What the research says
Elite controllers (ECs) - of which I happen to be one - are a subset of people living with HIV that are able to spontaneously maintain an undetectable viral load despite not being on antiretroviral therapy (ART).
A recent paper about ECs recently accepted to the Journal of Infectious Diseases has been getting a lot of attention, partially due to its captivating title: “Elite Controllers are Hospitalized More Often than Persons with Medically Controlled HIV”. The work was led by Trevor Crowell and Stephen Berry at Johns Hopkins University School of Medicine, with collaborations across the US.
This is a really bold statement about the health of ECs. For years researchers have been using ECs as a model in the search for clues of an HIV cure, control, or vaccine; taking blood and other tissues to try to understand how the immune system of these people is able to evade efficient HIV replication. But, if these people are more likely to get sick anyway, has all this been in vain?
It’s very important to interpret this information in context, and not spin it to mean something more than it is. I want to talk about exactly what I take from this paper as a person living with HIV who also happens to be an elite controller.
So, to get started, what were the authors actually analyzing? They were collecting information about people with HIV at a number of different clinics in the US, looking specifically at viral load and how frequently individuals were admitted to the hospital. They separated people into categories: ‘Elite Controllers’ were those maintaining viral suppression, ‘low virus’ or ‘high virus’ were individuals not on ART who had detectable virus below and above a threshold of 1000 copies/mL. They also had a ‘medical control’ group of people on ART, to use as a comparison.
This leads to one relatively minor beef I have with this paper, which is: why did they use 1000 viral copies/mL as the threshold difference between ‘high’ and ‘low’ virus? The number seems awfully low to me; usually when we talk about a high viral load we’re talking about 30,000-50,000 copies/mL or more. To me, it just seems arbitrary and not really aligned with meaningful clinical values.
The authors did a bunch of statistical modeling to determine hospitalization rates while adjusting for variations in the data that might relate to age, race, gender, etc. The information that came out of their analysis is certainly interesting. Looking at the adjusted rate of hospitalization for elite controllers compared to the ‘medical control’ group, there appears to be a 1.77x greater likelihood of hospitalization, meaning that for every 1 time a person in the medical control group is hospitalized, elite controllers were hospitalized 1.77 times. Obviously you can’t go to the hospital 1.77 times, but if you scale up the numbers, that’s the ratio we’re talking about.
In the discussion, though, the authors noted that one participant in this group was hospitalized 21 times during the study, and that removing that individual did reduce this number to about 1.56x. Overall the result is clear, then: ECs are more likely to have been hospitalized than those on ART.
When they broke down the results further, the authors found that this increase was largely attributable to cardiovascular problems. This result actually builds on some previous scientific work that has shown that elite controllers have higher levels of “atherosclerotic plaque” and blood markers of cardiovascular diseases.
The paper also provides some other information that largely seems intuitive: older people are more likely to be hospitalized than younger people, people who also have hepatitis are more likely to be hospitalized, as well as those with lower CD4 counts. I don’t mean to dismiss this data, as it’s certainly affirming, but it doesn’t really tell us anything new.
The bottom line
So, to get down to the point…
As an elite controller, what does this information actually tell me about my health? What does it tell me about how I can take care of my health?
Well, first of all, it tells me that I may be at an increased risk of heart disease.
What’s my reaction to this? Well, three out of four of my biological grandparents died of cardiovascular disease, so this isn’t new information… for me. Come to think of it, the research actually doesn’t control for family history of illness at all. It would be interesting to take a closer look at whether those individuals with elevated risk of cardiovascular disease show variation in these markers compared to their own relatives. Is it possible that a closer look at these trends might also hint at genes that might play a role in viral control for elite controllers?
It does tell me that MAYBE antiretroviral treatment could help. I don’t think the evidence is strong enough for me to jump on that bandwagon though. (Going on drugs also isn’t an argument the authors make, but has been suggested by other scientists).
More than that, though, I think it means I need to take care of my heart. Keeping a healthy body weight, watching my cholesterol, and engaging in physical activity will be the best ways to prevent illness. It’s possible that aspirin or statin drugs will be something I might want to consider, particularly as I get older.
Basically, I think this research means more for science than it does for those of us living with HIV who happen to be elite controllers. The only caveat is that it may be worthwhile to pay a bit of extra attention and take a little extra care of our hearts, which I think is true of most of us in the western world anyway.
Crowell, T.A. & et al. Elite Controllers are Hospitalized More Often than Persons with Medically Controlled HIV. J. Infect. Dis. (2014 - advance access manuscript).