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Antimicrobial Agents and Chemotherapy, November 2003, p. 3623-3626, Vol. 47, No. 11
0066-4804/03/$08.00+0     DOI: 10.1128/AAC.47.11.3623-3626.2003
Copyright © 2003, American Society for Microbiology. All Rights Reserved.

R57K Polymorphism in the Human Immunodeficiency Virus Type 1 Protease as Predictor of Early Virological Failure in a Cohort of Antiretroviral-Naive Patients Treated Mostly with a Nelfinavir-Containing Regimen

Bernard Masquelier,1* Cecile Droz,2 Martin Dary,3 Christian Perronne,4 Virginie Ferré,5 Bruno Spire,6 Diane Descamps,3 François Raffi,7 Françoise Brun-Vézinet,3 Geneviève Chêne,2 and the APROCO/COPILOTE Study Group 2

Laboratoire de Virologie, Hôpital Pellegrin, and,1 INSERM U 593, Université Victor Segalen Bordeaux 2, Bordeaux,2 Laboratoire de Virologie, Hôpital Bichat Claude Bernard, Paris,3 Service des Maladies Infectieuses, Hôpital Raymond Poincaré, Garches,4 Laboratoire de Virologie,5 Service des Maladies Infectieuses et Tropicales, Hôtel Dieu de Nantes, Nantes,7 INSERM U 379, Marseille, France6

Received 27 May 2003/ Returned for modification 21 July 2003/ Accepted 26 August 2003


   ABSTRACT
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In 243 antiretroviral-naive human immunodeficiency-infected patients starting a first-line-protease inhibitor (mainly nelfinavir)-containing therapy, the presence of the polymorphism R57K in the protease at the inception of therapy was independently associated with a higher rate of virological failure.


   TEXT
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The relation between the response to protease inhibitor (PI)-including regimens and the natural variability of the human immunodeficiency type 1 (HIV-1) protease is not fully elucidated (1, 3, 16, 17). Our study aimed at identifying the determinants of early treatment failure in APROVIR, a virological substudy of the APROCO/COPILOTE French multicenter cohort including antiretroviral-naive patients started on a PI-containing regimen.

(Presented in part at the 8th Conference on Retroviruses and Opportunistic Infections, 4 to 8 February 2001, Chicago, Ill., abstract 451.)

Patients were followed up every 2 months. Virological failure (VF) during the first year of therapy was defined as (i) viral rebound on two consecutive plasma specimens with HIV-1 RNA at >500 copies/ml after an initial response below 500 copies/ml or (ii) nonresponse with absence of viral drop below 500 copies/ml. The HIV-1 protease genotype was determined from plasma sampled at baseline for all the patients by the Agence Nationale de Recherches sur le SIDA consensus method (8). The definitions of the protease resistance mutations were those reported by the International AIDS Society-USA Panel (http://www.iasusa.org) on 1 October 2002. Major mutations corresponded to D30N, M46I/L, G48V, I50L/V, V82A/F/T/S, I84V, and L90M. The L10F/I/RV, K20M/R, L24I, V32I, L33F, M36I, M46I/L, I47V, F53L, I54V/L/M, A71V/T, G73S/A, V77I, and N88D/S changes were considered minor mutations. The L63P mutation and all other deviations from the protease subtype B consensus sequence, exclusive of the major and minor mutations, were considered polymorphisms. HIV-1 subtype analysis consisted of a serotyping and heteroduplex mobility assay (2, 6) or an env phylogenetic analysis. The adherence to treatment was assessed at month 4 (M4) by self-administered questionnaires (5).

A multivariate Cox proportional-hazards model was used to analyze the predictive factors of VF during the first year of follow-up. The model included clinical, behavioral, and virological characteristics of the patients; the number of protease amino acid mutations (major plus minor mutations); and all the protease amino acid polymorphisms at M0 present in at least 5% of the patients. We used the principle of intent to continue analysis, i.e., ignoring changes or modifications of antiretroviral treatment.

Between January 1998 and June 1999, 243 patients were included in APROVIR (Table 1). The genotype of the protease at baseline was documented for 236 of the 243 patients (Fig. 1). Only two patients (0.8%) exhibited a major PI resistance mutation (L90M). Minor mutations were observed at codons 77 (24%), 36 (22%), 10 (12%), 71 (8%), 20 (2%), and 47 (0.4%). Polymorphisms were also observed at low frequencies at positions involved in PI resistance: L10M (0.4%), K20I/V (6%), L33I/V (4%), I47M (0.4%), V77M (0.4%), and V82I/L (2%). Polymorphisms at other residues in the protease were also frequently observed.


