We identified clinical isolates with phenotypic resistance to nevirapine (NVP) in the absence of known nonnucleoside reverse transcriptase inhibitor (NNRTI) mutations. This resistance is caused by N348I, a mutation at the connection subdomain of human immunodeficiency virus type 1 (HIV-1) reverse transcriptase (RT). Virologic analysis showed that N348I conferred multiclass resistance to NNRTIs (NVP and delavirdine) and to nucleoside reverse transcriptase inhibitors (zidovudine [AZT] and didanosine [ddI]). N348I impaired HIV-1 replication in a cell-type-dependent manner. Acquisition of N348I was frequently observed in AZTand/or ddI-containing therapy (12.5%; n ‫؍‬ 48; P < 0.0001) and was accompanied with thymidine analogueassociated mutations, e.g., T215Y (n ‫؍‬ 5/6) and the lamivudine resistance mutation M184V (n ‫؍‬ 1/6) in a Japanese cohort. Molecular modeling analysis shows that residue 348 is proximal to the NNRTI-binding pocket and to a flexible hinge region at the base of the p66 thumb that may be affected by the N348I mutation. Our results further highlight the role of connection subdomain residues in drug resistance.

The N348I mutation at the connection subdomain of HIV-1 reverse transcriptase (RT) confers clinically significant resistance to both nucleoside and non-nucleoside RT inhibitors (NNRTIs) by mechanisms that are not well understood. We used transient kinetics to characterize the enzymatic properties of N348I RT and determine the biochemical mechanism of resistance to the NNRTI nevirapine (NVP). We demonstrate that changes distant from the NNRTI binding pocket decrease inhibitor binding (increase K d-NVP ) by primarily decreasing the association rate of the inhibitor (k on-NVP ). We characterized RTs mutated in either p66 (p66 N348I /p51 WT ), p51 (p66 WT /p51 N348I ), or both subunits (p66 N348I /p51 N348I ). Mutation in either subunit caused NVP resistance during RNA-dependent and DNA-dependent DNA polymerization. Mutation in p66 alone (p66 N348I / p51 WT ) caused NVP resistance without significantly affecting RNase H activity, whereas mutation in p51 caused NVP resistance and impaired RNase H, demonstrating that NVP resistance may occur independently from defects in RNase H function. Mutation in either subunit improved affinity for nucleic acid and enhanced processivity of DNA synthesis. Surprisingly, mutation in either subunit decreased catalytic rates (k pol ) of p66 N348I /p51 N348I , p66 N348I /p51 WT , and p66 WT /p51 N348I without significantly affecting affinity for deoxynucleotide substrate (K d-dNTP ). Hence, in addition to providing structural integrity for the heterodimer, p51 is critical for fine tuning catalytic turnover, RNase H processing, and drug resistance. In conclusion, connection subdomain mutation N348I decreases catalytic efficiency and causes in vitro resistance to NVP by decreasing inhibitor binding.Human immunodeficiency virus type 1 (HIV-1) reverse transcriptase (RT) converts the viral single-stranded, positive sense RNA genome to a double-stranded DNA, which is integrated into the host genome. To achieve this task, RT possesses multiple enzymatic activities, including both DNA-dependent and RNA-dependent DNA polymerase activities and RNase H activity. RT is a heterodimer composed of 66-kDa (p66) and 51-kDa (p51) subunits. p66 is 560 amino acids long and comprises the spatially distinct polymerase and RNase H domains. The polymerase domain of p66 includes the fingers, palm, and thumb subdomains that resemble a clasping right hand connected to the RNase H domain through the connection subdomain. p51 contains the first 440 amino acids of p66 and is derived by HIV-1 protease-mediated cleavage of an RNase H domain from the p66/p66 homodimer. Because p51 of the heterodimer has no enzymatic function, it has been proposed that its role is simply to provide structural support to p66.HIV-1 RT has been a prominent target of anti-AIDS therapies. There are two classes of approved drugs that target RT: the nucleoside RT inhibitors (NRTIs) 3 and the non-nucleoside RT inhibitors (NNRTIs). NRTIs mimic deoxynucleotide triphosphate (dNTP) substrates required for DNA synthesis. Once integrated into the ...

HIV-1 carrying the “Q151M complex” reverse transcriptase (RT) mutations (A62V/V75I/F77L/F116Y/Q151M, or Q151Mc) is resistant to many FDA-approved nucleoside RT inhibitors (NRTIs), but has been considered susceptible to tenofovir disoproxil fumarate (TFV-DF or TDF). We have isolated from a TFV-DF-treated HIV patient a Q151Mc-containing clinical isolate with high phenotypic resistance to TFV-DF. Analysis of the genotypic and phenotypic testing over the course of this patient's therapy lead us to hypothesize that TFV-DF resistance emerged upon appearance of the previously unreported K70Q mutation in the Q151Mc background. Virological analysis showed that HIV with only K70Q was not significantly resistant to TFV-DF. However, addition of K70Q to the Q151Mc background significantly enhanced resistance to several approved NRTIs, and also resulted in high-level (10-fold) resistance to TFV-DF. Biochemical experiments established that the increased resistance to tenofovir is not the result of enhanced excision, as K70Q/Q151Mc RT exhibited diminished, rather than enhanced ATP-based primer unblocking activity. Pre-steady state kinetic analysis of the recombinant enzymes demonstrated that addition of the K70Q mutation selectively decreases the binding of tenofovir-diphosphate (TFV-DP), resulting in reduced incorporation of TFV into the nascent DNA chain. Molecular dynamics simulations suggest that changes in the hydrogen bonding pattern in the polymerase active site of K70Q/Q151Mc RT may contribute to the observed changes in binding and incorporation of TFV-DP. The novel pattern of TFV-resistance may help adjust therapeutic strategies for NRTI-experienced patients with multi-drug resistant (MDR) mutations.

Background:The effect of HIV polymorphisms in drug resistance is unknown. Results: RT polymorphism 172K suppresses resistance to nucleoside (NRTIs) and non-nucleoside RT inhibitors (NNRTIs) by decreasing DNA binding and restoring NNRTI binding. Conclusion: 172K is the first HIV polymorphism suppressing resistance to diverse inhibitors. Significance: Results provide new insights into interactions between the polymerase active site and NNRTI-binding sites.

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