Current Treatment Options for HIV Elite Controllers: a Review
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Initiating antiretroviral therapy (ART) in human immunodeficiency virus (HIV) elite controllers remains controversial, because current evidence does not definitively demonstrate that the benefits of ART outweigh risk in this patient population. However, it is the opinion of the authors that in developed countries, where first-line ART regimens have minimal toxicities, treatment of elite controllers should be strongly considered. Treatment of elite controllers has the potential to minimize the size of the HIV reservoir, which benefits elite controllers who choose to pursue future cure, dampen immune activation, diminish risk of transmission, and encourage linkage and engagement in care allowing HIV providers the opportunity to address HIV-associated non-AIDS conditions and other co-morbidities.
Purpose of review
This review aims to summarize literature relevant to the management of elite controllers for clinicians caring for patients living with HIV. Key topics include timing of antiretroviral therapy (ART) and ART in the unique populations of elite controllers with concomitant cardiovascular disease and hepatitis C co-infection, and undergoing immunosuppressive therapy for other co-morbidities.
The persistent HIV reservoir in elite controllers has two main implications. First, increased immune activation appears to adversely impact clinical outcomes in elite controllers, but the role of ART in addressing this effect remains unclear. Second, elite control duration can be limited, but certain factors may help to predict disease progression with implications on timing of ART.
Initiation of ART during elite control remains controversial, although there are multiple theoretical benefits. Elite controllers comprise a heterogeneous population of patients living with HIV, and optimal management involves weighing the risk and benefit of ART as well as monitoring of clinical consequences of increased immune activation.
KeywordsElite controllers HIV Antiretroviral therapy Treatment options Cardiovascular disease Hepatitis C Immunosuppression
Dr. Katherine Promer is supported by a grant from the National Institutes of Health: T32 AI 007036.
Dr. Maile Y Karris is supported by grants from the National Institutes of Health: R01 AI28803, R21 AI134295, R01 MH110057, and P30 AI035214.
Compliance with Ethical Standards
Conflict of Interest
Dr. Katherine Promer declares that she has no conflicts of interest.
Dr. Maile Y Karris has served as an advisory board memory for Gilead Sciences and receives research funding to the institution from Gilead Sciences.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
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