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Antimicrobial Agents and Chemotherapy, March 2001, p. 946-948, Vol. 45, No. 3
0066-4804/01/$04.00+0 DOI: 10.1128/AAC.45.3.946-948.2001
Copyright © 2001, American Society for Microbiology. All rights reserved.
Prevalence and Conditions of Selection of E44D/A
and V118I Human Immunodeficiency Virus Type 1 Reverse Transcriptase
Mutations in Clinical Practice
Constance
Delaugerre,1
Mireille
Mouroux,1
Anne
Yvon-Groussin,1
Anne
Simon,2
Francis
Angleraud,1
Jean-Marie
Huraux,1
Henri
Agut,1
Christine
Katlama,3 and
Vincent
Calvez1,*
Departments of
Virology,1 Internal
Medicine,2 and Infectious
Diseases,3 Pitié-Salpêtrière
Hospital, Paris, France
Received 8 August 2000/Returned for modification 11 October
2000/Accepted 30 November 2000
 |
ABSTRACT |
Recently, it has been shown that a new mutational pattern (the
E44D/A and/or V118I mutation) confers moderate phenotypic lamivudine resistance in the absence of the M184V mutation. The E44D/A and/or the
V118I mutation does not exist in drug-naive patients, and the
prevalence increases with the number of treatment regimens and
lamivudine experience. The mutations can preexist in
nucleoside-experienced but lamivudine-naive patients. They are always
associated with zidovudine resistance-associated mutations, even in the
absence of M184V. These mutations are more stable than the M184V
substitution during antiretroviral treatment interruptions.
| |
TEXT |
The emergence of drug-resistant
human immunodeficiency virus type 1 (HIV-1) is frequently observed
during the course of treatment of patients with the use of
antiretroviral drugs (7). Mutation M184V in the HIV-1
reverse trancriptase (RT) has been shown to be specifically associated
with high-level (>50-fold) phenotypic resistance to lamivudine (3TC)
in vitro and in vivo (1, 9, 12). Previously, some mutation
patterns have been described to be associated with moderate levels of
phenotypic resistance (4- to <50-fold) to 3TC. This observation has
been associated with the selection of mutations implicated in
cross-resistance to other nucleoside analogs, such as in the case of
the nucleoside multidrug resistance complex of mutations (Q151M, F77L,
F116Y, A62V, and V75I) (6, 8, 10, 11). A moderate level of 3TC resistance has also been reported in strains harboring either the
insertion in position 69 of RT (2, 13) or the K65R
mutation (3, 4).
Recently, a novel mutational pattern in HIV-1 RT, associated with a
moderate level of phenotypic resistance to 3TC in the absence of the
characteristic replacement of methionine by valine at position 184, was
described. Thus, genotypic and phenotypic analyses of clinical isolates
revealed the presence of moderate levels of phenotypic resistance to
3TC in a subset of isolates that did not harbor the M184V substitution.
Mutational cluster analysis and comparison with the phenotypic data
revealed a significant correlation between a moderate level of
phenotypic 3TC resistance and an increased incidence of amino acid
changes at RT codons 44 (glutamic acid to aspartic acid or alanine) and
118 (valine to isoleucine). This occurred predominantly in isolates
harboring zidovudine (ZDV) resistance-associated mutations (M41L,
T215Y). Moreover, the results from the site-directed mutagenesis
experiment confirmed that mutations at codons 44 and 118 are indeed
associated with moderate levels of phenotypic resistance to 3TC when
they are present with ZDV resistance-associated mutations
(5).
In this study, we evaluated the prevalence and the conditions of
selection of the E44D or E44A (E44D/A) and/or V118I RT mutation in
clinical practice. Plasma samples obtained from 344 HIV-1-infected individuals from a routine clinical practice were analyzed by genotypic
resistance testing. Genotyping analysis were performed by automated
population-based full sequence analysis (ABI 377), and the results were
reported as the amino acid sequence compared to that for the RT gene
sequence of the HXB2 wild-type reference strain. Patients analyzed were
naive for treatment with antiretroviral drugs (n = 83)
or had been previously treated with antiretroviral drugs (n = 261). Among the previously treated patients, we defined as
moderately experienced patients who had received one to five antiretroviral regimens (n = 151) and as heavily
experienced patients who had received more than five antiretroviral
regimens (n = 110). An antiretroviral regimen was
defined in this study as a combination of antiretroviral drugs received
during a minimum of 1 month and should be different from the last
antiretroviral combination used.
(This work was presented in part at the 7th Conference on Retroviruses
and Opportunistic Infections, San Francisco, Calif., 2000 and at the
4th International Workshop on Drug Resistance and Treatment Strategies,
Sitgès 2000.)
Prevalences of E44D/A and V118I in the population studied.
The
E44A, E44D, and V118I mutations occurred in the clinical samples
studied at overall frequencies of 1.5, 10, and 21%, respectively. Forty-three percent of the clinical isolates with the V118I mutation simultaneously harbored the E44D or E44A mutation. In contrast, 82% of
the clinical isolates carrying E44D/A mutation simultaneously harbored
the V118I mutation. Statistical analysis showed a significant association between the frequencies of the E44D/A and/or the V118I mutation and the number of nucleoside analog resistance mutations, especially ZDV resistance mutations (P < 0.0001 by the
Fisher exact test) (Fig. 1). The E44D/A
and V118I mutations were also be observed in association with the Q151M
multidrug resistance pattern (n = 3) and with the
insertion at RT codon 69 (n = 2).
