The usual period of slow, but continuous viral replication of HIV-1, T CD4⁺ lymphocyte (LTCD4⁺) decline and the appearance of AIDS followed by death, was the natural history accompanying HIV-1 infecting humans [1, 2]. The use of different protocols which should be strictly followed to treat the viral infection (antiretroviral therapy, ART), made it possible to interfere in the process, although sometimes with several nasty side effects of the therapeutical drugs used [3, 4]. The suggestions of clinical and laboratory evidences that a small number of HIV-1 infected persons could be able to naturally control the virus without the use of anti-retroviral therapy, opened a window of hope to millions of persons carrying the enormous burden of a deadly infection [5–7].

A new phenotype of HIV-1 carriers, the long term non-progressor, elite controller or viral controller, among others, define a group of HIV-1 infected persons who could naturally maintain viral replication under control and the absence of precipitating events which could lead to AIDS [8–11]. The definition of viral controller and, particularly, elite controller, is not equally defined and there is no universal consensus as can be seen in the several different proposals [10, 12–14]. The suggestion of the possibility of HIV-1 eradication or the maintenance of a host who would be non infectious, is a bold proposal considering the retrospective and accumulated knowledge in virus strategies of replication, adaptation to the host and perpetuation together with the infected host [15–17].

There was a recent change in the time to start treatment of infected persons as soon as the infection is diagnosed which was also adopted in Brazil [18]. The recent evidences of three large and well conducted studies (HPTN 052, Temprano and START), were sufficiently strong to support the change, once more, in the usual protocol which define the starting point to treatment [19–21]. The “test and treat” approach may lead to a difficulty to recognize those patients who are able to maintain the virus under natural control and make it impossible to learn how the process can be attained. Here we present the characterization of the human model currently described in the city of Belem, Para (Northern Brazil), in order to provide additional criteria to turn the definition of this controversial point of discussion even more strict and to start collaborative studies in the country, aiming to better understand this phenotype of viral controllers. It is important to tighten the characterization of the subjects in order to make sure we can really believe in the control and a possible future cure of HIV-1 infection.

Since the 1990s, a new group of HIV-1 infected persons was detected and they raised new possibilities regarding the outcome of an infection, which was thought to be always fatal [25]. Viremia controllers were initially seen as the natural result of the evolution of host/agent interaction, although a few decades have elapsed since the recognition of the virus and its severe consequences to the human host [23]. Virus evolution and host genetic selection would fit the idea that a new human specific group could control the virus replication without disease development. Understanding the host behavior, the immunological response, genetic characteristics and virus pathogenesis, would certainly help understand how to improve the outcome of newly infected persons and possibly vaccine production [26, 27].

The present information is the first approach to characterize viral controllers in the North of the Amazon region and similar publications in the country are sparse. Demographic informations from the persons investigated were not relevant for their characterization as they were not different from the persons involved in the general epidemic of HIV-1 and AIDS elsewhere in the country. Similar results have been observed in other geographical settings regarding the demographics of viral controllers without statistical significance [28]. The importance of the similarity of the data is of relevance as the population group investigated, is highly miscigenetic [29], contrary to other groups.

The number of HIV-1 viral replication controllers is extremely low anywhere and their detection is a difficult task during the routine clinical approach. The use of statistical methods commonly used in epidemiology when dealing with rare events, was a strong statistical support, which corrected and balanced the low numbers of persons by using all the available measurements of TCD4⁺, TCD8⁺ and VL, along the observation period, and improved the statistical analysis of the numbers presented. VC1 did not show any detectable level of viral multiplication, but VC2 showed blips measured by the plasma viral load (in agreement with their definition in Table 1), which were controlled without the use of ART. It was remarkable to see that the group was able to recover from viral loads up to 10,000 copies, but this is not quite different from definitions [30] which include a limit of 2000 copies (log₁₀ = 3,3010). The peak of higher viral loads was more frequently seen in NC as expected. The persistence of the virus in the lymphatics acts as a constant repository for the virus from these reservoir tissues [31]. It is quite certain that the virus is in continuous replication, even among VC1 [16, 17, 32, 33] and it would certainly cause a decline in LTCD4⁺, which was not seen in our VC groups. Cure agendas can not ignore that the groups are different and should be addressed differently in the present suggestions for “test and treat”. The main point of interest is of how long should one go on waiting to consider a person as a viral controller? This is a controversial point [14] and should be addressed with priority.

