June 1st, 2009

“Long-term Nonprogressors” and “HIV Controllers”: Rare Indeed

When giving an overview of HIV pathogenesis to a group of clinicians, Bruce Walker usually asks the assembled if they have any patients in their practice who have undetectable viral loads without antiretroviral therapy.

Generally about three-quarters of the audience has at least one such patient.  They are then asked to refer them to his research cohort, which has a goal of trying to figure out why some patients can control HIV replication without needing antivirals.

But how common is this “controller” phenomenon really?  And how about its immunologic correlate — people with long-term HIV infection but no significant decline in the CD4 cell count?

Nifty paper in AIDS this month trying to answer this question:  Using the French Hospital Database, and starting with over 45,000 potentially eligible patients, the group found that only 69 were “elite controllers” — that is, had >10 years HIV infection, 90% of viral loads <500 cop/mL, and most recent viral load <50 cop/mL.

Stable CD4s were even less common.  Only 25 patients were “elite long-term nonprogressors” — that is, had HIV for more than 8 years, CD4 cells > 600, and no CD4 cell decline.  That’s an prevalence of 0.05%, or 5 for every 10,000 patients.

Medical students and residents sometimes ask me if a particular patient of mine, asymptomatic and not on antiretroviral therapy, is a “long-term nonprogressor.”

I always respond by asking them what specifically they mean by the term — because as this paper shows, when you look for a truly benign course of HIV infection, you need to look pretty darn hard.

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HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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