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  		TABLE 1. Clinical and biological characteristics of the 243 patients in the APROVIR study at baseline therapy

 


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  		FIG. 1. Frequency of baseline polymorphisms and resistance mutations in the protease gene in 236 patients started on a PI-containing regimen. Results are from the APROVIR substudy, 1997 to 2000. Resistance mutations are those reported by the International AIDS Society-USA Panel (http://www.iasusa.org). The L63P mutation was considered a polymorphism. Only codons with polymorphisms at a frequency >5% are shown.

 
At M12, the patients exhibited a mean decrease of plasma HIV-1 RNA of -2.6 log10 copies/ml, 83% had a plasma HIV-1 RNA below 500 copies/ml, and the mean increase of CD4+ cells was 203/µl. Out of 220 patients with a follow-up at or after M4, 35 (16%) patients experienced a VF during the first year of follow-up: 8 were nonresponders, whereas 27 patients had a virological rebound. The frequencies of VF were 16, 15, 27, and 10% in the patients treated with nelfinavir (NFV), indinavir (IDV), ritonavir (RTV), or another PI, respectively (P = 0.6). Adherence to PI therapy at M4 was reported by 132 of 220 (60%) patients. It was low for 20 (15%) patients, moderate for 35 (27%) patients, and high for 77 (58%) patients.

The number of PI resistance mutations at baseline, the number of protease polymorphisms at baseline, and the HIV-1 subtype were not associated with VF in the univariate analysis. In the multivariate analysis (Table 2), a higher plasma HIV-1 RNA at M0 and the failure of adherence to therapy at M4 were associated with a higher frequency of VF; an older age at inclusion was associated with a lower risk of VF. The presence of the polymorphic mutation R57K at baseline was also independently associated with a higher frequency of subsequent VF. This mutation was detected in 24 (10%) patients. VF occurred in 10 of 24 (42%) patients with the R57K mutation and in 25 of 196 (13%) patients with a wild-type protease codon 57. Among patients on NFV, 9 of 17 patients with the R57K mutation had a VF, compared with 14 of 140 patients without the R57K mutation. Although there was a trend for a stronger association between the R57K mutation and subsequent VF in those patients started on NFV (adjusted hazard ratio = 15.0; 95% confidence interval: 5.5 to 41.2; P < 0.0001), the interaction between R57K and the type of initial PI was not significant. It is, however, noteworthy that none of the four patients on IDV with the R57K polymorphism had a subsequent VF. Finally, a robustness analysis showed that missing data on adherence could not have substantially influenced the results for codon 57.


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  		TABLE 2. Determinants of VF in the first year of follow-up in 220 patients started on a PI-containing regimen, APROVIR substudy, 1997 to 2001 (multivariate Cox model)a

