Management

of
Academic in Service
HIV drugs resistance
53010710053
6
2558
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Outline
Introduction
Definition
HIV Resistance Testing
- Genotypic assay
- Phenotypic assay
- Virtual genotypic assay
HIV-1 Drug Resistance Mutations
Regimen Switching (2nd regimen)

Introduction
HIV-1

HIV

HIV-2
Ref : http://www.avert.org/hiv-types.htm

M (major) 90%
Subtype
A-H
J-K
O (outlier)
N(non-major-nonoutlier)

Introduction

Viral structural proteins

GAG
POL
ENV
Ref : http://www.hiv.lanl.gov/content/sequence/HIV/MAP/landmark.html

Introduction
GAG :
The genomic region encoding the capsid
proteins (group specific antigens)
The precursor is the p55 myristoylated
protein, which is processed to
- p17 (MAtrix)
- p24 (CApsid)
- p7 (NucleoCapsid)
- p6 proteins, by the viral protease.
Gag associates with the plasma membrane,
where virus assembly takes place.

Ref : http://www.hiv.lanl.gov/content/sequence/HIV/MAP/landmark.html

Introduction
POL :
The genomic region encoding the viral
- enzymes protease
cleave the precursor Gag
polyprotein to produce structural
proteins

- reverse transcriptase
required to transcribe DNA from
RNA template

- integrase.
integrate the double-stranded viral
DNA into the host genome

Ref : http://www.hiv.lanl.gov/content/sequence/HIV/MAP/landmark.html

Introduction
ENV :
a precursor (gp160), which is processed to
give a
- noncovalent complex of the external
glycoprotein gp120
- the transmembrane glycoprotein gp41.
The mature gp120-gp41 proteins are bound by
non-covalent interactions and are associated as
a trimer on the cell surface. gp120 contains the
binding site for the CD4 receptor

Ref : http://www.hiv.lanl.gov/content/sequence/HIV/MAP/landmark.html

Ref : http://www.ubooks.pub/Books/ON/B0/E22R2222/05MHIV.html

Introduction
Viral DNA is a code for RNA ,Which in turn codes for protein.
Each codon encodes a particular amino acid
Change in the codon may result in the incorporation of a different
amino acid (mutation).

Ref : http://www.thaiaidssociety.org/images/PDF/10thHIVDR/12Feb/0830somnuek.pdf

Definition
Virological failure
WHO
Immunological failure
(World Health Organization)
Clinical failure

Immunological
Clinical failure
failure
Adults and adolescents

Virological
failure
Plasma viral load
> 200 copies/ ml
after 6 months

Adults and adolescents

- CD4 count falls to the
baseline (or below) or
Persistent CD4 levels
< 100 cells/mm3
Children
- < 5 years
Persistent CD4 levels
< 200 cells/mm3
- > 5 years
Persistent CD4 levels
< 100 cells/mm3

Ref : http://www.who.int/hiv/pub/guidelines/arv2013/art/WHO_CG_table_7.15.pdf

severe immunodeficiency
(WHO clinical stage 4 ) a
after 6 months of effective
treatment
Children
- advanced or severe
immunodefiency (WHO
clinical stage 3 and 4
exception of TB) after 6
months of effective
treatment

HIV Resistance Testing

Genotypic assay
Phenotypic assay
Virtual phenotypic assay

Ref : http://hivinsite.ucsf.edu/InSite?page=kb-02-02-03
http://www.aidsinfonet.org/fact_sheets/view/126#_WHAT_IS_RESISTANCE_
http://www.thaiaidssociety.org/images/PDF/10thHIVDR/13Feb/0830ekawat.pdf

HIV Resistance Testing

Genotypic assay
Investigate the nucleotide sequence of an HIV on
the region that control the Protease and reverse
transcriptase enzyme
Comparing with nucleotide sequence of HIV
wild-type
Ref : http://hivinsite.ucsf.edu/InSite?page=kb-02-02-03
http://www.aidsinfonet.org/fact_sheets/view/126#_WHAT_IS_RESISTANCE_
http://www.thaiaidssociety.org/images/PDF/10thHIVDR/13Feb/0830ekawat.pdf

