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Peixoto RT, Nogueira LFS, de Oliveira SA, Souza VD, Felipo BSL. Study of HIV Resistance Mutations Against Antiretrovirals using Bioinformatics Tools. Curr HIV Res 2020; 17:343-349. [PMID: 31629397 DOI: 10.2174/1570162x17666191019114250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 09/25/2019] [Accepted: 10/08/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Antiretroviral drugs to HIV-1 (ARV) are divided into classes: Nucleotide Reverse Transcriptase Inhibitors (NRTIs); Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs); Protease Inhibitors (PIs); Integrase Inhibitors (INIs); fusion inhibitors and entry Inhibitors. The occurrence of mutations developing resistance to antiretroviral drugs used in HIV treatment take place in a considerable proportion and has accumulated over its long period of therapy. OBJECTIVE This study aimed to identify resistance mutations to antiretrovirals used in the treatment of HIV-1 in strains isolated from Brazilian territory deposited at Genbank, as well as to relate to the clinical significance and mechanism of action. METHODS Elucidation of these mutations was by comparative method of peptide sequence resulting from genes encoding therapeutic targets in HIV antiretroviral therapy (ART) of the strains with a reference sequence through bioinformatic genetic information manipulation techniques. RESULTS Of the 399 sequences analyzed, 121 (30.3%) had some type of mutations associated with resistance to some class of antiretroviral drug. Resistance to NNRTIs was the most prevalent, detected in 77 (63.6%) of the 121 mutated sequences, compared to NRTIs and PIs, whose resistance was detected in 60 (49.6%) and 21 (17.3%), respectively, and to INIs, only 1 (0.8%) sample showed associated resistance mutation. CONCLUSION Resistance to HIV ARV was detected at a considerable rate of 30.3%, showing some concerns about the percentage of viral strains that escape the established therapeutic regimen and that circulate currently in Brazil. The non-use of NNRTIs in Brazil is justified by the emergence of resistance mutations. The low prevalence of mutations against INIs is because drugs in this class have a high genetic barrier.
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Affiliation(s)
- Roca Tárcio Peixoto
- Faculdades Integradas Aparicio Carvalho-FIMCA, School of Biomedicine, Research Group on Health Sciences, Porto Velho, Brazil.,Laboratório de Virologia Molecular, Fundação Oswaldo Cruz Rondônia-FIOCRUZ-RO, Porto Velho, Brazil.,Universidade Federal de Rondônia - UNIR, Porto Velho, Brazil
| | - Lima Felipe Souza Nogueira
- Faculdades Integradas Aparicio Carvalho-FIMCA, School of Biomedicine, Research Group on Health Sciences, Porto Velho, Brazil.,Laboratório de Virologia Molecular, Fundação Oswaldo Cruz Rondônia-FIOCRUZ-RO, Porto Velho, Brazil.,Universidade Federal de Rondônia - UNIR, Porto Velho, Brazil
| | - Santos Alcione de Oliveira
- Faculdades Integradas Aparicio Carvalho-FIMCA, School of Biomedicine, Research Group on Health Sciences, Porto Velho, Brazil.,Laboratório de Virologia Molecular, Fundação Oswaldo Cruz Rondônia-FIOCRUZ-RO, Porto Velho, Brazil.,Universidade Federal de Rondônia - UNIR, Porto Velho, Brazil
| | - Vieira Deusilene Souza
- Faculdades Integradas Aparicio Carvalho-FIMCA, School of Biomedicine, Research Group on Health Sciences, Porto Velho, Brazil.,Laboratório de Virologia Molecular, Fundação Oswaldo Cruz Rondônia-FIOCRUZ-RO, Porto Velho, Brazil.,Universidade Federal de Rondônia - UNIR, Porto Velho, Brazil
| | - Botelho-Souza Luan Felipo
- Faculdades Integradas Aparicio Carvalho-FIMCA, School of Biomedicine, Research Group on Health Sciences, Porto Velho, Brazil.,Laboratório de Virologia Molecular, Fundação Oswaldo Cruz Rondônia-FIOCRUZ-RO, Porto Velho, Brazil.,Universidade Federal de Rondônia - UNIR, Porto Velho, Brazil.,National Institutes of Science and Technology - CNPq- INCT-EpiAmO, Porto Velho, Brazil
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HIV-1 subtypes and drug resistance profiles in a cohort of heterosexual patients in Istanbul, Turkey. Med Microbiol Immunol 2015; 204:551-5. [PMID: 25916350 DOI: 10.1007/s00430-015-0419-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 04/20/2015] [Indexed: 12/23/2022]
Abstract
Turkey is seeing a steady rise in rates of HIV infection in the country. The number of individuals with HIV/AIDS was greater than 7000 in 2014 according to data released by the Ministry of Health, and heterosexual contacts were reported to be the main transmission routes. Istanbul has the highest number of reported cases of HIV infection. The aim of the study was to determine the prevalence of HIV-1 drug resistance in 50 heterosexual patients from Istanbul. The most prevalent subtype was found to be subtype B (56.2 %). Resistance-associated mutations were found in 14 patients with 6/14 patients being therapy-experienced and 8/14 therapy naive at the time point of analysis. With increasing number of patients who require treatment and the rapid up-scaling of the antiretroviral therapy in Turkey, HIV-1 drug resistance testing is recommended before starting treatment in order to achieve better clinical outcomes.
