Hepatitis delta virus (HDV) is encapsidated by the envelope proteins of hepatitis B virus (HBV).The hepatitis delta virus (HDV) can cause severe chronic and acute hepatitis in humans (11). HDV coexists with hepatitis B virus (HBV) as it is dependent on the HBV envelope proteins for virus assembly. Inside the HBV envelope, the HDV virion contains a 1.7-kb circular RNA genome complexed with two HDV-encoded proteins, the large (214-aminoacid) and small (195-amino-acid) forms of hepatitis delta antigen (HDAg-L and HDAg-S, respectively) (22, 28). HDAg-L is crucial for virus assembly and interaction with the HBV envelope proteins (6). The other viral protein, HDAg-S, is essential for viral RNA replication (17).The HBV genome is approximately 3.2 kb and contains a number of overlapping reading frames. The HBV envelope consists of three surface proteins, small (hepatitis B surface antigen; HBsAg), middle, and large. All three HBV envelope proteins are encoded by a single open reading frame. The mRNA transcripts have different in-phase translational start codons and share a common stop codon, resulting in proteins with identical C-terminal ends and different N-terminal sequences. The HBsAg protein can form subviral particles that are secreted in excess in comparison to the HBV virion. The presence of HBsAg alone is sufficient for HDV assembly, although as with HBV, the large hepatitis B surface protein is required for infectivity. The envelope genes overlap the gene encoding the polymerase, and mutations may result in concomitant changes in both reading frames (21).The nucleoside analogue lamivudine (LMV) has been used for the treatment of hepatitis B infection (12,19,20). Lau and coworkers (18) demonstrated that although LMV is a potent inhibitor of HBV DNA replication, it did not inhibit HDV RNA replication or improve disease activity. Nevertheless, LMV is being used to treat hepatitis B infection in patients that are coinfected with HDV (4, 20, 29, 30). The major problem with LMV treatment has been the selection of HBV-resistant strains. In a study of long-term LMV treatment, HBV resistance was detected in 67% of patients after 4 years and 69% of patients after 5 years (19,20). Resistance to LMV is associated with a mutation in the reverse transcriptase (rt) region of the polymerase gene at the M204V/I codon (rtM204V/I), with or without an accompanying rtL180M mutation (according to the nomenclature by Stuyver and coworkers [24]) ( Table 1). The rtL180M change does not result in an amino acid change within the envelope protein. The concomitant HBsAg mutations selected by the antiviral agents are located towards the C-terminal region of the envelope protein. The mutation at the rtM204V codon results in a change in the envelope gene at the sI195M codon, and the rtM204I mutation results in changes to the sW196L/S/Stop codon. In addition to these changes, the rtV173L mutation occurs in 9 to 22% of patients with LMV resistance (8,9). This mutation results in a change in the envelope gene at the sE164D codon. Recently, Tor...