 
In this study, we found previously reported covariates (9, 11, 12, 14, 18, 20) associated with VF: age, high plasma HIV-1 RNA at baseline, and failure to adhere to therapy. More surprisingly, the presence of the polymorphism R57K in the HIV-1 protease at baseline therapy was also strongly associated with VF in the first year of follow-up, conversely to the presence and number of major and minor PI resistance mutations at baseline. Very few major protease mutations were present at baseline in our cohort, a finding consistent with previous reports (1, 7), whereas minor PI resistance mutations were frequently present at baseline (10), although not associated with a subsequent VF (1, 3). Mutations other than R57K, such as A71V/T, particularly for patients on a first-line RTV therapy, and I93L and a high number of polymorphisms were shown to have some predictive value for failure of therapy (17). Studying patients from the ICONA cohort, mainly treated with IDV or saquinavir, Perno et al. (16) found that both a higher number of PI resistance mutations and the presence of the mutation L10I or M36I at baseline therapy were associated with higher risks of VF. We do not confirm these findings, in that we studied patients who were mostly started on NFV. Though the polymorphism R57K was highly associated with a higher risk of subsequent VF in our cohort, its relevance needs to be further evaluated with other databases, in order to clarify if this finding is dependent on the nature of the PI. When we studied the evolution of the viral genotype at the time of virological failure in APROVIR (13), we found that the D30N mutation was the most frequently selected PI resistance mutation; interestingly, the R57K polymorphism was present at baseline and at the time of VF in six of nine patients with a selection of D30N (data not shown). The mutation L90M was detected in only one patient on NFV at month 10 and disappeared at month 12, with detection of a virus presenting both the D30N and the R57K mutations, suggesting the existence of a selective advantage for this combination of mutations. Moreover, two studies suggested that the NFV resistance pathway including the D30N mutation, which is generally used by HIV-1 clade B isolates (15), is underrepresented in HIV-1 subtype C- or CRF02_AG-infected individuals failing on NFV (4; P. Gomes, I. Diogo, F. Gonçalves, P. Carvalho, J. Cabanas, M. C. Lobo, and R. Camacho, Abstr. 9th Conf. Retrovir. Opportunistic Infect., abstr. 46, 2002). In APROVIR, all viruses with the R57K mutation belonged to clade B or to CRF01_AE. We did not detect the R57K polymorphism in the baseline samples from a cohort of recently infected patients from Abidjan (Ivory Coast) mainly infected with HIV-1 CRF02_AG (19) or in a cohort of ARV-naive HIV-1 clade C-infected patients (unpublished data); taken together, these observations could also indicate a role for the R57K mutation in facilitating the D30N NFV resistance pathway. In vitro studies could also help to evaluate the impact of the R57K polymorphism on viral fitness, in the presence or absence of the major NFV resistance mutations. If confirmed, our data suggest that genotyping before introduction of a first-line-PI-containing therapy could be of clinical use.


   ACKNOWLEDGMENTS
 
This study was supported by the Agence Nationale de Recherches sur le SIDA (Paris, France), the Association des Professeurs de Pathologie Infectieuse et Tropicale, and associated pharmaceutical companies (Abbott, Boehringer-Ingelheim, Roche, Bristol-Myers Squibb, Merck Dohme Chibret, GlaxoSmithKline).

We thank all the patients who participated in the cohort. We are indebted to Valérie Birac and Muriel Faure for excellent technical assistance.

Members of the APROCO/COPILOTE study group are C. Leport, F. Raffi, G. Chêne, R. Salamon, J.-P. Moatti, J. Pierret, F. Brun-Vézinet, H. Fleury, G. Peytavin, R. Garraffo, F. Ballereau, D. Costagliola, P. Dellamonica, C. Katlama, B Masquelier, L. Meyer, M. Morin, D. Sicard, A. Sobel, B Spire, L. Cuzin, M. Dupon, X. Duval, V. Le Moing, B. Marchou, T. May, P. Morlat, C. Rabaud, A. Waldner-Combernoux, C. Lewden, P Choutet, J.-F. Delfraissy, J. Dormont, C. Grillot-Courvalin, Y. Souteyrand, J.-L. Vildé, C. Alfaro, C. Barennes, D. Beniken, S. Boucherit, C. Brunet-François, M. P. Carrieri, V. Charlois-Ou, C. Droz, S. Duran, J. L. Ecobichon, V. El-Fouikar, V. Journot, R. Lassalle, J. P. Legrand, B. Matera, W. Nouioua, G. Palmer, S. Perchart, C. Petit, E. Pereira, M. Préau, M. Savès, H. Zouari, J. L. Schmit, J. M. Chennebault, J. P. Faller, J. M. Estavoyer, R. Laurent, D. Vuitton, J. Beylot, M. Le Bras, J. M. Ragnaud, P. Granier, M. Garré, C. Bazin, P. Veyssier, A. Devidas, H. Portier, C. Perronne, P. Lagarde, J. Ceccaldi, D. Peyramond, C. Allard, J. Reynes, J. P. Cassuto, P. Arsac, E. Bouvet, F. Bricaire, Cabane, C. Caulin, P.-M. Girard, S. Herson, J. C. Imbert, M. Molina, W. Rozenbaum, B. Becq-Giraudon, G. Rémy, C. Michelet, F. Lucht, T. Debord, J. M. Lang, J. P. de Jaureguiberry, P. Massip, and P. Choutet.