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Azam M, Malik A, Rizvi M, Rai A. Trends of drug-resistance-associated mutations in the reverse transcriptase gene of HIV type 1 isolates from North India. Arch Virol 2013; 159:719-25. [DOI: 10.1007/s00705-013-1889-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 10/08/2013] [Indexed: 11/24/2022]
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Koning FA, Castro H, Dunn D, Tilston P, Cane PA, Mbisa JL. Subtype-specific differences in the development of accessory mutations associated with high-level resistance to HIV-1 nucleoside reverse transcriptase inhibitors. J Antimicrob Chemother 2013; 68:1220-36. [PMID: 23386260 DOI: 10.1093/jac/dkt012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To identify accessory mutations associated with high-level resistance to reverse transcriptase (RT) inhibitors in HIV-1 subtypes B and C. METHODS Changes relative to the wild-type for codons 1-400 of RT were analysed from treatment-experienced patients infected with subtypes B (5464 patients) and C (1920 patients). Positions associated with the accumulation of mutations conferring resistance to thymidine analogues and to non-nucleoside RT inhibitors (NNRTIs) were identified. A subtype-specific single-replication cycle drug susceptibility assay was used to determine whether some of the mutations affected drug susceptibility or viral infectivity. RESULTS In subtype B, mutations at 31 and 26 positions were associated with the accumulation of thymidine analogue mutations (TAMs) and NNRTI mutations, respectively; in subtype C, 18 and 13 positions were identified, respectively. Amino acid changes at the following positions were differentially associated with (i) the accumulation of 0-4+ TAMs in subtypes B and C (away from consensus): 43 (27.0% B versus 2.5% C); 118 (36.4% B versus 16.2% C); 135 (12.5% B versus 28.0% C); and 326 (2.6% towards consensus in B versus 7.6% away in C) and (ii) the accumulation of 0-3+ NNRTI mutations (away from consensus): 43 (10.2% B versus 0.5% C); and 68 (5.2% B versus 10.3% C). Codon changes K43E, E44D and V118I were found to have no effect on susceptibility to three NRTIs with or without TAMs in either subtype; however, some accessory mutations had subtype-specific effects on viral infectivity. CONCLUSIONS Differences between subtypes B and C were observed in the development and effect of accessory mutations associated with high-level resistance to RT inhibitors.
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Affiliation(s)
- F A Koning
- Antiviral Unit, Virus Reference Department, Health Protection Agency, London, UK
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Detection of minority resistance during early HIV-1 infection: natural variation and spurious detection rather than transmission and evolution of multiple viral variants. J Virol 2011; 85:8359-67. [PMID: 21632754 DOI: 10.1128/jvi.02582-10] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Reports of a high frequency of the transmission of minority viral populations with drug-resistant mutations (DRM) are inconsistent with evidence that HIV-1 infections usually arise from mono- or oligoclonal transmission. We performed ultradeep sequencing (UDS) of partial HIV-1 gag, pol, and env genes from 32 recently infected individuals. We then evaluated overall and per-site diversity levels, selective pressure, sequence reproducibility, and presence of DRM and accessory mutations (AM). To differentiate biologically meaningful mutations from those caused by methodological errors, we obtained multinomial confidence intervals (CI) for the proportion of DRM at each site and fitted a binomial mixture model to determine background error rates for each sample. We then examined the association between detected minority DRM and the virologic failure of first-line antiretroviral therapy (ART). Similar to other studies, we observed increased detection of DRM at low frequencies (average, 0.56%; 95% CI, 0.43 to 0.69; expected UDS error, 0.21 ± 0.08% mutations/site). For 8 duplicate runs, there was variability in the proportions of minority DRM. There was no indication of increased diversity or selection at DRM sites compared to other sites and no association between minority DRM and AM. There was no correlation between detected minority DRM and clinical failure of first-line ART. It is unlikely that minority viral variants harboring DRM are transmitted and maintained in the recipient host. The majority of low-frequency DRM detected using UDS are likely errors inherent to UDS methodology or a consequence of error-prone HIV-1 replication.