HIV Resistance Testing

Genotypic assay
1. the TruGene HIV-1 genotyping assay
2. the Viroseq genotyping assay
3. in house Genotypic assay

Ref : http://hivinsite.ucsf.edu/InSite?page=kb-02-02-03
http://www.aidsinfonet.org/fact_sheets/view/126#_WHAT_IS_RESISTANCE_
http://www.thaiaidssociety.org/images/PDF/10thHIVDR/13Feb/0830ekawat.pdf

Genotypic assay

1.the TruGene
HIV-1
genotyping assay

Ref : http://www.medscape.org/viewarticle/429693_4

HIV Resistance Testing

Genotypic assay
Results :
the TruGene HIV-1 genotypic assay
the Viroseq genotypic assay
No evidence of resistance
Possible resistance
Resistance
Insufficient evidence
Ref : http://www.medscape.org/viewarticle/429693_4

HIV Resistance Testing

Genotypic assay

3.in house
Genotypic assay

Ref : http://i-base.info/appendix-9-example-of-a-resistance-report/

HIV Resistance Testing

Genotypic assay

in house
Genotypic assay
Ref : hivdb.stanford.edu/DR/asi/releaseNotes/index.html#hivalg_algorithmsavailable

HIV Resistance Testing

Phenotypic assay
A sample of HIV is grown in the laboratory.
A dose of one ARV is added. The growth rate
of the HIV is compared to the rate of wild
type virus. If the sample grows more than
normal, it is resistant to the medication.

Ref : http://www.aidsinfonet.org/fact_sheets/view/126

HIV Resistance Testing

Phenotypic assay

Ref : http://hiv.uw.edu/arvres/case2/discussion.html

HIV Resistance Testing

Phenotypic assay

hypersusceptible

susceptible
Ref : http://hiv.uw.edu/arvres/case2/discussion.html

resistant

HIV Resistance Testing

Virtual phenotypic assay
Virtual phenotyping is a combination of genotypic
and phenotypic assays
If the fold change is below the lower cut-off the
drug is sensitive. If it is between this range the drug is
intermediate with a reduced response. If it is above the
upper cut-off it is resistant.
Ref : http://i-base.info/appendix-9-example-of-a-resistance-report/

HIV Resistance Testing

Virtual phenotypic assay

Ref : http://i-base.info/appendix-9-example-of-a-resistance-report/

HIV-1 Drug Resistance Mutations

K65R
- K lysine
- 65 65
-
K (lysine) R (arginine)
Ref : https://www.iasusa.org/sites/default/files/tam/22-3-642.pdf

HIV-1 Drug Resistance Mutations

NRTI Resistance
Nucleotide Reverse Transcriptase Inhibitors

HIV-1 Drug Resistance Mutations

Ref : https://www.iasusa.org/sites/default/files/tam/22-3-642.pdf

HIV-1 Drug Resistance Mutations

69 Insertion Complex
Insertion of 2 or more amino acids
Resistance to all NRTIs
69 insertions usually occur in combination with
multiple TAMs (41,210 or 215)

Ref : http://hivdb.stanford.edu/DR/NRTIResiNote.html

HIV-1 Drug Resistance Mutations

Multi-Nucleoside RT Inhibitor Resistance Mutations

- A62V
- V75I
- F77L
- F116Y
- Q151M
Q151M usually occurs in combination with two or more of
the following four accessory mutations.
Q151M alone causes high-level resistance to AZT, d4T, ddI
and ABC.
Ref : http://hivdb.stanford.edu/DR/NRTIResiNote.html

HIV-1 Drug Resistance Mutations

Thymidine Analog Mutations (TAMs)

- M41L
- D67N
- K70R
- L210W
- T215Y ,T215F
- K219Q ,K219E

Ref : http://hivdb.stanford.edu/DR/NRTIResiNote.html

HIV-1 Drug Resistance Mutations

Thymidine Analog Mutations (TAMs)
- Type 1 : M41L, L210W, and T215Y
- Type 2 : D67N, K70R, T215F, and K219Q/E
Type 1 TAMs have a greater negative impact on virological
response to an ABC-, ddI-, or TDF-containing regimen than
do Type 2 TAMs.

