Barbara,
Current guidelines recommend treating elite controllers. The main reason to treat your patient is not his low-level viremia, but the fact that untreated elite controllers seem to do worse than people on ART, perhaps because they have higher levels of inflammation and immune activation. You didn't mention his CD4 count, but some elite controllers also experience disease progression (decline in CD4 count) despite having an undetectable viral load. There was a time when we had to balance the uncertain benefits of treatment against drug toxicity, but that's not really an issue now given the safety and tolerability of our current regimens.
Transmission is also a consideration. While he's very unlikely to transmit HIV with the low viral loads he has now, elite controllers don't necessarily stay that way forever. I would think he and his partner would want the added security of a durably suppressed viral load.
Here's what the DHHS guidelines have to say on the subject:
"Even elite controllers with normal CD4 counts show evidence of abnormally high immune activation and surrogate markers of atherosclerosis, which may contribute to an increased risk of non-AIDS–related diseases. One observational study suggested that elite controllers are hospitalized more often for cardiovascular and respiratory disease than patients from the general population and ART-treated patients. Moreover, elite controllers with preserved CD4 counts appear to experience a decline in immune activation after ART initiation, suggesting that treatment may be beneficial... There is a clear rationale for prescribing ART to elite controllers even in the absence of detectable plasma HIV RNA levels. If ART is withheld, elite controllers should be followed closely, as some may experience CD4 cell decline, loss of viral control, or complications related to HIV infection."
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Joel Gallant, MD, MPH
Johns Hopkins University
Baltimore, MD
AXCES Research Group
Santa Fe, NM
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Original Message:
Sent: 05-28-2025 14:55
From: Barbara Hart
Subject: Elite controller/non-responder with new viral load
Hello clinicians
I have a question regarding an HIV pt who has been considered an elite controller or non-responder for many years. Chart review notes he had a positive antibody test in California in 2005. Has not been on ART to date. He has regular visits, with HIV VL usually reported as <30. He had one level of 47 in March 2023. In January 2025, he developed syphilis, and HIV viral load was 865. Treated for syphilis. Repeat HIV viral load was 104 on 2/25/25. He is a married male with female partner, and other than one episode of unprotected sex with outside partner, denies high risk sexual activity. He is aware of risk of HIV transmission due to detectable viral load and is using condoms.
My ID team recommended monitoring previously. On recheck 5/5/25, HIV viral load remains 104. Review of literature notes that non-responders do often require ART. The patient is reluctant to start ART, however, I feel he may not return to undetectable.
Will you let me know your experience and recommendation in this case? Thank you.
Barbara Hart APRN
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Barbara Hart
Lawrence KS
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