husband is also living with HIV. Her husband recently lost his job and has been drinking heavily, though she denies any drinking on her part. Her viral load had been undetectable on EFV/TDF/3TC, but her last 2 viral loads were 1,877 and 4,125 copies/ml, respectively. On exam, she is not as meticulously groomed as she typically is. All other labs are normal.

Questions a clinician may want to consider when treating this patient:

Case Study

Case Study 2

A 48-year-old man with no known past medical history presents for evaluation of new headaches. He is accompanied by his wife. He is not on medications and his history is unremarkable except for the mention of the occasional use of cocaine, which he fails to mention – his wife states this. His BP is 149/92 and HR is 102. Exam is otherwise normal. Laboratory studies are unremarkable. Further history elicits more frequent cocaine use than initially reported – “Saturdays, Sundays and sometimes on weekdays”. Further testing is positive for HCV, negative for HIV and HBV. He is referred for HIV prevention, and behavioral health evaluation and treatment is indicated.

Questions a clinician may want to consider when treating this patient:


Strategies for Improving Adherence to Lifelong Antiretroviral Treatment (November 7, 2019)

Access the corresponding webinar here.

Case Study

Case Study 1

JR is a 43-year-old patient diagnosed HIV positive in 2004 at a private medical clinic. ART Htx: LSN 2005-2018. Atripla in 2018 and TLD in 2019.  He was referred to a faith-based care and treatment site in 2018. His labs were as follows: Viral Load: 28,910; CD4: 23 c/ul / 1%; Hepatitis C: positive; ALT: 115; ALT :66; and Creatinine :12.9. JR was treated for OI’s and started on Atripla, Septrin, Fluconazole, IPT and weekly Azithromycin. His condition deteriorated (weight loss, recurrent candida).

Questions a clinician may want to consider when treating this patient:

Case Study

Case Study 2

CO is a 3 ½-year-old male child born to an HIV positive mother. The mother attended the PMTCT clinic during her pregnancy and the child’s DNA-PCR test was HIV negative at birth and at 4 months.  The mother and child defaulted from care in the 6th month and returned to care when the child was 21 months. The child is malnourished, with oral candidiasis and muscle wasting. He is HIV positive.

The mother was counseled on the child’s diagnosis and on ART for the child. She was encouraged to bring the child’s father in for testing. The child was started on ART: Lamivudine, Abacavir and Lopinavir/ritonavir. His baseline VL: 5,642,820; CD4:157/2% and his weight is 9.1kg.

Three months later, the father has not come in for testing. Calls to the father’s alleged number proved futile. The child’s physical condition is not improving. His VL:3,562,298. Adherence counseling with the clinic nurse reveals that the child is vomiting with LPV/r.  LPV/r was stopped and NVP started.  Six months later, the father still hasn’t come to the clinic. The child’s condition is very slightly improved. The mother is counseled by a nurse, counselor and physician and reveals that the father does not know her, nor the child’s, status.  She does not give the medication to the child if the father is at home. Since the father is the sole bread winner in the family, the mother is afraid he may leave if he knows the truth.

Questions a clinician may want to consider when treating this patient:


HIV and Neurocognitive Disorders Management (December 5, 2019)

Access the corresponding webinar here.

Case Study

Case Study 1

Ernest is 60-years old and recently retired from the Hospitality and Tourism Industry after 35 years. He is originally from Grenada but left at age 25 to pursue a degree in Hospitality Management in Trinidad. After graduation, he was hired by one of the top hotels and worked his way up to a senior managerial position. He was diagnosed with HIV nine years ago. He has had limited contact with his family in Grenada. At the time of diagnosis, Ernest was very ill due to advanced HIV infection; he was hospitalized for several weeks and treated for severe pneumonia. Once stabilized, his doctor suggested that he go abroad and get further tests and treatment. Ernest was also diagnosed with HIV-associated dementia (HAD).