   FOOTNOTES
 
* Corresponding author. Mailing address: Laboratoire de Virologie, Place Amélie Raba Léon, 33076 Bordeaux cedex, France. Phone: 335 56 79 55 10. Fax: 335 56 79 56 73. E-mail: bernard.masquelier{at}chu-bordeaux.fr. Back

2 Members of the APROCO/COPILOTE study group are listed in the Acknowledgments. Back


   REFERENCES
Top
 Abstract
 Text
 References
 

  1. Alexander, C. S., W. Dong, K. Chan, N. Jahnke, M. V. O'Shaughnessy, T. Mo, M. A. Piaseczny, J. S. Montaner, and P. R. Harrigan. 2001. HIV protease and reverse transcriptase variation and therapy outcome in antiretroviral-naive individuals from a large North American cohort. AIDS 15:601-607.[CrossRef][Medline]
  2. Barin, F., Y. Lahbabi, L. Buzelay, B. Lejeune, A. Baillou-Beaufils, F. Denis, C. Mathiot, S. M'Boup, V. Vithayasai, U. Dietrich, and A. Goudeau. 1996. Diversity of antibody binding to V3 peptides representing consensus sequences of HIV type 1 genotypes A to E: an approach for HIV type 1 serological subtyping. AIDS Res. Hum. Retrovir. 12:1279-1289.[Medline]
  3. Bossi, P., M. Mouroux, A. Yvon, F. Bricaire, H. Agut, J. M. Huraux, C. Katlama, and V. Calvez. 1999. Polymorphism of the human immunodeficiency virus type 1 (HIV-1) protease gene and response of HIV-1-infected patients to a protease inhibitor. J. Clin. Microbiol. 37:2910-2912.[Abstract/Free Full Text]
  4. Cane, P. A., A. De Ruiter, P. Rice, M. Wiselka, R. Fox, and D. Pillay. 2001. Resistance-associated mutations in the human immunodeficiency virus type 1 subtype C protease gene from treated and untreated patients in the United Kingdom. J. Clin. Microbiol. 39:2652-2654.[Abstract/Free Full Text]
  5. Carrieri, M. P., V. Cailleton, V. Le Moing, B. Spire, P. Dellamonica, E. Bouvet, F. Raffi, V. Journot, J. P. Moatti, and the APROCO Cohort Study Group. 2001. The dynamic of adherence to highly active antiretroviral therapy: results from the French national APROCO cohort. J. Acquir. Immune Defic. Syndr. 28:232-239.
  6. Delwart, E. L., E. G. Shpaer, F. E. McCutchan, M. Grez, H. Rubsamen-Waigmann, and J. I. Mullins. 1993. Genetic relationships determined by a DNA heteroduplex mobility assay: analysis of HIV-1 env genes. Science 262:1257-1261.[Abstract/Free Full Text]
  7. Descamps, D., V. Calvez, J. Izopet, C. Buffet-Janvresse, A. Schmuck, P. Colson, A. Ruffault, A. Maillard, B. Masquelier, J. Cottalorda, M. Harzic, F. Brun-Vezinet, and D. Costagliola. 2001. Prevalence of resistance mutations in antiretroviral-naive chronically HIV-infected patients in 1998: a French nationwide study. AIDS 15:1777-1782.[CrossRef][Medline]
  8. Fleury, H., P. Recordon-Pinson, A. Caumont, M. Faure, P. Roques, J. C. Plantier, E. Couturier, D. Dormont, B. Masquelier, F. Simon, and the ANRS AC11 Laboratory Network. 2003. HIV-1 diversity in France, 1999-2001: molecular characterization of non-B HIV type 1 subtypes and potential impact on susceptibility to antiretroviral drugs. AIDS Res. Hum. Retovir. 19:41-47.
  9. Grabar, S., C. Pradier, E. Le Corfec, R. Lancar, C. Allavena, M. Bentata, P. Berlureau, C. Dupont, P. Fabbro-Peray, I. Poizot-Martin, and D. Costagliola. 2000. Factors associated with clinical and virological failure in patients receiving a triple therapy including a protease inhibitor. AIDS 14:141-149.[CrossRef][Medline]
  10. Kozal, M. J., N. Shah, N. Shen, R. Yang, R. Fucini, T. C. Merigan, D. D. Richman, D. Morris, E. Hubbell, M. Chee, and T. R. Gingeras. 1996. Extensive polymorphisms observed in HIV-1 clade B protease gene using high-density oligonucleotide arrays. Nat. Med. 2:753-759.[CrossRef][Medline]