Ref : http://hivdb.stanford.edu/DR/NRTIResiNote.html

HIV-1 Drug Resistance Mutations

-

M41L usually occurs in combination with T215Y. Together, M41L and T215Y
confer high-level resistance to AZT and d4T and intermediate-level resistance to
ABC, ddI and TDF
D67N reduces susceptibility primarily to AZT and d4T. When present with other
TAMs it is also associated with reduced susceptibility to ABC, ddI and TDF
K70R confers intermediate-level resistance to AZT and low-level resistance to
d4T and TDF.
L210W usually occurs in combination with M41L and T215Y. Together, M41L,
L210W and T215Y confer high-level resistance to AZT and d4T and intermediate
to high-level resistance to ABC, ddI and TDF
T215Y/F confer intermediate-level resistance to AZT and d4T and low-level
resistance to ABC, ddI and TDF.
K219Q/E reduce susceptibility to AZT and d4T when present with other TAMs.

Ref : http://hivdb.stanford.edu/DR/NRTIResiNote.html

HIV-1 Drug Resistance Mutations

Ref : https://www.iasusa.org/sites/default/files/tam/22-3-642.pdf

HIV-1 Drug Resistance Mutations

M184V
- selected by 3TC/FTC and reduces susceptibility to these drugs >100-fold.
- causes low-level resistance to, ABC and ddI .
- increases susceptibility to AZT, d4T and TDF and slows the emergence of
AZT, d4T, and TDF resistance .
- M184V is also associated with reduced viral replication in vitro and in
vivo. A combination of TDF, AZT or d4T plus 3TC/FTC often partially
inhibits viruses with M184V.

Ref : http://hivdb.stanford.edu/DR/NRTIResiNote.html

HIV-1 Drug Resistance Mutations

L74V/I
- L74V is selected by ABC and ddI. Together,
- L74V and M184V are the most common mutations to develop in patients
receiving ABC/3TC .
- In combination, they reduce ABC susceptibility by >5-fold and ddI
susceptibility >2-fold.
- L74V increases susceptibility to AZT and AZT treatment selects against
the development of this mutation . In contrast, TDF treatment does not
select against L74V even though this mutation increases susceptibility to
TDF in vitro .
- L74I is selected primarily by ddI and ABC, and occasionally by TDF .
It is less effective than L74V in reducing susceptibility to ABC and ddI.
It does not appear to significantly increase AZT and TDF susceptibility

Ref : http://hivdb.stanford.edu/DR/NRTIResiNote.html

HIV-1 Drug Resistance Mutations

Ref : http://www.thaiaidssociety.org/images/PDF/10thHIVDR/13Feb/0830ekawat.pdf

HIV-1 Drug Resistance Mutations

2007 2014
K65E ,K65N

K65R ,K65E ,K65N

Ref : https://www.iasusa.org/sites/default/files/tam/22-3-642.pdf

HIV-1 Drug Resistance Mutations

NNRTIs
Non-Nucleoside Reverse Transcriptase Inhibitors

HIV-1 Drug Resistance Mutations

2007 2014
Ref : https://www.iasusa.org/sites/default/files/tam/22-3-642.pdf

HIV-1 Drug Resistance Mutations

Cross-resistance
Ref : http://www.thaiaidssociety.org/images/PDF/10thHIVDR/12Feb/1030weerawat.pdf

HIV-1 Drug Resistance Mutations

K103N
It reduces NVP and EFV susceptibility by about 50 and
20-fold
Y181C
about >50-fold reduced susceptibility to NVP
about 5-fold reduced susceptibility to ETR
about 3-fold reduced susceptibility to RPV
about 2-fold reduced susceptibility to EFV
Y188L
It confers high-level resistance (>50-fold reduction in
susceptibility) to NVP and EFV

Ref : http://hivdb.stanford.edu/DR/NNRTIResiNote.html

HIV-1 Drug Resistance Mutations

2007 2014

Ref : https://www.iasusa.org/sites/default/files/tam/22-3-642.pdf

HIV-1 Drug Resistance Mutations

2007 2014
Ref : https://www.iasusa.org/sites/default/files/tam/22-3-642.pdf

nd

Regimen Switching (2 regimen)

Failing an NNRTI plus NRTI regimen.
- Second-line ART for adults should consist of two nucleoside reversetranscriptase inhibitors (NRTIs) + a ritonavir-boosted protease inhibitor
(PI).
- The following sequence of second-line NRTI options is recommended:
- After failure on a TDF + 3TC (or FTC) -based first-line regimen,
use AZT + 3TC as the NRTI backbone in second-line regimens.
- After failure on an AZT or d4T + 3TC-based first-line regimen, use
TDF + 3TC (or FTC) as the NRTI backbone in second-line
regimens.

Ref : http://www.who.int/hiv/pub/guidelines/arv2013/intro/rag/en/index6.html

Case I
45 HIV infection 27/09/55

stavudine (d4T) 20 mg.

1x2 (8.00,20.00)
lamivudine (3TC) 150 mg. 1x2 (8.00,20.00)
efavirenz (EFV) 600 mg.
1x1 (8.00)
5
Restart 13/01/57
Lastavir (d4T 30 mg.+3TC 150 mg.)
1x2
Nevirapine 200 mg.
1x2
27/01/57
GPO virS30 (d4T 30 mg.+3TC 150 mg.+NVP 200 mg.) 1x2
(7.00,19.00)
26/02/58 VL=32,035 ,CD4=242(17%)
VL,CD4 1 19/03/58

Case I

6/5/58

Case I

Case I

TDF 300 mg.
3TC 300 mg.
ATV 300 mg.
RTV 100 mg.

1x1
1x1
1x1
1x1

Case II
57 Refer . 6/08/58

TDF,3TC,EFV
VL,CD4 14/03/58
VL=85,626
CD4= 174 (12%)

Case II

Case II
57 Refer . 6/08/58

TDF,3TC,EFV
VL,CD4 14/03/58
VL=85,626
CD4= 174 (12%)

AZT 100 mg. 2x2
3TC 150 mg. 1x2
LPV/RTV
2x2

Case III
36 HIV infection 2/02/52

GPO virS30 (d4T 30 mg.+3TC 150 mg.+NVP 200 mg.) 1x2

(8.00,20.00)
4/05/53 ADR
GPO virZ250 (AZT 250 mg.+3TC 150 mg.+NVP 200 mg.) 1x2
(7.00,19.00)
10/01/54 Imp. HBV
Tenofovir (TDF) 1x1
Lamivudine (3TC) 150 mg. 1x2
(8.00,20.00)
Nevirapine (NVP) 1x2
VL,CD4 14/05/55
VL=102,000 CD4=107

Case III

Case III

Case III

TDF 300 mg. 1x1
Zilavir (AZT 300 mg.+3TC 150 mg) 1x2
LPV/RTV 2x2

Case III

Ref : http://www.thaiaidssociety.org/images/PDF/hiv_guideline_2557.pdf

Case IV
42 loss F/U 1
restart ARV 57
TDF 300 mg. 1x1
3TC 150 mg. 1x2
NVP 200 mg. 1x2
VL,CD4 18/05/58
VL=9,395
CD4= 283 (13%)

Case IV

Case IV

Susceptible: Total score 0 to 9

Potential low-level resistance: Total score 10 to 14
Low-level resistance: Total score 15 to 29
Intermediate resistance: Total score 30 to 59
High-level resistance: Total score >= 60

Ref : http://hivdb.stanford.edu/DR/asi/releaseNotes/index.html#hivdb

Case IV
Zilavir (AZT 300 mg.+3TC 150 mg) 1x2
LPV/RTV 2x2

Case IV

Ref : http://www.thaiaidssociety.org/images/PDF/hiv_guideline_2557.pdf