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FIG. 1.
Frequency of the E44D/A and/or V118I mutation according
to the number of nucleoside analog resistance-associated mutations.
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Among the subgroups studied, the E44D/A and/or V118I mutation was not
observed in antiretroviral-naive patients and was found
in 78 of 261 (30%) previously treated patients. This frequency
was statistically
higher when the patients were heavily previously
treated (more than
five regimens) than when the patients were
moderately experienced (one
to five regimens) (
P < 0.001 by the
Fisher exact
test). This difference was observed whether the M184V
mutation was
present or not (Fig.
2).
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FIG. 2.
Frequencies of E44D/A and/or V118I mutation pattern and
the M184V mutation among drug-naive patients and previously treated
patients who were moderately (one to five regimens) and heavily (more
than five regimens) experienced.
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|
Details of association between E44D/A and/or V118I pattern and
M184V mutation among previously treated patients.
As can be
deduced from the data in Table 1, changes
at RT positions 44 and 118 can exist in clinical samples with or
without the presence of the M184V substitution, but their prevalence
was higher when the M184V mutation was present (P = 0.03 by the Fisher exact test). In the absence of the M184V
mutation, the E44D/A and/or V118I pattern was observed among 23 previously treated patients (9%), including 17 heavily experienced
patients (more than five regimens) and 6 moderately experienced
patients (one to five regimens). In these patients, the E44D/A and/or
V118I mutation was always associated with a median of four ZDV
resistance-associated mutations (range, two to six mutations),
including in all patients the ZDV major resistance-associated mutation
T215Y.
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TABLE 1.
Prevalence of E44D/A and/or V118I pattern in association
with 3TC resistance-associated mutation M184V in RT in clinical samples
of previously treated patients
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|
Conditions of selection and reversion of E44D/A and V118I
mutations.
We carefully investigated a subset of 3TC-naive
patients who had received ZDV, didanosine, and zalcitabine
(n = 22). The E44D/A and/or V118I mutation existed
prior to 3TC therapy in 14% of these patients, but always in
association with ZDV resistance-associated mutations. It is interesting
that in this group of patients, the selection of the M184V substitution
was observed in all patients when 3TC was added to the regimen.
Among 19 previously treated patients who had discontinued an
antiretroviral regimen for 2 to 6 months, the reversion of E44D/A
to
wild-type codon E (acid glutamic) and V118I to wild-type codon
V
(valine) was observed for only two patients. The reversion of
these
mutations was seen exclusively in a context of a complete
shift of the
mutations to genotypic wild-type virus. Thus, this
reversion of the
E44D/A and V118I mutations seems to happen only
when codons with
nucleoside analog RT inhibitor (NRTI)-associated
resistance mutations
shift to wild-type codons. The E44D/A and
V118I mutations seem to be
more stable than the 3TC-associated
M184V substitution that reverts to
the wild-type codon rapidly
and individually from all RT gene
mutations.
In conclusion, our results confirm that the E44D/A and V118I
substitutions in HIV-1 RT can occur with or without the M184V
mutation but always occur in a ZDV resistance-associated mutation
background. The E44D/A and/or V118I mutation rarely if ever exists
in
drug-naive patients, and the prevalence increases with the
number of
treatment regimens and 3TC experience. Their prevalence
also increases
with the number of mutations in the RT gene, like
nucleoside analog
associated resistance mutations and especially
the
ZDV-resistance-associated mutations, but their selection seems
to be
independent of the presence or the absence of the M184V
mutation. Thus,
when the antiretroviral treatment is totally interrupted,
the codons
with the E44D/A and/or V118I mutations shift to wild-type
codons only
in the context of a complete shift to wild-type virus
codons and
particularly the shift of nucleoside analog resistance-associated
mutations. These mutations seem to be more stable in the viral
genome
than the classic M184V substitution. This suggests that
the fitness
impairment induced by the M184V mutation is higher
than the one induced
by E44D/A and/or V118I. Finally, whereas
the 3TC resistance-associated
mutation M184V appears independently
of a ZDV treatment background and
clearly appears to be due to
3TC selection pressure, the accumulation
of E44D/A and/or V118I
appears to be selected by ZDV or other
nucleoside analogs and,
fortuitously, confers only a moderate level of
resistance to 3TC.
The fact that the prevalence of the E44D/A and/or
V118I mutation
increases with the number of antiretroviral treatments
suggests
that the mutation might be involved in a more broad-spectrum
nucleoside
resistance.
| |
FOOTNOTES |
*
Corresponding author. Mailing address: Department of
Virology, 83, Blvd. de l'hôpital, 75013 Paris, France. Phone:
33142177401. Fax: 33142177411. E-mail:
vincent.calvez{at}psl.ap-hop-paris.fr.
| |
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Antimicrobial Agents and Chemotherapy, March 2001, p. 946-948, Vol. 45, No. 3
0066-4804/01/$04.00+0 DOI: 10.1128/AAC.45.3.946-948.2001
Copyright © 2001, American Society for Microbiology. All rights reserved.
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