  11. Le Moing, V., G. Chêne, M. P. Carrieri, A. Alioum, F. Brun-Vézinet, L. Piroth, J. P. Cassuto, J. P. Moatti, F. Raffi, C. Leport, and the Aproco Study Group. 2002. Predictors of virological rebound in HIV-1-infected patients initiating a protease inhibitor-containing regimen. AIDS 16:21-29.[CrossRef][Medline]
  12. Lucas, G. M., R. E. Chaisson, and R. D. Moore. 1999. Highly active antiretroviral therapy in a large urban clinic: risk factors for virological failure and adverse drug reactions. Ann. Int. Med. 131:81-87.[Abstract/Free Full Text]
  13. Masquelier, B., G. Peytavin, C. Leport, C. Droz, S. Duran, R. Verdon, J. M. Besnier, G. Chêne, F. Raffi, F. Brun-Vézinet, and the APROCO Study Group. 2002. Mechanisms of early virological failure in antiretroviral-naive patients starting on PI-containing regimens: the APROVIR study. J. Infect. Dis. 186:1503-1507.[CrossRef][Medline]
  14. Paredes, R., A. Mocroft, O. Kirk, A. Lazzarin, S. E. Barton, J. van Lunzen, T. L. Katzenstein, F. Antunes, J. D. Lundgren, and B. Clotet. 2000. Predictors of virological success and ensuing failure in HIV-positive patients starting highly active antiretroviral therapy in Europe: results from the EuroSIDA study. Arch. Int. Med. 160:1123-1132.[Abstract/Free Full Text]
  15. Patick, A. K., M. Duran, Y. Cao, D. Shugarts, M. R. Keller, E. Mazabel, M. Knowles, S. Chapman, D. R. Kuritzkes, and M. Markowitz. 1998. Genotypic and phenotypic characterization of human immunodeficiency virus type 1 variants isolated from patients treated with the protease inhibitor nelfinavir. Antimicrob. Agents Chemother. 42:2637-2644.[Abstract/Free Full Text]
  16. Perno, C. F., A. Cozzi-Lepri, C. Balotta, F. Forbici, M. Violin, A. Bertoli, G. Facchi, P. Pezzotti, G. Cadeo, G. Tositti, S. Pasquinucci, S. Pauluzzi, A. Scalzini, B. Salassa, A. Vincenti, A. N. Phillips, F. Dianzani, A. Appice, G. Angarano, L. Monno, G. Ippolito, M. Moroni, and A. d'Arminio Monforte. 2001. Secondary mutations in the protease region of human immunodeficiency virus and virologic failure in drug-naive patients treated with protease inhibitor-based therapy. J. Infect. Dis. 184:983-991.[CrossRef][Medline]
  17. Servais, J., C. Lambert, E. Fontaine, J. M. Plesseria, I. Robert, V. Arendt, T. Staub, F. Schneider, R. Hemmer, G. Burtonboy, and J. C. Schmit. 2001. Variant human immunodeficiency virus type 1 proteases and response to combination therapy including a protease inhibitor. Antimicrob. Agents Chemother. 45:893-900.[Abstract/Free Full Text]
  18. Staszewski, S., V. Miller, C. Sabin, A. Carlebach, A. M. Berger, E. Weidmann, E. B. Helm, A. Hill, and A. Phillips. 1999. Virological response to protease inhibitor therapy in an HIV clinic cohort. AIDS 13:367-373.[CrossRef][Medline]
  19. Toni, T. A., B. Masquelier, D. Bonard, M. Faure, C. Huët, A. Caumont, P. Roques, F. Dabis, R. Salamon, H. Fleury, and the Primo-CI/PAC-CI Study Group. 2002. Primary HIV-1 drug resistance in Abidjan (Côte d'Ivoire): a genotypic and phenotypic study. AIDS 16:478-481.
  20. Valdez, H., M. M. Lederman, I. Woolley, C. J. Walker, L. T. Vernon, A. Hise, and B. M. Gripshover. 1999. Human immunodeficiency virus 1 protease inhibitors in clinical practice: predictors of virological outcome. Arch. Intern. Med. 159:1771-1776.[Abstract/Free Full Text]

Antimicrobial Agents and Chemotherapy, November 2003, p. 3623-3626, Vol. 47, No. 11
0066-4804/03/$08.00+0     DOI: 10.1128/AAC.47.11.3623-3626.2003
Copyright © 2003, American Society for Microbiology. All Rights Reserved.



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