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Huigen MCDG, van Ham PM, de Graaf L, Kagan RM, Boucher CAB, Nijhuis M. Identification of a novel resistance (E40F) and compensatory (K43E) substitution in HIV-1 reverse transcriptase. Retrovirology 2008; 5:20. [PMID: 18271957 PMCID: PMC2276231 DOI: 10.1186/1742-4690-5-20] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2007] [Accepted: 02/13/2008] [Indexed: 01/05/2023] Open
Abstract
Background HIV-1 nucleoside reverse transcriptase inhibitors (NRTIs) have been used in the clinic for over twenty years. Interestingly, the complete resistance pattern to this class has not been fully elucidated. Novel mutations in RT appearing during treatment failure are still being identified. To unravel the role of two of these newly identified changes, E40F and K43E, we investigated their effect on viral drug susceptibility and replicative capacity. Results A large database (Quest Diagnostics database) was analysed to determine the associations of the E40F and K43E changes with known resistance mutations. Both amino acid changes are strongly associated with the well known NRTI-resistance mutations M41L, L210W and T215Y. In addition, a strong positive association between these changes themselves was observed. A panel of recombinant viruses was generated by site-directed mutagenesis and phenotypically analysed. To determine the effect on replication capacity, competition and in vitro evolution experiments were performed. Introduction of E40F results in an increase in Zidovudine resistance ranging from nine to fourteen fold depending on the RT background and at the same time confers a decrease in viral replication capacity. The K43E change does not decrease the susceptibility to Zidovudine but increases viral replication capacity, when combined with E40F, demonstrating a compensatory role for this codon change. Conclusion In conclusion, we have identified a novel resistance (E40F) and compensatory (K43E) change in HIV-1 RT. Further research is indicated to analyse the clinical importance of these changes.
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Affiliation(s)
- Marleen C D G Huigen
- Department of Medical Microbiology, University Medical Center Utrecht, The Netherlands.
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de Medeiros LB, Lacerda HR, Cavalcanti AMS, de Albuquerque MDFPM. Primary resistance of human immunodeficiency virus type 1 in a reference center in Recife, Pernambuco, Brazil. Mem Inst Oswaldo Cruz 2007; 101:845-9. [PMID: 17293977 DOI: 10.1590/s0074-02762006000800004] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2006] [Accepted: 09/20/2006] [Indexed: 11/22/2022] Open
Abstract
To assess the prevalence of primary resistance of human immunodeficiency virus type 1 (HIV-1) to antiretrovirals, 84 patients chronically infected with HIV without prior antiretroviral treatment from Northeast Brazil were studied. Genotyping was performed using the ViroSeq Genotyping System. Thimidine analog mutations occurred in 3 (3.6%) patients. Accessory mutations related to NRTI occurred in 6 (7.1%) and related to PI in 67 (79.8%). Subtypes B (72.6%), F (22.6%), B/F 3 (3.6%), and C (1.2%) were detected. A low prevalence of major mutations related to NRTI in patients chronically infected by HIV was observed.
