What is an elite controller?

An elite controller is a person living with HIV who is able to maintain undetectable viral loads for at least 12 months despite not having started antiretroviral therapy (ART) . Elite controllers are rare: for every two hundred people living with HIV, approximately one may be an elite controller (0.5%).

It is not entirely understood why some patients are able to achieve undetectable viral loads without ART. There is good evidence to suggest that a person’s individual immune response plays the most crucial part in maintaining viral suppression. This can be due to genetic influences and/or the way the immune system reacts and adapts to the early stage of HIV infection.

There is variety amongst elite controllers in the extent to which viral replication is suppressed. In some there may be little to no ongoing replication anywhere in the body. Others demonstrate evidence in the blood of ongoing viral replication somewhere in the body, but not enough to cause a detectable viral load.

The term doesn’t describe a permanent state; elite controllers frequently go on to develop detectable virus in the blood, as well as other HIV-related complications. In one study, the median time to disease progression for elite controllers was four years. In other words, if there were 100 elite controllers, by four years, 50 of them would either have a detectable viral load, falling CD4+ count or an AIDS-defining illness.

People classed as elite controllers are at higher risk of cardiovascular events and AIDS-defining illnesses than those with well controlled HIV who are taking ART. International guidelines vary, but there is a school of thought that given the tolerable side effect profile of modern ART, elite controllers gain health advantages by starting treatment. 

With guidelines now recommending starting treatment at diagnosis it is possible that the pool of elite controllers may decline, as it will be impossible to tell which people would have otherwise controlled HIV without treatment.

There are related sub-groups of people living with HIV. ‘Viraemic controllers’ are able to maintain a low viral load off ART with CD4 counts above 200. ‘Post-treatment controllers’ are able to maintain undetectable viral loads despite stopping ART. These groups of people provide compelling examples of how the immune system can inhibit viral reproduction without antiretrovirals.


elite controllers

A small subset of people living with HIV who are able to control HIV replication in the absence of antiretroviral treatment for an unusually long period of time. Definitions vary, but an elite controller is usually defined as a person whose viral load has remained below 50 copies. However, because HIV continues to replicate even in elite controllers, ART is recommended for elite controllers who have declining CD4 counts or who develop HIV-related complications. Elite controllers and viraemic controllers are members of a larger group known as HIV controllers. Around half of HIV controllers can also be described as long-term non-progressors.


Acronym for antiretroviral therapy. Antiretroviral therapy usually includes at least two antiretroviral drugs.

detectable viral load

When viral load is detectable, this indicates that HIV is replicating in the body. If the person is taking HIV treatment but their viral load is detectable, the treatment is not working properly. There may still be a risk of HIV transmission to sexual partners.

undetectable viral load

A level of viral load that is too low to be picked up by the particular viral load test being used or below an agreed threshold (such as 50 copies/ml or 200 copies/ml). An undetectable viral load is the first goal of antiretroviral therapy.


The process of viral multiplication or reproduction. Viruses cannot replicate without the machinery and metabolism of cells (human cells, in the case of HIV), which is why viruses infect cells.

A similar term, but not interchangeable, is ‘long term non-progressors’ – people who are able to maintain CD4 counts greater than 500 without ART, for a prolonged period of time (at least eight years in most studies). There are some elite or viraemic controllers who may also be classed as long-term non progressors and vice versa.

Much is still to be learned about the exact conditions required to gain control of the virus without ART, but the understanding gained so far is already being applied to further both vaccination and cure research. With the appropriate resources, willpower and perhaps good fortune, elite controllers and others like them may hold the key to unlocking a whole new era of HIV prevention and management.

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