Ernest took a leave of absence and went to New York for treatment. Following successful treatment and initiation of HIV medicines, Ernest’s physical health and cognitive function steadily improved over the next year and he returned to his job. However, in the last two years Ernest’s physical health declined, and he worked a limited schedule at his job. It is becoming difficult for Ernest to take care of himself, and he is concerned that his memory problems are getting worse. He forgets to turn off the stove after preparing a meal, has problems remembering phone numbers and his medical appointments; he rarely leaves his home and frequently appears disoriented.

About twelve years ago, in preparation for his retirement, Ernest moved to a rural farming community. His neighbors in this small close-knit community are very helpful and assist when they can, but they are also concerned about him

Questions a clinician may want to consider when treating this patient:

Case Study

Case Study 2

A 62-year-old Caribbean male living in Miami was referred from a general practitioner to an Infectious Disease provider for HIV care. The patient, JR, was diagnosed HIV positive many years ago and is treatment experienced. He is currently on Abacavir, lamivudine and ritonavir boosted duranavir bid. While under the care of his Infectious Disease provider, JR remains relatively stable on his current ARV regimen. He is maintaining a steady CD4 count ranging in the 700-900’s with a CD4% ranging 18%-25%, and a low-level viremia over 5 years ranging between 300-2000 copies. In the 5th year of care, he started having recurrent episodes of urinary frequency, urgency, nocturia that required recurrent hospital visits where he was diagnosed with Benign Prostatic Hyperplasia, or BPH.

Despite treatment for his BPH and being under the care of a Urologist, JR kept complaining of urinary symptoms, including nocturia, episodes of falling, leg weakness and AMS. With the episodes of AMS, he was admitted to the hospital for Urosepsis which was treated with IV antibiotics and had improvement in his urinary symptoms and mild improvement in his AMS. His leg weakness and poor balance remained so an LP was performed. Results showed CSF HIVRNA of 45,900 while his peripheral HIV RNA PCR was 1600 copies/ml. At this point, a diagnosis of HIV-associated Neurocognitive Disorders (HAND) was confirmed and he was referred to the neuropsychiatric division of NIH where he was placed in a clinical trial.

Questions a clinician may want to consider when treating this patient:


HIV Update: Clinical Trials in HIV Prevention (January 16, 2020)

Access the corresponding webinar here.

Case Study

Case Study 1

Janis, a 28-year-old registered nurse, was born in Trinidad but has been living in Grenada for the past 8 years. Janis was diagnosed with HIV five years ago while she was on vacation in the Bahamas. She has a 3- year- old son who was born HIV-negative. Janis is virologically suppressed on a regimen of Triumeq (dolutegravir/lamivudine/abacavir). Three months ago, Janis got married to Neville, a high school principal who is from Barbados. Neville wants to start a family with Janis. Neville has approached his physician about starting PrEP. He undergoes screening.

All of the labs come back fine. The husband is counseled on adherence, given a prescription for a 30- day supply of Truvada and given an appointment for a 3-month follow-up for monitoring.

Questions a clinician may want to consider when treating this patient:

Case Study

Case Study 2

Claude is a 24-year-old bisexual male who approaches you to learn about PrEP. He has a girlfriend and uses condoms during sex, but mainly as a barrier contraception. He has become increasingly concerned about HIV in his encounters with men where condoms are sometimes not used. He has heard about PrEP but has some concerns about the possible adverse effects and whether he could commit to taking a daily regimen. An alternative dosing regimen that appears effective in men on PrEP is episodic PrEP (“PrEP on Demand”). In this scheme, PrEP is only used around the time of sex. Daily dosing is not required. The regimen is 2:1:1, meaning a double dose of Truvada is taken at least an hour before sex. Then two regularly spaced single doses follow at 24 and 48 hours after the first dose.