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Affiliation(s)
- Luzidalva Barbosa de Medeiros
- Hospital das Clínicas, Departamento de Medicina Clínica, Universidade Federal de Pernambuco, Cidade Universitária, Recife, PE, Brasil
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Zaccarelli M, Tozzi V, Lorenzini P, Forbici F, Narciso P, Ceccherini-Silberstein F, Trotta MP, Bertoli A, Liuzzi G, Marconi P, Mosti S, Perno CF, Antinori A. The V118I Mutation as a Marker of Advanced HIV Infection and Disease Progression. Antivir Ther 2007. [DOI: 10.1177/135965350701200210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The V118I mutation is included in the nucleoside analogue mutations (NAMs) set. It contributes to thymidine-analogue resistance and, consequently, to resistance to the whole nucleoside reverse transcriptase inhibitor (NRTI) class. We focused on the V118I mutation in order to evaluate factors associated with its detection and its relationship with HIV progression. Methods Clinical and laboratory data at genotypic resistance test (GRT) of highly active antiretroviral therapy-failing patients were collected and their association with the V118I mutation was analysed. Patients were also followed over time to determine factors related to progression to a new AIDS-related event or death. Results Of the 792 patients included, 114 (14.4%) carried the V118I mutation. In univariate analysis, the V118I mutation was significantly associated with a higher HIV RNA level, lower CD4+ T-cell count, Centers for Disease Control and Prevention (CDC) stage C, higher number of pre-GRT regimens and class-wide resistance (CWR) to NRTIs, protease inhibitors and non-nucleoside reverse transcriptase inhibitors. Higher numbers of pre-GRT regimens and NRTI CWR were also associated in the multivariable analysis. Within the post-GRT observation period of up to 6 years (median: 72 months; interquartile range: 33–109) 107 events (58 new AIDS-related diseases and 49 deaths) were observed. Using the Cox proportional hazard model and the major clinical, behavioural and laboratory data, the V118I mutation was found to be associated with the endpoint (hazard ratio: 1.93, 95% confidence interval: 1.06–3.50; P=0.031). Other factors associated with disease progression were CDC stage C and lower CD4+ T-cell count at GRT. Conclusions The analysis of our observational database suggests that the onset of the V118I mutation after treatment failure is unfavourable for the patient and can be considered a strong marker of disease progression.
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Affiliation(s)
- Mauro Zaccarelli
- Clinical Department, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy
| | - Valerio Tozzi
- Clinical Department, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy
| | - Patrizia Lorenzini
- Clinical Department, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy
| | - Federica Forbici
- Virological Department, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy
| | - Pasquale Narciso
- Clinical Department, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy
| | | | - Maria Paola Trotta
- Clinical Department, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy
| | - Ada Bertoli
- Virological Department, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy
| | - Giuseppina Liuzzi
- Clinical Department, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy
| | - Patrizia Marconi
- Clinical Department, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy
| | - Silvia Mosti
- Clinical Department, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy
| | - Carlo Federico Perno
- Virological Department, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy
| | - Andrea Antinori
- Clinical Department, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy
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Gianotti N, Galli L, Boeri E, De Bona A, Guffanti M, Danise A, Salpietro S, Lazzarin A, Castagna A. The 118I Reverse Transcriptase Mutation Is the Only Independent Genotypic Predictor of Virologic Failure to a Stavudine-Containing Salvage Therapy in HIV-1-Infected Patients. J Acquir Immune Defic Syndr 2006; 41:447-52. [PMID: 16652052 DOI: 10.1097/01.qai.0000209903.89878.80] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients infected with HIV-1 with more than 1000 HIV-1 RNA copies/mL, who were genotyped within 3 months before starting stavudine and treated for at least 3 months with a stable stavudine-containing highly active antiretroviral therapy, were selected from our database to identify the determinants of response to stavudine. Nonresponse was defined as a failure to achieve HIV-1 RNA level of less than 400 copies/mL or a reduction of more than 2 log10 by week 12. Univariate logistic analysis was used to elicit the failure-associated reverse transcriptase mutations (scored 1 to develop a genotype score). Eighty-one patients were eligible for the analysis, including 75 (93%) who previously received zidovudine. Thirty-five (43%) were nonresponders. Univariate logistic analysis revealed the following failure-associated mutations: 41L (P = 0.0001), 44D (P = 0.02), 118I (P = 0.0006), 184V (P = 0.04), 210W (P = 0.0004), and 215Y (P = 0.002) for a median stavudine score of 2. Failure was observed in 7 (18.9%) of 37 patients with a score less than 2, compared with 28 (63.6%) of 44 patients with a score of 2 or greater (P < 0.0001). The multivariable analysis showed that the 118I mutation (P = 0.04) was the only independent genotypic predictor of failing on a stavudine- containing highly active antiretroviral therapy.
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Affiliation(s)
- Nicola Gianotti
- Clinic of Infectious Diseases, Vita-Salute San Raffaele University, Italy.