Levels of LTCD4⁺ were consistently high, along the observation period among the viral controllers and the evolution of the counts showed no decrease, contrary to what has been described [17]. Absolute and relative counts of LTCD4⁺, were commonly used as predictors of disease progression and the recovery of cell counts after ART, a highly relevant variable to monitor the clinical outcome of HIV-1 infected persons [34–37]. The overall annual change in their values along the observation period was not significant, although it was not possible to measure whether the lymphocytes were fully functional or abnormally activated. They should still be useful markers even in the present protocol of ART.

LTCD8⁺ counts were also kept higher and did not change their levels during the observation period in the VC and NC groups. They were constantly stimulated which led to values quite higher than the uninfected controls and did not change along the years. It is still not completely understood the interaction of LTCD8⁺ in the pathogenesis of HIV-1, thus it is fair to think in the increase of the immunological response based in LTCD8⁺, both to protect and to change the outcome of the disease [38–40]. A recent report showed that HIV suppressive activity mediated by CD8⁺ T lymphocytes in vitro was significantly greater among VC than NC cells, with a significant correlation between the suppressive activity and the plasma viral load [41]. It is a regular activity of LTCD8⁺ to keep adequate levels of IFN-γ, an important cytokine in the arrest of viral multiplication, both during the innate immunological response (by natural killer T cells) and by LTCD8⁺ cytotoxic cells [8, 15, 42, 43].

“Non-AIDS related events”, involving chronic disorders of the CNS, the cardiovascular system and cancers are frequently described [44, 45]. Atherosclerosis and coronary heart disease, are commonly observed in an earlier age among HIV-1 carriers and no relevant clinical signs are readily detected by the patient or the attending physician. The inversion of LTCD4⁺/LTCD8⁺ ratio values, is in direct association with the progress towards AIDS and non-AIDS related events and when the inversion is sharp (below 0.5), this simple measurable variable becomes a good biomarker of mortality by other causes than AIDS [46–48] and an apparently reliable marker to trace early heart disease among infected persons virally suppressed under ART [49]. Our results showed that the groups have a clear inversion of the ratio, although in a more subtle level among the viral controllers (VC1 and VC2). The marker did not change with time and the general health of the persons was apparently good. If there is a possibility of using the ratio as a biomarker, it will certainly require the definition of a cut off to establish an appropriate moment to start looking for other chronic disorders among non-controllers and the adequate moment to intervene with viral controllers as well. Apparently, there is no other published similar result considering the long term decline of LTCD4⁺/LTCD8⁺ ratio among viral controllers, but for the period of observation in the present study, the decrease in the inversion of the ratio was not enough to be significant in the VC group.

The presence of CCR5∆32 and SDF1–3’A polymorphisms could not be associated to a better response against virus multiplication and control by the host, but the number of persons involved in the present study clearly did not allow an appropriate statistical evaluation. Our previous data showed that these polymorphisms are not usual among HIV-1 infected persons in the North region of the country [50]. Although some polymorphisms are strongly associated with viral controllers, HLA subtypes were also not associated with differences in the cytokines and chemokines production between elite controllers and viremic controllers regarding the frequencies of the alleles B27 or B57 [17, 33], contrary to what is generally accepted [26, 51–54]. In the present study, the evolution in the counts of LTCD4⁺ and LTCD8⁺ were not influenced by both polymorphisms. Larger studies will be necessary to confirm or not the influence of the allele 3’A in the low counts of LTCD4⁺ and LTCD8⁺. Despite the absence of statistical significance there is an indication for the possible involvement of M-tropic, using CCR5 related co-receptors and T-tropic isolates, using CXCR4 [55, 56]. Most of these studies with polymorphisms were performed using samples from non-viral controllers with a regular progression to AIDS; viral controllers are still poorly understood regarding these and other polymorphisms.

