broad phenotypic cross-resistance to elvitegravir in hiv-infected
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Broad Phenotypic Cross-Resistance to Elvitegravir in HIV-Infected 1 Patients Failing on Raltegravir-Containing Regimens 2
3 Carolina Garrido1, Jorge Villacian2, Natalia Zahonero1, Theresa Pattery2, Federico Garcia3, 4
Felix Gutierrez4, Estrella Caballero5, Margriet Van Houtte2, Vincent Soriano#1 and Carmen de 5 Mendoza1; on behalf of the SINRES Group 6
7 1Hospital Carlos III, Madrid, Spain; 2Virco BVBA, Mechelen, Belgium; 3Hospital Clínico 8
Universitario San Cecilio, Granada, Spain; 4Hospital General Universitario, Elche, Spain; 9 5Hospital Vall d’Hebrón, Barcelona, Spain 10
11 12 13
Key words: HIV, elvitegravir, raltegravir, drug resistance. 14 15 Running title: Elvitegravir and Raltegravir cross-resistance 16 17 18 Corresponding author: 19 20 Dr. Vincent Soriano 21 Department of Infectious Diseases 22 Hospital Carlos III 23 Calle Sinesio Delgado 10 24 28029 Madrid, Spain 25 Phone: 34 91 4532500 26 Fax: 34 91 7336614 27 e-mail: vsoriano@dragonet.es 28 29 Alternative corresponding author: 30 Dr. Carolina Garrido 31 Department of Infectious Diseases 32 Hospital Carlos III 33 Calle Sinesio Delgado 10 34 28029 Madrid, Spain 35 Phone: 34 91 4532500 36 Fax: 34 91 7336614 37 e-mail: garridocarolina@yahoo.es 38
Copyright © 2012, American Society for Microbiology. All Rights Reserved.Antimicrob. Agents Chemother. doi:10.1128/AAC.06170-11 AAC Accepts, published online ahead of print on 26 March 2012
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Spanish INtegrase RESistance (SINRES) Group 39 J Pedreira (Hospital Juan Canalejo, La Coruña); JA Iribarren (Hospital de Donostia, San 40 Sebastián); J Solá (Hospital de Navarra, Pamplona); MJ Téllez, V Estrada (Hospital Clínico San 41 Carlos, Madrid); S García, JR Arribas (Hospital La Paz, Madrid); l Santos (Hospital de la 42 Princesa, Madrid); P Miralles (Hospital Gregorio Marañón, Madrid); JE Losa (Hospital 43 Universitario Fundación de Alcorcón, Madrid); M Cervero (Hospital Severo Ochoa, Madrid); J 44 Sanz (Príncipe de Asturias, Madrid); C Barros (Hospital de Móstoles, Madrid); M de Górgolas 45 (Fundación Jiménez Díaz, Madrid); E Ribera, E Caballero (Hospital Vall d’Hebrón, Barcelona); 46 C Vidal, M Riera (Hospital Son Dureta, Palma de Mallorca); C Gómez (Complejo Hospitalario 47 de Toledo); A Chocarro (Virgen de la Concha, Zamora); MJ Galindo (Hospital Clínico 48 Universitario, Valencia); F Gutiérrez (Hospital General Universitario, Elche); I Viciana, J. 49 Santos (Hospital Virgen de la Victoria, Málaga); M Omar (Hospital Ciudad de Jaén); A 50 Collado, C Gálvez (Hospital Torrecardenas, Almeria); AB Lozano, JM Fernández (Hospital 51 Poniente, Almería); V Gutiérrez-Ravé (Hospital de Motril, Granada); F García, MA López Ruz, 52 C Hidalgo, J Pasquau (Hospital Universitario Virgen de las Nieves, Granada); F García, V 53 Guillot, J Hernández-Quero (Hospital Universitario San Cecilio Granada); JA Pineda (Hospital 54 de Valme, Sevilla); C Garrido, L Anta, C de Mendoza, V Soriano (Hospital Carlos III, Madrid). 55
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ABSTRACT 57
58
Background: Failure of raltegravir (RAL) is generally associated with selection of mutations 59
at integrase positions Y143, Q148 or N155. However, a relatively high proportion of failures 60
occur in the absence of these changes. Herein, we report the phenotypic susceptibility to 61
RAL and elvitegravir (EVG) in a large group of HIV-infected patients failing on RAL. 62
Methods: Plasma from HIV-infected individuals failing on RAL-containing regimens 63
underwent genotypic and phenotypic resistance testing (Antivirogram v2.5.01, Virco). A 64
control group of patients failing on other regimens were similarly tested. 65
Results: Sixty-one samples were analysed, 40 of which belonged to patients failing on RAL. 66
Full RAL susceptibility was found in 20/21 controls, while susceptibility to EVG was 67
diminished in 8, with a median fold-change (FC) of 2.5 [2.1-3.1]. Fourteen samples from RAL 68
failures showed diminished RAL susceptibility, with a median FC of 38.5 [10.8-103.2]. 69
Primary integrase resistance mutations were found in 11 of these samples, displaying a 70
median FC of 68.5 [23.5-134.3]. The remaining 3 samples showed a median FC of 2.5 [2-2.7]. 71
EVG susceptibility was diminished in 19/40 samples from RAL failures (median FC=7.71 72