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Montes B, Vergne L, Peeters M, Reynes J, Delaporte E, Segondy M. Comparison of Drug Resistance Mutations and Their Interpretation in Patients Infected With Non-B HIV-1 Variants and Matched Patients Infected With HIV-1 Subtype B. J Acquir Immune Defic Syndr 2004; 35:329-36. [PMID: 15097148 DOI: 10.1097/00126334-200404010-00001] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the prevalence of mutations associated with resistance to antiretroviral drugs and their interpretation in patients infected with non-B HIV-1 variants versus HIV-1subtype B-infected patients with similar treatment regimens. METHODS The reverse transcriptase (RT) and protease genes of HIV-1 were sequenced, and subtypes were determined by phylogenetic analysis. Each sequence belonging to a non-B variant was matched with a sequence belonging to subtype B. Patterns of resistance mutations were interpreted in terms of drug resistance using the HIV db algorithm. RESULTS RT mutations M41L, L210W, and, to a lesser extent, T215Y were less prevalent in patients infected with non-B variants. This lower prevalence was associated with subtypes A (A1/A2), C, F (F1/F2), and CRF06_cpx. A lower prevalence of high-level resistance to zidovudine was also observed in patients infected with these HIV-1 variants. In the protease gene, differences between patients infected with B or non-B strains were mainly observed for mutations playing a minor role in drug resistance and known to occur mainly as a natural polymorphism in non-B strains: K20R/M/I, M36I, L63P, A71V/T, and V77I. Interpretation of genotypes using the HIV db algorithm indicated that resistance to saquinavir, ritonavir, indinavir, and amprenavir was more frequently a high-level resistance for subtype B and an intermediate-level resistance for non-B variants, but this difference was only significant for amprenavir. CONCLUSION Our results suggest that the genetic diversity of HIV-1 does not play a major role in the development of resistance to antiretroviral drugs.
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Affiliation(s)
- Brigitte Montes
- Department of Virology, University Hospital of Montpellier, Montpellier, France
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Girouard M, Diallo K, Marchand B, McCormick S, Götte M. Mutations E44D and V118I in the reverse transcriptase of HIV-1 play distinct mechanistic roles in dual resistance to AZT and 3TC. J Biol Chem 2003; 278:34403-10. [PMID: 12819190 DOI: 10.1074/jbc.m303528200] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Retroviral resistance to AZT and 3TC has been associated with two different mechanisms. The M184V mutation in the reverse transcriptase (RT) of the human immunodeficiency virus, type 1 (HIV-1) diminishes the incorporation of 3TC-monophosphate (3TC-MP), whereas AZT resistance-conferring mutations were shown to facilitate the phosphorolytic excision of incorporated AZT-MP in the presence of ATP. Both mechanisms show a certain degree of incompatibility; however, previous clinical data revealed that mutations E44D and V118I, when present in a background of classical AZT mutations (M41L, D67N, L210W, and T215Y), confer dual resistance to AZT and 3TC. We have purified RT enzymes that contain E44D and V118I either alone or in a background of different combinations of AZT mutations to study the underlying biochemical mechanisms. We found that enzymes containing E44D in a background of these latter mutations increase the efficiency of excision of 3TC-MP. Unexpectedly, V118I-containing enzymes show dramatic reductions in rates of incorporation of AZT-MP and 3TC-MP. The V118I mutant is also associated with diminished rates of ATP-dependent primer unblocking. The additional presence of mutations M41L, D67N, L210W, and T215Y can partially neutralize this deficit, which helps to explain the concurrent presence of these changes in resistant isolates. These biochemical data make clear that mutations E44D and V118I play distinct mechanistic roles in dual resistance to AZT and 3TC. Our findings are consistent with an increasing number of clinical studies suggesting that the V118I cluster constitutes a novel pathway for HIV resistance to multiple nucleotide analogue RT inhibitors.
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Affiliation(s)
- Mélanie Girouard
- McGill University AIDS Centre, Lady Davis Institute-Jewish General Hospital and Department of Microbiology and Immunology, McGill University, Montréal, Québec, Canada
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Montes B, Segondy M. Amino acid substitutions at position 69 of the reverse transcriptase of human immunodeficiency virus type 1 are frequent in zalcitabine-naive antiretroviral-drug-experienced patients. Antimicrob Agents Chemother 2002; 46:3110-1. [PMID: 12183287 PMCID: PMC127403 DOI: 10.1128/aac.46.9.3110-3111.2002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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