IFN-γ was the sole cytokine presenting a higher level in the VC group. The relevance of IFN-γ resides in its ability to inhibit viral replication. The maintenance of regular levels of this cytokine is a possible consequence of LTCD8⁺ activity. These cells have an important role in the expression of IFN-γ both in the innate immunological response (by natural killer T cells) and by CD8⁺ cytotoxic T lymphocytes once antigen-specific immunity develops [8, 42]. IFN-γ is also an inducer of inflammatory chemokines (MIG and IP-10) which are responsible for the recruitment of leucocytes to the inflammation site and act in the chronic immune activation [56–58]. Comparisons have been drawn among different groups. The chemokines were described in lower levels among elite controllers (named VC1 in the present study) in comparison to other groups capable of viral replication control without ART (named as VC2 group), HIV-1 negative volunteers and HIV-1 persons under ART, but it was coherently raised among those regular progressors [10, 12, 17]. It was not possible to show in our work 7or in any other, the extension of the inflammatory response, and considering the low levels, IFN-γ is probably more involved with control of viral replication, as we are dealing with a persistent and active viral infection. Most of the time it is shown that LTCD8⁺ producing IFN-γ are weak responders among the VC and their levels of production gradually increases among regular progressors under ART [31, 53, 59]. Inflammation markers are a common finding [60, 61] in the cases of treatment interruptions and the objectives of ART with the new protocol intend to suppress virus multiplication, prevent inflammation and provide an effective immune response.

Th1 and Th2 cytokine profile between the VC and NC groups, made it possible to observe the higher plasma concentration of Th2 cytokines in the NC group and Th1 cytokines in the VC. The immune response centered in Th1 cytokines reflects a non-progressive HIV-1 disease, but it may indicate a probable helper protection against HIV-1 infection promoting phagocytosis, stimulating NK cells, T lymphocytes and a consequent elimination of the virus, suggesting a low grade inflammation, persistence and low level viral replication. The exacerbation of Th2 cytokine profile leading to an increased humoral response, is not sufficient for the containment of intracellular infectious agents, contributing to viral multiplication and a faster progression to AIDS [62–64]. The down regulatory effect of IL-10 on Th1 cytokines was not evident among VC; indeed, the shift observed here from Th1 to Th2 cytokines is related to progression of HIV-1 disease. IgG antibody response to HIV-1 gradually increases from viral controllers to non-viral controllers [33, 39, 65–67] which is in clear agreement with this Th1 to Th2 signature change presented here. Our results point to a distinct hypothesis proposed [17, 68] who associate the AIDS progression to the continuous inflammatory environment. It is possible to suggest that an equilibrium of the cytokine Th1 synthesis, especially the IFN-y, could be more favorable to the VC regarding the activation of the cellular immune response, an important step against to impair viral replication.

Numerous comparisons have been drawn among the different groups, including elite controllers, viremia controllers, HIV-1 progressors (successfully being treated or not) and HIV-1 negative volunteers [10, 12, 17], but the definition of viral controllers was not consistent in the past [25, 69, 70] and it continues in the present. The description of this new and rare phenotype of HIV-1 infected persons, so far, has not elicited a successful characterization of the group and a large number of proposed definitions continue to impair a better understanding not only of the real prevalence numbers of the controllers, but also, of the biological mechanisms involved in the control of the virus, including those so called elite controllers [7–10, 12, 14, 71–75].

The recent suggestion for a new ART protocol [19–21], is also making us face a continuous and worrying increase in the adoption of the protocol to treat as soon as one discover his/her status of HIV-1 infection [37]. This will also soon hide all the chances to understand how the infection is modulated by the host in such a rare and special situation. Adherence to rigid criteria in the definition of viral controllers is still not attainable. The variables considered and the values taken into consideration with each of the groups, is far from a consensus. Laboratory variables, including immunological and virological ones, time of known infection, time of maintenance of virus under replicative control and decrease of host cell destruction in the absence of ART, should be more strictly followed. It is not possible to continuously face self-adequate, home made, laboratory, institution or country definitions for viral controller or elite controllers. It is relevant to mention that the conclusion of a large cohort study indicates that interruption of ART started at the early stages of infection is apparently not detrimental to treatment in the chronic phase of the disease [76].

The knowledge of viral controller characteristics in different population groups, including genetic background, is important to define an strict universal definition for the sake of learning about the pathogenesis of HIV-1. It is required to adhere to long periods of observation without ART, regular counts of LTCD4⁺ and LTCD8⁺ and undetected viremia. This will be the only possible way to compare such important information in order to understand the mechanisms which lead to the control of viral replication. Data on LTCD4⁺ seems to be stable and repetitive from published data, but the LTCD8⁺ response and the significance of LTCD4⁺/LTCD8⁺ ratio values are in need to further exploration as biomarkers. The change from Th1 to Th2 cytokine profile may help to design and adjust specific treatment protocols for the group.