[2.48-99.93]). Cross-resistance between RAL and EVG was high (R2=0.8, p<0.001), being drug 73
susceptibility more frequently reduced for EVG than for RAL (44.3% vs 24.6%, p=0.035). 74
Conclusions: The susceptibility to RAL and EVG is rarely affected in the absence of primary 75
integrase resistance mutations. There is broad cross-resistance between RAL and EVG, 76
which should preclude their sequential use. Resistance to EVG seems to be more frequent 77
and might be more influenced by integrase variability. 78
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INTRODUCTION 80
81
The introduction of highly active antiretroviral therapy (HAART) has transformed the 82
prognosis of HIV-positive patients, with dramatic improvements in survival. However, 83
selection of drug resistance still represents a major challenge, and promotes switches in 84
therapeutic regimens in a substantial proportion of patients (3). Virologic failure under 85
some antiretroviral drugs is associated with cross-resistance to agents within the same 86
family, limiting rescue therapeutic options (16). Nevirapine and efavirenz are good examples 87
of cross-resistance between members of the same drug family, sharing almost completely 88
resistance patterns. To a lesser exent, it also occurs with failures under some protease 89
inhibitors (12) and nucleoside analogues. 90
91
Integrase inhibitors (INI) are a new and promising drug family for the treatment of HIV 92
infection. Raltegravir (RAL) is the first-in-class approved drug for clinical use in both 93
treatment-naïve (11) and treatment-experienced individuals (19). Elvitegravir (EVG) will 94
most likely be the second INI compound to be marketed (4). Resistance to INIs has shown to 95
be driven by changes mainly located in the central domain of the viral integrase. The results 96
of clinical trials and clinical experience have highlighted that failure on RAL-containing 97
regimens is generally driven by selection of mutations Y143RHC, Q148HRK and/or N155H, 98
often accompanied by secondary changes (G140SA, E138K, L74M, etc.) (2). However, a 99
relatively high proportion of patients do not show such changes upon virologic failure on 100
RAL. Although unidentified resistance mutations might exist, a recent report has highlighted 101
that the absence of INI resistance mutations in these individuals is mainly explained by poor 102
drug compliance, given that RAL plasma levels were undetectable in most of them (6). 103
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104
Information about resistance to EVG in vivo is scarce. In the phase II GS-US-183–105 study 105
(13), 28 individuals failed EVG after 24 weeks of treatment. Overall, 39% of them selected 106
the mutation E92Q, 32% selected Q148HRK and 25% selected N155H. Accordingly, broad 107
cross-resistance between RAL and EVG should be expected. The aim of our study was to 108
characterize RAL phenotypic susceptibility in samples from a group of patients experiencing 109
RAL failure, exploring whether mutations not previously involved in RAL resistance might be 110
recognised and the extent of phenotypic cross-resistance to EVG. 111
112
PATIENTS AND METHODS 113
114
Study population 115
HIV-1-infected individuals treated at several clinics in Spain who experienced virological 116
failure under a RAL-containing antiretroviral regimen, were identified during 2009. 117
Virological failure was defined as the first sample with plasma HIV-RNA >50 copies/mL, 118
confirmed in a second specimen collected within a month. Then, plasma specimens 119
collected at the time of first RAL failure were sent to Hospital Carlos III along with 120
information on viral load, CD4 counts and antiretroviral combinations. In addition, samples 121
from INI naïve patients were also sent to be used as controls. Most participating centres 122
belonged to RIS (Red de Investigación en SIDA), the government funded Spanish AIDS 123
research network, which involves around twenty-five HIV clinics across the country and 124
whose main characteristics have already been described elsewhere (17). All specimens that 125
were examined in the current study were part of the repository collected for the SinRes 126
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study, a previous survey that characterized virologically RAL failures in a total of 106 127
patients (6). Signed informed consent was obtained from each individual. 128
