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The Mystery of Exceptional Elite Controllers (EEC) and Spontaneous Viral Control

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By Editorial Team

3 min read

Doctors have known for years that a small number of people with HIV maintain an undetectable viral load without taking HIV medicines. Called HIV controllers, elite controllers, or exceptional elite controllers, these people have been studied closely in hopes of finding a vaccine or cure.1

What is an HIV controller?

There is no single definition for HIV controller. Generally, the terms used to describe different types of HIV controllers include:1,2

  • HIV controllers are people who maintain a high CD4 count and a low (or sometimes undetectable) viral load without taking antiretroviral drugs (ARVs).
  • Elite controllers are people who maintain a high CD4 count and a consistently undetectable viral load (often under 50) without treatment.
  • Exceptional elite controllers maintain a viral load so low that even the most sensitive tests cannot find HIV in their cells.

Some people with HIV have remained healthy for 25 years or longer without treatment. However, 1 study found the average is 4 years.2,3

HIV controllers are rare. Fewer than 1 out of every 100 people living with HIV are elite controllers. Some untreated elite controllers lose their ability to control HIV over time. Fewer than 10 people worldwide seem to have eliminated HIV from their bodies, or self-cure.1-3

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Spontaneous or "natural" HIV control

The first 4 cases of exceptional elite controllers were reported in 2012. Over the years, doctors have found more people who test positive for HIV but do not develop AIDS despite not having treatment. Three HIV controllers even had healthy pregnancies and delivered HIV-negative babies. Doctors sometimes call this "spontaneous" or "natural" HIV control.2

While they do not know for sure, experts believe there are a few possible reasons that elite controllers are able to stay healthy without treatment. These reasons include:2

  • Some elite controllers have differences in certain genes, such as HLA-B57, that seem to provide a type of natural protection against HIV.
  • Some people have unusually active immune systems and higher levels of CD4 and CD8 cells that seem to keep HIV from growing (replicating).
  • Some people contract a faulty or damaged form of HIV that their body is able to fight.
  • People assigned female at birth tend to have lower viral loads because estrogen seems to suppress the virus.

Doctors in the United States and the United Kingdom are studying the genes of elite controllers to better understand what makes them unique.1

Ambiguous testers

There are 2 tests given to confirm that you have HIV. The first test looks for an immune system reaction and the proteins (antibodies) the body produces to fight HIV. If you test positive, you are given a second test made by a different manufacturer to confirm your diagnosis.1

When tested for HIV, some people test positive for the first test and negative for the second. These test results are called ambiguous or indeterminate results.1

Ambiguous HIV test results may happen if you are taking PrEP, have hepatitis, or live with an autoimmune condition. But experts believe that elite controllers also may have ambiguous HIV tests, depending on how their body fights HIV.1

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Starting treatment anyway

There are good reasons why elite controllers begin taking ARVs even though they do not yet have HIV-related illnesses or a falling CD4 count. For instance, elite controllers who have an overactive immune system also tend to develop health conditions related to chronic inflammation. An example of these conditions is heart disease.1,3,4

International guidelines recommend starting anti-HIV medicine right away to prevent early damage that may occur before more noticeable symptoms appear. This applies even to elite controllers. However, some doctors believe it is okay to delay the start of anti-HIV drugs if an elite controller can be followed closely and tested often.4

More research is needed to better understand the bodies of elite controllers. However, there are very few people who naturally or spontaneously control HIV. So, it may be some time before their bodies reveal answers that will help doctors find a vaccine or a cure.1,2

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