Hospitalization rates greater among elite controllers

Elite controllers were hospitalized more frequently than people with HIV who control the disease with antiretroviral therapy, according to new data.

The association mainly appears to be driven by a higher rate of cardiovascular hospitalizations among elite controllers, according to the data, which were published in the Journal of Infectious Diseases. Elite controllers, however, had a lower rate of non-AIDS-defining infections.

“Elite control of HIV infection is not the same as medical control of HIV infection with ART,” Trevor A. Crowell, MD, a research physician with the US Military HIV Research Program and assistant professor of medicine at the Uniformed Services University of the Health Sciences, told Infectious Disease News. “It is possible that clinical outcomes among elite controllers might be improved by the initiation of ART or anti-inflammatory therapies. Further research is needed to identify the best practices for providing care to elite controllers.”

Trevor A. Crowell

 

Crowell, who was involved with the study during his infectious diseases fellowship at Johns Hopkins University, and colleagues evaluated adults with HIV and CD4 counts of 350 cells/mm3 or more, and compared the rates of hospitalization among elite controllers, people medically controlled with ART, patients with low viremia and patients with high viremia (using a threshold of 1,000 copies/mL). They used data from 11 sites in the HIV Research Network, and the analysis included 23,461 individuals from 2005 to 2011. The analysis included 64,290 person-years of observation.

There were 149 confirmed elite controllers in the study, which makes it one of the largest published cohorts of elite controllers, Crowell said. Among the remaining participants, 9,226 were medically controlled, 12,044 had low viremia and 12,847 had high viremia. Of the 8,456 hospitalizations among participants, the elite controllers had the highest all-cause hospitalization rate: 23.3 hospitalizations per 100 person-years. By comparison, there were 16.9 hospitalizations for high viremia patients, 12.6 for low viremia patients and 10.5 for medically controlled patients.

In a multivariable analysis, elite control was associated with a higher hospitalization rate compared with medical control (adjusted IRR=1.77; 95% CI, 1.21-2.6). The rate of cardiovascular hospitalizations (aIRR=3.19; 95% CI, 1.5-6.79) and psychiatric hospitalizations (aIRR=3.98; 95% CI, 1.54-10.28) were higher among the elite controllers vs. medically controlled patients. Elite controllers experienced with a lower hospitalization rate due to non-AIDS-defining infection (aIRR=0.32; 95% CI, 0.08-1.3) compared with medically controlled participants. However, overall, non-AIDS-defining infections were the most common reason for hospitalization, accounting for 24.1% of admissions.

According to Crowell, elite controllers have historically been told they do not require ART because their virus appeared to be suppressed naturally, resulting in relative preservation of the immune system and delayed progression to AIDS. However, it is now known that elite controllers have chronic inflammation that is at least partially driven by low levels of viral replication, he said.

“This study adds to the growing body of evidence suggesting that elite control of HIV infection is inferior to medical control with ART,” Crowell said. “If inflammation contributes to poor clinical outcomes among elite controllers, then it is possible that elite controllers would benefit from interventions to reduce this inflammation, including ART. Patients and health care providers may want to consider starting ART in the setting of elite control.”  by Emily Shafer

Trevor A. Crowell, MD, can be reached at: trevor.crowell@jhmi.edu.

Disclosure: Crowell reports no relevant disclosures.