Editor’s Choice: Antiretroviral Therapy in the Elite Controller: Justified or Premature?
June 1, 2015 211 (11) P.1689-1691
Maile Y. Karris and Richard H. Haubrich
Investigating the immune system of human immunodeficiency virus (HIV) elite controllers, or HIV-infected individuals who maintain undetectable plasma HIV RNA levels without antiretroviral therapy (ART), has led to advances in our understanding of HIV pathogenesis  and may be critical to the development of a functional cure for HIV infection [2, 3]. However, although other studies have shown that elite controllers maintain immune control of their viral replication, preventing disease progression in some, these individuals have higher levels of immune activation and chronic inflammation than HIV-infected persons with viral suppression during ART [4–7]. Whether or not elevated markers of inflammation in elite controllers are clinically meaningful is relevant to the question of whether elite controllers should be treated with ART.
Elite controllers have also demonstrated higher levels of atherosclerosis than chronically HIV-1–infected persons receiving ART with undetectable HIV loads and HIV negative controls [5, 8]. The Strategies for Management of Anti-Retroviral Therapy (SMART) trial very clearly highlighted the association between chronic inflammation, observed in suppressed HIV-infected subjects receiving ART, and excess morbidity and mortality; subjects with elevated levels of the inflammatory markers interleukin 6 and D-dimer had higher all-cause mortality  and serious non-AIDS events, such as cardiovascular disease (CVD) [10, 11], than similarly suppressed subjects with lower inflammatory markers….
Journal of Infectious Diseases June 1, 2015 211 (11) P.1692-1702
Editor’s Choice: Hospitalization Rates and Reasons Among HIV Elite Controllers and Persons With Medically Controlled HIV Infection
Trevor A. Crowell, Kelly A. Gebo, Joel N. Blankson, P. Todd Korthuis, Baligh R. Yehia, Richard M. Rutstein, Richard D. Moore, Victoria Sharp, Ank E. Nijhawan, W. Christopher Mathews, Lawrence H. Hanau, Roberto B. Corales, Robert Beil, Charurut Somboonwit, Howard Edelstein, Sara L. Allen, and Stephen A. Berry for the HIV Research Network
Elite controllers spontaneously suppress human immunodeficiency virus (HIV) viremia but also demonstrate chronic inflammation that may increase risk of comorbid conditions. We compared hospitalization rates and causes among elite controllers to those of immunologically intact persons with medically controlled HIV.
For adults in care at 11 sites from 2005 to 2011, person-years with CD4 T-cell counts ≥350 cells/mm2 were categorized as medical control, elite control, low viremia, or high viremia. All-cause and diagnostic category-specific hospitalization rates were compared between groups using negative binomial regression.
We identified 149 elite controllers (0.4%) among 34 354 persons in care. Unadjusted hospitalization rates among the medical control, elite control, low-viremia, and high-viremia groups were 10.5, 23.3, 12.6, and 16.9 per 100 person-years, respectively. After adjustment for demographic and clinical factors, elite control was associated with higher rates of all-cause (adjusted incidence rate ratio, 1.77 [95% confidence interval, 1.21–2.60]), cardiovascular (3.19 [1.50–6.79]) and psychiatric (3.98 [1.54–10.28]) hospitalization than was medical control. Non–AIDS-defining infections were the most common reason for admission overall (24.1% of hospitalizations) but were rare among elite controllers (2.7%), in whom cardiovascular hospitalizations were most common (31.1%).
Elite controllers are hospitalized more frequently than persons with medically controlled HIV and cardiovascular hospitalizations are an important contributor.
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