Zidovudine Resensitization and Dual HIV-1 Resistance to Zidovudine and Lamivudine in the Delta Lamivudine Roll-Over Study

Objective

To study zidovudine resensitization and dual resistance to zidovudine/lamivudine in HIV-1 isolates from nucleoside reverse transcriptase (RT) inhibitor-experienced patients during selective pressure exerted by zidovudine/lamivudine combination therapy.

Design and methods

HIV-1 isolates from 29 patients receiving zidovudine/lamivudine combination therapy in the Delta roll-over study were analysed at entry and during a 1 year follow-up period for phenotypic susceptibility to zidovudine and lamivudine in the ANRS PBMC assay. The RT gene from codon 20 to 230 and at codon 333 was analysed by nucleotide sequencing of the corresponding isolates.

Results

HIV-1 isolates from 23 of the 29 patients were phenotypically resistant to zidovudine at baseline; 61% of these patients showed significant zidovudine resensitization during follow-up. The zidovudine IC50 value correlated positively with log10 plasma HIV-1 RNA ( P=0.02) and negatively with the CD4 cell count ( P=0.004). Zidovudine resensitization (related to acquisition of the M184V mutation) was transient, with evolution towards dual resistance to zidovudine and lamivudine in 20 of the 29 patients. The phenotype of certain dually resistant isolates coincided with the emergence of multiple mutations in the 5’ part of the RT gene.

Conclusions

M184V-mediated zidovudine resensitization of HIV-1 is transient in most patients who are given zidovudine/lamivudine combination therapy when zidovudine resistance has already emerged. The subsequent evolution towards dual phenotypic resistance to zidovudine/lamivudine corresponds to complex genotypic profiles.

Identification of a new human immunodeficiency virus type 1 distinct from group M and group O

A highly divergent HIV-1 isolate, designated YBF 30, was obtained in 1995 from a 40-year-old Cameroonian woman with AIDS. Depending on the genes studied, phylogenetic analysis showed that YBF30 branched either with SIVcpz-gab or between SIVcpz-gab and HIV-1 group M. The structural genes and tat, vpr, and nef of YBF30 are approximately equidistant from those of HIV-1 group M and SIVcpz-gab. In contrast, vif and rev are closer to HIV-1 group M, and vpu is highly divergent. Using a YBF30 V3 loop peptide enzyme immunoassay, we screened 700 HIV-1-positive sera collected in Cameroon; three reacted strongly with the YBF30 peptides and one was confirmed as being related to YBF30 by genetic analysis of a pol fragment. YBF30 is as distinct from SIVcpz-gab as it is from HIV-1 group M and can thus be considered as the prototype strain of a new human immunodeficiency virus group.

Changes in blood CD8+ lymphocyte activation status and plasma HIV RNA levels during antiretroviral therapy

OBJECTIVE

To analyse the relationship between CD8+ lymphocyte phenotype alterations and plasma HIV RNA levels in HIV-infected patients treated with the zidovudine-didanosine combination.

METHODS

A total of 30 HIV-infected patients who had never received antiretroviral therapy and who were starting treatment with a combination of zidovudine and didanosine were prospectively studied. Multiparameter flow cytometric analysis of CD8+ lymphocytes and plasma HIV RNA determination were performed on day 0, day 15 and monthly from months 1 to 6.

RESULTS

Patients were divided into three categories according to the time-course of plasma HIV RNA levels. In 14 patients, an early and sustained fall in plasma HIV RNA to below the detection limit (500 copies/ml) was observed; in 10 patients, the fall was transient; in six patients, plasma HIV RNA was always detectable (non-responders). The mean CD4+ lymphocyte gain was 120 x 10(6)/l at month 6 in sustained and transient responders, and 55 x 10(6)/l in non-responders. A significant fall in the proportion of CD8+ lymphocytes with an activated phenotype was observed only in the two groups of responders, and was higher in the sustained responders (CD38+HLA-DR+, -56.8%; CD38+CD45RO+, -54.0%; HLA-DR+CD45RO+, -48.4%; CD38+CD28-, -47.3%).