This regimen is not recommended for women. The drug concentrations may not be adequate at the right time to provide protection in women. It is possible that TAF/FTC may be an option considering its more favorable PK profile, once it is approved for PrEP. Claude is counseled on the regimen and told that PrEP does not protect against other STI’s, and that quarterly clinic visits to monitor labs and screen for HIV /STI’s are required.

Questions a clinician may want to consider when treating this patient:


HIV and Aging (January 30, 2020)

Access the corresponding webinar here.

Case Study

Case Study 1

Dorothy Samuel, a 58-year-old female was diagnosed with HIV 3 years ago. She is adherent to her medication and as result her viral load has consistently been undetected. Trevor, her husband of 15 years, died 4 years ago due to liver failure, secondary to alcoholism. He was never tested for HIV. Dorothy has been celibate since Trevor’s death. Two years ago, Dorothy married 65 years old David. David lost his first wife 12 years prior due to breast cancer.

For the past 7 years, David has visited several doctors, both in the public and private setting, because “he has not been feeling well”. Many laboratory investigations, ultrasounds and scans were ordered. Most of the time he received vitamins and anxiolytics, as no somatic cause was found. While at a pre-Carnival event near to his job, David decided to get one of the free gifts (a water bottle) but first he had to take an HIV test. The results came back positive. He was sent for a confirmatory test and that too was positive. He is worried about how to tell his wife.

Questions a clinician may want to consider when treating this patient:

Case Study

Case Study 2

Patrick, a 52-year-old taxi driver and former cricket-club captain with a very sexually active lifestyle, frequently gets tested for HIV. Other health issues are not his priority. One week ago, Patrick tested positive for HIV and syphilis. He agreed to be counselled and to enroll in a care and treatment site two communities away from his taxi route and where he is less likely to be known. Even more importantly, he hopes that his current live-in girlfriend, Patsy, will not find out. Physical examination and labs revealed Patrick is hypertensive and diabetic with altered renal function, CD4 is 546 (20%), creatinine clearance 48 and HbA1C 7.2%. Patrick is free from active OI’s and is placed on treatment for his co- morbidities and initiated on HAART.

Questions a clinician may want to consider when treating this patient:


HIV and Cardiovascular Diseases (Presented in French) (February 20, 2020)

Access the corresponding webinar here.

Case Study

Case Study 1

Patient: A 35- year- old Haitian man living in Nassau, Bahamas is diagnosed HIV+ in 2000: PMH: acute hepatitis A with the following:

  • PMH: acute hepatitis A
  • Herpes zoster
  • Peripheral neuropathy
  • Secondary syphilis/Neurosyphilis
  • Asthma
  • Hypertension
  • Hyperlipidemia
  • DVT/recurrent pulmonary embolism
  • Peripheral vascular disease
  • GERD/duodenal ulcer
  • Acute anterior wall myocardial infarction with PCI
  • Congestive heart failure
  • Lymphoma
  • Osteopenia


Questions a clinician may want to consider when treating this patient:

Case Study

Case Study 2

A 40-year-old Haitian woman, Fabienne, with a history of HIV disease, dyslipidemia and diabetes mellitus type 2 comes to the emergency department after she passed out in church. Her medication includes emtricitabine, tenofovir alafenamide, dolutegravir, metformin, and pravastatin sodium. She is obese, diaphoretic and cold, but in no obvious distress. Her vital signs show: Temperature 93?F, pulse 60/minute, respirations 16/minute, and blood pressure 90/65.

Questions a clinician may want to consider when treating this patient:

Case Study

Case Study 3

A 50-year-old HIV positive man, Jean-Paul, comes to your clinic. The patient is taking lamivudine, tenofovir, boosted darunavir, and atorvastatin. His CD4 cell count is 250 cells/mm3, plasma viral load 800 copies/mL, total serum cholesterol 220, triglycerides 180, HDL, 35, and LDL 120. He complains of headache, insomnia, and epigastric upset, nausea, and pain in the deltoid muscle.

Questions a clinician may want to consider when treating this patient: