Although combination antiretroviral therapy has resulted in a considerable improvement in the treatment of human immunodeficiency virus (HIV) type 1 (HIV-1) infection, the emergence of resistant virus is a significant obstacle to the effective management of HIV infection and AIDS. We have developed a novel phenotypic drug susceptibility assay that may be useful in guiding therapy and improving long-term suppression of HIV replication. Susceptibility to protease (PR) and reverse transcriptase (RT) inhibitors is measured by using resistance test vectors (RTVs) that contain a luciferase indicator gene and PR and RT sequences derived from HIV-1 in patient plasma. Cells are transfected with RTV DNA, resulting in the production of virus particles that are used to infect target cells. Since RTVs are replication defective, luciferase activity is measured following a single round of replication. The assay has been automated to increase throughput and is completed in 8 to 10 days. Test results may be useful in facilitating the selection of optimal treatment regimens for patients who have failed prior therapy or drug-naive patients infected with drug-resistant virus. In addition, the assay can be used to evaluate candidate drugs and assist in the development of new drugs that are active against resistant strains of HIV-1.

Most human immunodeficiency virus type 1 (HIV-1) strains require either the CXCR4 or CCR5 chemokine receptor to efficiently enter cells. Blocking viral binding to these coreceptors is an attractive therapeutic target. Currently, several coreceptor antagonists are being evaluated in clinical trials that require characterization of coreceptor tropism for enrollment. In this report, we describe the development of an automated and accurate procedure for determining HIV-1 coreceptor tropism (Trofile) and its validation for routine laboratory testing. HIV-1 pseudoviruses are generated using full-length env genes derived from patient virus populations. Coreceptor tropism is determined by measuring the abilities of these pseudovirus populations to efficiently infect CD4 ؉ /U87 cells expressing either the CXCR4 or CCR5 coreceptor. Viruses exclusively and efficiently infecting CXCR4 ؉ /CD4 ؉ /U87 cells are designated X4-tropic. Conversely, viruses exclusively and efficiently infecting CCR5 ؉ /CD4 ؉ /U87 cells are designated R5-tropic. Viruses capable of infecting both CXCR4 ؉ /CD4 ؉ /U87 and CCR5 ؉ /CD4 ؉ /U87 cells are designated dual/mixed-tropic. Assay accuracy and reproducibility were established by evaluating the tropisms of well-characterized viruses and the variability among replicate results from samples tested repeatedly. The viral subtype, hepatitis B virus or hepatitis C virus coinfection, and the plasma viral load did not affect assay performance. Minority subpopulations with alternate tropisms were reliably detected when present at 5 to 10%. The plasma viral load above which samples can be amplified efficiently in the Trofile assay is 1,000 copies per ml of plasma. Trofile has been automated for high-throughput use; it can be used to identify patients most likely to benefit from treatment regimens that include a coreceptor inhibitor and to monitor patients on treatment for the emergence of resistant virus populations that switch coreceptor tropism.

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Amprenavir (Agenerase, 141-W94, VX-478) is a human immunodeficiency virus type 1 (HIV-1) protease inhibitor (PRI) recently approved for the treatment of HIV-1 infection in the United States. A major cause of treatment failure is the development of resistance to PRIs. One potential use for amprenavir is as salvage therapy for patients for whom treatment that includes one (or more) of the other four currently approved PRIs-saquinavir, indinavir, ritonavir, and nelfinavir-has failed. We evaluated the cross-resistance to amprenavir of viruses that evolved during treatment with the two most commonly prescribed PRIs, nelfinavir and indinavir. Unexpectedly, a dramatic increase in susceptibility (2.5-to 12.5-fold) was observed with 20 of 312 (6.4%) patient viruses analyzed. The most pronounced increases in susceptibility were strongly associated with an N88S mutation in protease. All viruses that carried the N88S mutation were hypersensitive to amprenavir. Site-directed mutagenesis studies confirmed the causal role of N88S in determining amprenavir hypersensitivity. The presence of the N88S mutation and associated amprenavir hypersensitivity may be useful in predicting an improved clinical response to amprenavir salvage therapy.

To evaluate the cross-resistance profile of the human immunodeficiency virus type 1 protease inhibitor (PI) atazanavir (BMS-232632), a panel of 551 clinical isolates exhibiting a wide array of PI resistance profiles and a variety of genotypic patterns were assayed for susceptibility to atazanavir and six other PIs: amprenavir, indinavir, lopinavir, nelfinavir, ritonavir, and saquinavir. In general, reductions in atazanavir susceptibility in vitro required several amino acid changes and were relatively modest in degree, and susceptibility was retained among isolates resistant to one or two of the currently approved PIs. There was a clear trend toward loss of susceptibility to atazanavir, as isolates exhibited increasing levels of cross-resistance to multiple PIs

NNRTI hypersusceptibility is common among patient HIV-1 isolates, especially in NRTI-resistant viruses. Genotypic correlates of hypersusceptibility are complex and not easily defined by a simple analysis of NRTI-associated resistance mutations. NNRTI hypersusceptibility may provide an explanation for the superior virologic response to NNRTI-containing salvage regimens observed in NRTI-experienced patients in several clinical trials.

Fully suppressive antiretroviral therapy (ART) for human immunodeficiency virus type 1 (HIV-1) infection requires the administration of drug combinations that target multiple sites on one or more proteins required for viral replication. Approved antiretrovirals (ARVs) include nucleoside/nucleotide and nonnucleoside reverse transcriptase inhibitors (NRTIs and NNRTIs, respectively), protease inhibitors (PIs), entry inhibitors, and integrase strand-transfer inhibitors (INSTIs). With the exception of the NRTIs, which require intracellular phosphorylation, plasma drug concentrations are correlated with drug efficacy. At the same time, high drug concentrations are associated with excess toxicity.To durably suppress HIV replication in infected patients, ARV concentrations must reach and be maintained at levels that exceed the susceptibility of the virus to that drug. Treatment response is often hampered by the failure to achieve sufficient drug exposure (i.e., poor adherence and drug interactions), reduced drug susceptibility (i.e., viral drug resistance), or both. Drug concentrations within patients vary over time and, due to ease of sampling, are generally characterized by minimum (trough) concentrations (C trough ) immediately prior to administration of the next scheduled dose. Drug concentrations also vary considerably between individual patients as a result of differences in absorption, distribution, metabolism, and excretion. In addition, each drug characteristically binds to human plasma proteins to different extents. Furthermore, the susceptibility of HIV-1 variants, even in patients not previously exposed to drug therapy, varies over a range that is unique to each drug (23,24,46).In vivo clinical pharmacodynamic data are available for some, but not all, ARVs. Efficient collection of these data is difficult and ideally performed early in the drug development process. Alternative methods of incorporating ARV pharmacokinetics into therapeutic decision making are being explored. In vitro phenotypic drug susceptibility testing of individual patient viruses is now widely available and generates information that can be used to calculate an inhibitory quotient (IQ), defined as the ratio between the C trough and the drug concentration that inhibits in vitro replication by a defined percentage (e.g., 50% or 95% inhibitory concentration [IC 50 or IC 95 , respectively]) (27,35,43,56). Derivatives of the IQ, including the genotypic IQ (GIQ; C trough divided by the number of resistance-associated mutations for a given drug) have also been evaluated (36). Several studies have attempted to define the optimal IQ required to produce long-term viral suppression: in some cases, IQ has been retrospectively linked to clinical outcome (15,34,41,42,55), while in others, direct relationships between IQ and viral load response were not observed (5, 12).For most ARV drugs, few or no in vivo concentration-response data have been generated, or these data are inconsistent with clinical observations. Collectively, there is insufficient agr...

Development of a vaccine for HIV-1 requires a detailed understanding of the neutralizing antibody responses that can be experimentally elicited to difficult-to-neutralize primary isolates. Rabbits were immunized with the gp120 subunit of HIV-1 JR-CSF envelope (Env) using a DNA-prime protein-boost regimen. We analyzed five sera that showed potent autologous neutralizing activity (IC50s at ∼103 to 104 serum dilution) against pseudoviruses containing Env from the primary isolate JR-CSF but not from the related isolate JR-FL. Pseudoviruses were created by exchanging each variable and constant domain of JR-CSF gp120 with that of JR-FL or with mutations in putative N-glycosylation sites. The sera contained different neutralizing activities dependent on C3 and V5, C3 and V4, or V4 regions located on the glycan-rich outer domain of gp120. All sera showed enhanced neutralizing activity toward an Env variant that lacked a glycosylation site in V4. The JR-CSF gp120 epitopes recognized by the sera are generally distinct from those of several well characterized mAbs (targeting conserved sites on Env) or other type-specific responses (targeting V1, V2, or V3 variable regions). The activity of one serum requires specific glycans that are also important for 2G12 neutralization and this serum blocked the binding of 2G12 to gp120. Our findings show that different fine specificities can achieve potent neutralization of HIV-1, yet this strong activity does not result in improved breadth.