CONCLUSION

A fall in the proportion of activated CD8+ lymphocytes is associated with the disappearance of HIV RNA from plasma during antiretroviral therapy. Undetectable plasma HIV RNA is not associated with a return to normal CD8+ lymphocyte activation status after 6 months of treatment, suggesting that viral replication persists in lymphoid tissues.

HIV type 1 diversity and the reliability of the heteroduplex mobility assay

We investigated HIV-1 diversity by means of heteroduplex mobility assay (HMA) genotyping. We studied 199 samples from patients originating from 26 countries and living in France. The HMA successfully genotyped 182 (91%) of these samples, as follows: 77 (42%) subtype A, 57 (31%) subtype B, 5 (3%) subtype C, 5 (3%) subtype D, 8 (4%) subtype E, 22 (12%) subtype F, 5 (3%) subtype G, and 3 (2%) subtype H. We were not able to genotype 12 samples by means of the HMA. These latter strains were sequenced, and phylogenetic analyses revealed that they were highly divergent subtype A-, D-, or G-related strains. Eight (of 12) subtype D strains were indeterminate by HMA, owing to the broad intrasubtype diversity, suggesting that new reference subtype D plasmids are required, as previously proposed. Thirty-seven strains belonging to the different subtypes were sequenced, and the results showed perfect concordance with the HMA results. Interlaboratory quality controls confirmed the reliability of the HMA for HIV-1 subtyping, despite the extensive viral variability. However, plasmid selection must be continuously revised to cover viral diversification.

Line probe assay for detection of human immunodeficiency virus type 1 mutations conferring resistance to nucleoside inhibitors of reverse transcriptase: comparison with sequence analysis

We compared the line probe assay (LiPA) to sequence analysis for the detection of mutations conferring resistance to nucleoside inhibitors of human immunodeficiency virus type 1 (HIV-1) reverse transcriptase (RT). Plasma samples from 40 patients who had received zidovudine, dideoxyinosine, and dideoxycytosine, alone or in combination, and who were enrolled in the ALTIS 2 clinical trial (lamivudine [3TC] plus stavudine) were tested at enrollment and at week 24. RT PCR products from plasma were used for LiPA, and DNA was used for sequence analysis. LiPA gave uninterpretable results for 8.5% of the analyzed codons corresponding to 63 samples, mainly for codons 41, 69, and 70. Several minor discrepancies between the two methods occurred, mainly due to the ability of LiPA to detect mixed populations while sequence analyses detect a single homogeneous population. LiPA is suitable for detecting mixed populations and easy to implement in clinical laboratories and might be useful for epidemiological surveys of primary HIV-1 resistance.

Antiretroviral drug resistance testing in adults with HIV infection: implications for clinical management. International AIDS Society--USA Panel

OBJECTIVES

To review current knowledge of the biology and clinical implications of human immunodeficiency virus (HIV) resistance to antiretroviral drugs, describe assays for measuring resistance, and assess their use in clinical practice.

PARTICIPANTS

The International AIDS Society-USA assembled a panel of 13 physicians with expertise in basic science, clinical research, and patient care relevant to HIV resistance to antiretroviral drugs.

EVIDENCE

We reviewed available data from published reports and presented at national and international research conferences. Basic science research, clinical trial results, and expert opinions were used to form the basis of this report. Data on methods for and characteristics of specific genotypic and phenotypic assays were obtained from manufacturers and service providers.

CONSENSUS PROCESS

The panel met regularly between October 1997 and April 1998. Panel subgroups developed and discussed different sections of the report before discussing them with the entire panel. Conclusions and suggested approaches to the use of resistance testing were determined by group consensus.

CONCLUSIONS

Plasma HIV RNA level and CD4+ cell count are the primary values that should be used to guide the initiation of antiretroviral therapy and subsequent changes in therapy. Possible causes of treatment failure other than development of drug resistance that should be considered are adherence, drug potency, and pharmacokinetic issues. Genotypic and phenotypic testing for HIV resistance to antiretroviral drugs may prove useful for individual patient management. Assays under development need validation, standardization, and a clearer definition of their clinical roles. Possible current roles of resistance testing for choosing an initial regimen or changing antiretroviral therapy, as well as possible implications of the presence or absence of phenotypic resistance and genotypic changes, are discussed.

HIV-1 diversity in Romania

OBJECTIVES

To evaluate the prevalence and the dynamics of HIV-1 subtypes in Romanian adults and children, and to investigate the origins of the nosocomial epidemic.

DESIGN

A total of 1000 serum and plasma samples, from adults (n = 579) and children (n = 421) who were diagnosed as being HIV-1-infected during 1990-1997 in 39 of the 41 Romanian districts, were serotyped. Viral DNA was isolated from blood samples of 84 patients and the viruses were genotyped.

METHODS

Serotyping was performed with a peptide subtype-specific enzyme immunoassay (SSEIA), based on in vitro competition for antibody binding between the representative V3 peptides of the different clades (A-F). Proviral HIV-1 DNA was genotyped by heteroduplex mobility assay or by sequence analysis of the C2-V3 env region.

RESULTS

SSEIA showed that 93% of the samples from horizontally infected children were serotype F, 1% were serotype B, and the remaining 6% were uninterpretable. In vertically infected children, 74% of strains were serotype F, 10% were serotype A, 3% were serotype B, and 3% were serotype E. Serotype F was also the dominant subtype in adults (68%), but serotypes A, B, C, D and E were also detected. SSEIA gave indeterminate results in 7% of cases. A strong correlation (90%) between serotyping and genotyping for subtype F was found. Analysis of the relative incidence of the different serotypes over a 7-year period (1990-1997) showed a stable distribution.

CONCLUSIONS

Subtype F largely dominates the epidemiology of HIV-1 infection in both children and adults in Romania, although other major subtypes are present. The predominance of subtype F in Romania may be a future potential source of HIV-1 variability in Europe.

Human immunodeficiency virus type 1 subtype F reverse transcriptase sequence and drug susceptibility

We sequenced and phylogenetically analyzed the reverse transcriptase (RT) regions of the pol genes of 14 human immunodeficiency virus type 1 (HIV-1) isolates from Romanian patients, which were classified as subtype F on the basis of env gene structure. The RT sequences showed that the strains clustered phylogenetically and were equidistant from other HIV-1 subtypes as shown by the neighbor-joining and maximum-likelihood methods, allowing us to define HIV-1 subtype F according to the pol classification. The subtype F RT sequences differed from reported group M RT sequences by 10.94% (for nucleotides) and 7.6% (for amino acids). Phenotypic analysis of subtype F susceptibility to three classes of antiretroviral compounds showed an increase in the 50% inhibitory concentration of the tetrahydroimidazo[4,5,1-jk] [1,4]-benzodiazepin-2-(1H)-one and -thione (TIBO) derivate R82913 for one strain which was naturally resistant to this compound. This first report of subtype F pol sequences confirms the perfect correlation between the phylogenetic positions determined by env and pol analyses and suggests that virus variability might influence the efficacy of antiretroviral treatments. This finding warrants a global evaluation of the phenotypic and genotypic susceptibility of HIV-1 subtypes to antiretroviral drugs.

Switch to unusual amino acids at codon 215 of the human immunodeficiency virus type 1 reverse transcriptase gene in seroconvertors infected with zidovudine-resistant variants

Sequences of the human immunodeficiency virus type 1 (HIV-1) reverse transcriptase (RT) domain were determined by direct sequencing of HIV-1 RNA in successive plasma samples from eight seroconverting patients infected with virus bearing the T215Y/F amino acid substitution associated with zidovudine (ZDV) resistance. At baseline, additional mutations associated with ZDV resistance were detected. Three patients had the M41L amino acid change, which persisted. Two patients had both the D67N and the K70R amino acid substitutions; reversion to the wild type was seen at both positions in one of these patients and at codon 70 in the other one. Reversion to the wild type at codon 215 was observed in only one of eight patients. Unusual amino acids, such as aspartic acid (D) and cysteine (C), appeared at position 215 in four patients during follow-up. These variants isolated by coculturing were sensitive to ZDV. Overgrowth of these variants suggests that they have better fitness than the original T215Y variant. Intraindividual nucleoside substitutions over time were 10 times more frequent in codons associated with ZDV resistance (41, 67, 70, 215, and 219) than in other codons of the RT domain. The predominance of nonsynonymous substitutions observed over time suggests that most changes reflect adaptation of the RT function. The variance in sequence evolution observed among patients, in particular at codon 215, supports a role for chance in the evolution of the RT domain.

Highly sensitive method for amplification of human immunodeficiency virus type 2 DNA

We evaluated a new human immunodeficiency virus type 2 (HIV-2) DNA amplification strategy based on peripheral blood mononuclear cell long PCR (XL PCR) followed by nested PCR amplification. The primers used were located in the highly conserved long terminal repeat and in the pol regions of the genome. Five primer pairs corresponding to different regions of the HIV-2 env gene were used in the nested step. Samples from 42 patients were tested, which yielded positive amplification with at least two primer pairs in 40 (95%) samples. A primer pair (EB2/EB5) located on the V3 region succeeded in amplifying proviral DNA in 40 samples.

Susceptibility of human immunodeficiency virus type 1 group O isolates to antiretroviral agents: in vitro phenotypic and genotypic analyses

We investigated the phenotypic and genotypic susceptibility of 11 human immunodeficiency virus type 1 (HIV-1) group O strains to nucleoside and nonnucleoside reverse transcriptase (RT) inhibitors and protease inhibitors in vitro. Phenotypic susceptibility was determined by using a standardized in vitro assay of RT inhibition, taking into account the replication kinetics of each strain. HIV-1 group M and HIV-2 isolates were used as references. DNA from cocultured peripheral blood mononuclear cells was amplified by using pol-specific group O primers and cloned for sequencing. Group O isolates were highly sensitive to nucleoside inhibitors, but six isolates were naturally highly resistant to all of the nonnucleoside RT inhibitors tested. Phylogenetic analysis of the pol gene showed that these isolates formed a separate cluster within group O, and genotypic analysis revealed a tyrosine-to-cysteine substitution at residue 181. Differences in susceptibility to saquinavir and ritonavir (RTV) were not significant between group O and group M isolates, although the 50% inhibitory concentration of RTV for group O isolates was higher than that for the HIV-1 subtype B strains. The study of HIV-1 group O susceptibility to antiretroviral drugs revealed that the viruses tested had specific phenotypic characteristics contrasting with the group M phenotypic expression.

HIV-1 viral load, phenotype, and resistance in a subset of drug-naive participants from the Delta trial. The National Virology Groups. Delta Virology Working Group and Coordinating Committee

BACKGROUND

The Delta trial showed that combination therapy (zidovudine plus didanosine and zidovudine plus zalcitabine) substantially lengthened life and reduced disease progression compared with zidovudine monotherapy. We did a nested virological study in three countries (France, the Netherlands, and the UK) to investigate changes in markers for viral load and antiretroviral-drug resistance during therapy.

METHODS

240 zidovudine-naive HIV-1-infected patients were randomly assigned zidovudine only (n = 87), zidovudine plus didanosine (n = 80), or zidovudine plus zalcitabine (n = 73). Viral load in peripheral-blood mononuclear cells and plasma was measured by quantitative culture. Plasma HIV-1 RNA was measured by reverse-transcriptase PCR amplification, and serum p24 antigen by ELISA. Resistance to antiretroviral drugs was measured phenotypically by culture and genotypically by detection and quantification of drug-related point mutations in the pol gene. Analyses were done by intention to treat.

FINDINGS

The reduction in viral load was greatest 4-12 weeks after the start of therapy and was most pronounced in the combination-therapy study groups (median reductions of RNA at 4 weeks 1.58, 1.28, and 0.49 log10 copies/mL for zidovudine plus didanosine, zidovudine plus zalcitabine, and zidovudine only, respectively). RNA levels at 8 weeks were predictive of disease progression and death after allowance for baseline values. At 48 weeks, the proportion of participants with phenotypic zidovudine resistance was similar in all three groups: didanosine and zalcitabine resistance were rare; zidovudine genomic resistance correlated with phenotypic resistance (r = 0.54, p < 0.0001) and developed earlier in the combined-therapy groups. However, participants in the zidovudine monotherapy group had higher circulating loads of resistant virus than those in the combined-therapy groups.

INTERPRETATION

Combined antiretroviral therapy was more efficient at lowering virus load than monotherapy. Although zidovudine resistance was common in monotherapy and combined-therapy groups, circulating concentrations of resistant virus were substantially lower in the combination groups, which is likely to be a result of the continued antiviral activity of didanosine or zalcitabine.

Synthetic peptide ELISAs for detection of and discrimination between group M and group O HIV type 1 infection

We developed and evaluated two peptide-based immunoassays to confirm and discriminate between group M and group O HIV-1 infection. These assays are based on in vitro competition for antibody binding between M and O peptides. The first EIA is based on competition between group M and group O gp41 immunodominant domains and the second on competition between group O and group M V3 regions of gp120. Two panels of sera were used: the first consisted of 109 sera collected from 27 group O- and 92 group M-infected patients in whom the HIV isolates had been genotyped by sequencing or heteroduplex mobility assay. In this panel, the combination of the two assays correctly discriminated 106 samples (100% group O and 96.7% group M samples). The second panel, used for the field evaluation of the two assays, consisted of 157 samples from HIV-1-infected Cameroonian patients, 33 strains having been genotyped. The combination of the two techniques in a serogrouping algorithm discriminated 147 of these samples, 74 being HIV-1 group O and 73 group M. These results always correlated with genotyping results. The 10 sera that were not successfully classified by these assays were from early seroconverters. Altogether, the two assays clearly differentiated 263 of 276 (94.9%) samples in the two panels. On the basis of the genotyping results, the positive predictive value for group discrimination in the two panels was 100% for both GSEIA assays. Our peptide-blocking group-specific EIAs for differentiation and confirmation of HIV-1 group M and group O infection are complementary tools for epidemiological studies and surveillance of HIV-1 group O strain trafficking.

Cytomegalovirus (CMV) viremia and the CD4+ lymphocyte count as predictors of CMV disease in patients infected with human immunodeficiency virus

We screened 192 patients infected with human immunodeficiency virus (HIV) to examine the relation between CD4+ lymphocyte counts and cytomegalovirus (CMV) viremia and the occurrence of CMV disease and subsequent duration of survival. When we stratified the viremic patients by CD4+ lymphocyte counts, the proportions were as follows: <50/mm3, 20 (25%) of 80 patients; 50-100/mm3, 2 (5.5%) of 36; 101-150/mm3, none of 14; and >150/mm3, 1 (1.5%) of 62. After a mean follow-up period of 8.5 months, 21 (11%) of 192 patients developed CMV disease. The probability of developing CMV disease at 6 months was 13% when the CD4+ lymphocyte count was <50/mm3, 3% when the CD4+ lymphocyte count was 50-100/mm3, and 0 when the CD4+ lymphocyte count was >100/mm3; this probability was 46% for viremic patients and 1% for nonviremic patients. In a multivariate analysis, CMV viremia was independently prognostic of CMV disease (relative risk, 22.03; 95% confidence interval, 6.49-78.97; P < .001), whereas a CD4+ lymphocyte count of <50/mm3 was not (P = .26). These results support the value of CMV viremia for predicting which HIV-infected patients are at risk of developing CMV disease and should therefore receive primary prophylaxis.

[Drugs active against retroviruses]

Major advances in understanding the pathogenesis and treatment of human immunodeficiency virus (HIV) infection have been made recently. The reverse transcriptase and protease enzymes of HIV are currently the targets of antiretroviral therapy. Nucleoside analogues were the first class of antiretroviral drugs which demonstrated antiviral activity in treating patients. More recently protease inhibitors have provided new approaches in the treatment of HIV infection, with encouraging trial results in patients receiving combined therapy. This review presents their mechanisms of activity and patterns of resistance. Apart from these main drug groups many new compounds are under development.

Serological and virological characterization of HIV-1 group O infection in Cameroon

OBJECTIVES

To study the presence of HIV-1 group O infection among HIV-infected people in Cameroon and to further characterize the HIV-1 group O infections.

DESIGN AND METHODS

During a 2-year survey (1994-1995), all samples tested positive in screening methods in the National Reference and Public Health Laboratory, Centre Pasteur, Yaoundé, Cameroon were identified as HIV-1 group M, HIV-1 group O or HIV-2 by using a serological algorithm. HIV-1 group M and HIV-1 group O were distinguished on the basis of competitive enzyme-linked immunosorbent assay (ELISA) reactivity against gp41 group M recombinant protein. HIV-1 group O infections were confirmed by using group O-specific V3 synthetic peptides. HIV-1 group O strains were isolated by lymphocyte cocultures, proviral DNA was amplified with specific primers, and sequencing was performed on the C2V3 and gag regions.

RESULTS

Of the 8,331 screened samples, 3,193 were HIV-reactive, 2,376 (74%) of which were considered to belong to group M. The 817 (26%) that had reacted poorly or not at all against group M gp41 were further characterized: 10 were confirmed as HIV-2 and 82 as HIV-1 group O, the others being indeterminate (n = 285) or negative (n = 440). The frequency of group O relative to group M ranged from 1% in Far North province to 6.3% in the capital. There was no difference in sex, age or frequency of clinical manifestations between group M and group O infections. Group O infection was confirmed in a subset of cases by polymerase chain reaction (n = 14), with perfect concordance. Sequencing and phylogenetic analyses confirmed the high variability inside group O.

CONCLUSIONS

Group O and group M epidemiological patterns are known to be similar so the reason for the lower prevalence of group O remains to be found. The wide distribution of group O infection in all Cameroonian provinces underlines the importance of further characterizing the epidemic spread and diffusion of this group.

Lack of screening test sensitivity during HIV-1 non-subtype B seroconversions

OBJECTIVE

To evaluate the serological consequences of HIV-1 group M diversity we studied the ability of screening tests to detect anti-HIV antibodies in early seroconverters infected by different HIV subtypes.

SETTING

Virology Department, Bichat-Claude Bernard Hospital, Paris, France.

DESIGN AND METHODS

Symptomatic patients with serial samples and with infective strains characterized by heteroduplex mobility assay. In each case, two sera were selected. The first (pre-seroconversion sample) was the last p24 antigen-positive/Western blot-non-reactive sample. The second (seroconversion sample) was the first Western blot-reactive sample. One second-generation enzyme immunoassay (EIA; Abbott) based on anti-human immunoglobulin (Ig) G-conjugate and three third generation EIA (Abbott; Enzygnost; Genscreen) based on the double antigen sandwich principle, detecting IgM and IgG, were used.

RESULTS

Ten patients had subtype B strains and nine had non-B strains (seven were A, one E and one G). The Abbott third-generation test was more sensitive than the second generation test for pre-seroconversion subtype B samples (nine versus four out of 10; P < 0.05), but not for non-B subtypes; only two of the nine non-B sera tested were positive by both EIA. Positivity rates and optical densities differed (P < 0.05) between B and non-B subtypes in all third-generation EIA. There was no significant difference between the subtype B and non-B groups with regard to the interval between the pre-seroconversion sample and the seroconversion sample (subtype B, 6.7 +/- 2.6 days; non-B, 5.2 +/- 1.7 days). No significant difference in positivity rates and optical densities were found between B and non-B subtypes in these seroconversion samples.

CONCLUSION

The shorter time since HIV infection required for sera to become reactive in third-generation EIA screening tests is due to better sensitivity for subtype B strains only. These results stress the importance of strict donor selection, the need to test screening kits against large panels of all subtypes, and the place of p24 antigen testing in closing the window of seroconversion.

V3 loop sequence analysis of seven HIV type 1 group O isolates phenotyped in peripheral blood mononuclear cells and MT-2 cells

HIV-1-infected individuals from which syncytium-inducing (SI) viruses are isolated most often progress more rapidly to AIDS than individuals carrying only non-syncytium-inducing (NSI) viruses. The syncytium-inducing capacity of virus isolates is commonly determined in conjunction to replication in MT-2 cells. Comparison of HIV-1 env sequences and a site-directed mutagenesis study have indicated that the presence of a positively charged amino acid at position 11 or 25 in the V3 loop is minimally required for the SI capacity of HIV-1 subtype B viruses. Studies have also shown a similar correlation between positively charged signature amino acids in the V3 loop and syncytium formation in MT-2 cells for HIV-1 subtypes A, D, and E. In the present study virus phenotype was determined and compared to the V3 loop sequence of seven HIV-1 group O isolates. Three of the HIV-1 group O isolates showed the NSI/non-MT-2 tropic phenotype and two showed the SI/MT-2 tropic phenotype, whereas two isolates presented an uncommon NSI/MT-2 tropic phenotype. The V3 loop of the two SI/MT-2 tropic isolates had a high net positive charge and contained a positively charged amino acid at position 11 or 25. The V3 loop of the two NSI/MT-2 tropic isolates had a low net positive charge and contained a single positively charged amino acid at position 37.

HIV type 1 diversity in northern Paris, France

During a 6-month period, we studied the diversity of HIV-1 subtypes in 392 adult patients seen in Bichat-Claude Bernard Hospital, northern Paris, France. All the samples were serotyped and a subset was genotyped by means of HMA. Serotyping was performed with a new peptide subtype-specific EIA (SSEIA), based on in vitro competition for antibody binding between the representative V3 peptides of the different clades (A to E). HMA with plasmids from clades A to H gave unambiguous results on 105 of the 116 samples tested. The agreement between SSEIA and HMA was 36/41 for subtype B, 2/2 for subtype D, and 4/5 for subtype E. We found a discrepancy in the results between clade A and C: the patients with sera reacting to peptide C were confirmed by HMA as being infected by clade A strains. Three patients reactive with peptide A were infected by a subtype F. These results indicate that peptide cross-reactivity, even in the SSEIA format, hinders serotyping. In 11 samples, all from African patients, the subtype remained indeterminate because PCR or HMA failed. Caucasian patients (n = 223) were mainly infected by subtype B. HMA and/or SSEIA revealed non-subtype B infection in 14 Caucasians, who were infected by the sexual route overseas or in France. Patients originating from other countries (mainly in Africa) exhibited a broad strain diversity, with most of the different subtypes so far described being represented. This study confirms the frequency of subtype B strains in Caucasians living in France, but emphasizes the emergence of the different HIV-1 subtypes in Paris, together with the extent of strain trafficking. Discordances between serotype and genotype assays confirm that both tests require additional development.