Viral load rebound in presumed elite controllers: a small case series of the potential use of non‐prescribed HAART in African patients

HIV elite controllers are rare with an incidence of <1/300 [1]. We report 4 cases of presumed elite control with subsequent viral load rebound possibly due to non‐prescribed HAART. Case 1: A 37‐year‐old African woman trafficked to the UK was diagnosed HIV‐positive with viral load (VL) <40 copies/mL and CD4 count of 436 cells/cmm. She denied prior diagnosis and was presumed an elite controller until a rise in VL to 26,5205 copies/mL 6 months later (Table 1).Time from diagnosis CD4 (cells/cmm) Viral load (copies/mL)0 436 (26%) <40 1 month 424 (18%) <40 3 months N/A <40 6 months 387 (29%) 265,205 6 months 264 (18%) 338,291A resistance test reported HIV‐1 subtype C with a minor protease inhibitor mutation (A71T). It was subsequently disclosed she was given unidentified tablets by traffickers. Case 2: A 31‐year‐old African woman presented 37 weeks pregnant and was diagnosed HIV‐positive with VL 147 copies/mL and CD4 count of 1065 cells/cmm. She denied prior diagnosis, however stated an African doctor visited her ex‐partner's home and supplied tablets identified as lopinavir/ritonavir and zidovudine/lamivudine. Clinics in this area were contacted but had no record of this patient. There was a rise in VL with a resistance test reporting HIV‐1 subtype C/D with no mutations. Case 3: A 53‐year‐old African woman presented 6 weeks after a sexual assault in her home country and was diagnosed HIV‐positive with VL<40 copies/mL and CD4 count of 609 cells/cmm. She denied prior diagnosis but stated her employers gave her unidentified tablets after the assault. Over 3 months VL increased to 390,751 copies/mL (Table 2).Time from diagnosis CD4 (cells/cmm) Viral load (copies/mL)0 609 (30%) <40 1 month 763 (29%) <40 2 months N/A 417 4 months 616 (19%) 390,751 6 months 237 (18%) 67,833A resistance test reported HIV‐1 subtype A with no mutations. Case 4: A 42‐year‐old African man was diagnosed HIV positive with VL 269 copies/mL and CD4 count of 562 cells/cmm. A resistance test reported HIV‐1 subtype B with minor PI and NRTI mutations (L10V and V118L respectively). HIV parameters remained stable until 20 months later with an increase in VL to 1,463,132 copies/mL (Table 3).Time from diagnosis CD4 (cells/cmm) Viral load (copies/mL)0 562 (33%) 269 3 months 454 (37%) 810 6 months 456 (29%) 1110 9 months 492 (31%) 1013 14 months 473 (27%) 199 20 months 279 (13%) 1,463,132 20 months 299 (12%) 1,070,823A resistance test excluded super‐infection reporting a similar sequence and no new mutations. Co‐existing pathology was also excluded. He subsequently disclosed taking medication supplied by his family but denied this was HAART. Conclusion The viral load rebound seen in these cases may be due to a viral or immune mediated phenomenon; however, the possibility of non‐prescribed HAART has to be considered. Home test kits for HIV are widely available and there are reports of counterfeit HAART in the developing world [2]. The HIV community has to be vigilant in reporting cases of this nature which create many anxieties regarding toxicity and resistance.