129
Genotypic resistance analysis 130
The analysis of the HIV integrase gene was performed by bulk sequencing using an in-house 131
PCR protocol, with primers and conditions previously described (7). Primary integrase 132
resistance mutations were defined as those changes that cause significant loss of drug 133
susceptibility by themselves. This is the case for Y143RHC, Q148HRK and N155H. 134
135
Phenotypic resistance analysis 136
Viral RNA was isolated from all plasma samples using NucliSENS EasyMAG (Biomerieux). One 137
amplicon per sample containing the reverse transcriptase – integrase (RT-IN) regions was 138
sequenced and cloned into an HXB2 backbone. Recombinant viruses were titrated and 139
subjected to an antiviral experiment in MT4-LTR eGFP cells, as previously described (20). 140
Briefly, MT4-LTR-eGFP cells were inoculated with a titrated amount of virus in the presence 141
of 3-fold dilutions of the compound tested. After 3 days of incubation at 37°C, infection was 142
quantified by means of fluorescent microscopy measuring HIV Tat-induced enhanced green 143
fluorescent protein (eGFP) expression. Using the HIV-1 wild-type strain IIIB as reference, fold 144
change (FC) values were calculated by dividing the mean 50% effective concentration (EC50) 145
for a recombinant virus stock by that for the reference strain. A biological cutoff (BCO) for 146
RAL and EVG was calculated on clonal database (991 clones from 153 clinical isolates) as the 147
97.5 percentile of the log FC phenotypes of patient-derived clonal viruses not containing any 148
of the mutations listed in the RAL package insert label: 74M, 92Q, 97A, 138A/K, 140A/S, 149
143C/H/R, 148H/K/R, 151I, 155H, 163R, 183P, 226C/D/F/H, 230R and 232N, and/or not 150
containing mutations with score >0 for RAL/EVG in the Stanford algorithm 6.0.11. Before 151
calculating the BCO, outliers (log FC > mean log FC +3 standard deviations) were removed 152
(22). Thus, biological cut-offs were preliminarly established as FC=2 for RAL and FC=1.9 for 153
EVG. 154
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155
Statistical analysis 156
Results are expressed as medians [IQR] and percentages. Comparisons were performed with 157
non-parametric tests using Mann-Whitney or Chi-square tests. FC values were log 158
transformed for analysis of the phenotypic resistance correlation using bivariate analysis. All 159
statistical analyses were carried out using the SPSS v15 software (SPSS Inc., Chicago, IL). 160
161
RESULTS 162
163
Study population 164
A total of 61 samples were examined, 21 belonging to INI-naïve patients and 40 obtained 165
from patients experiencing early virological failure on RAL-containing regimens. All INI-naïve 166
individuals were antiretroviral-experienced. The main characteristics of this population are 167
summarized in Table 1. 168
169
Resistance testing in INI-naïve patients 170
Phenotypic results in specimens collected from the 21 INI-naïve individuals, showed that all 171
but one (95.2%) were susceptible to RAL. The single sample displaying a FC of 2.4 to RAL did 172
not harbor any primary nor secondary known integrase resistance mutation. However, 173
compared to reference sequences the following changes at the integrase gene were 174
present: E11D, S24G, D25E, S39C, M50IM, I72V, L101I, V201I and S283G. In contrast, up to 175
8/21 (38%) of the INI-naïve samples displayed FC above 1.9 for EVG. Primary or secondary 176
resistance changes were neither found in these specimens, as shown in Table 2. 177
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Resistance testing in RAL failures 179
Overall, 11 out of 40 (27.5%) samples collected from patients experiencing early RAL failure 180
harbored primary INI resistance mutations, distributed as follows: Q148H/R (n=5), N155H 181
(n=3), Y143R (n=2) and a complex pattern including Y143HY+N155H (n=1). All sequences 182
examined in this study have been submitted to Genbank, with accession numbers 183
JQ716857-JQ716918. 184
185
Fourteen (35%) samples displayed phenotypic FC above 2 for RAL, including the 11 186
specimens with primary INI resistance mutations. Three samples, which did not contain any 187
primary INI resistance change, displayed low FC values for RAL (2, 2.5 and 2.7, respectively). 188
As a comparison, median FC was of 58.9 [26.5-125.3] for the eleven patients with INI 189
resistance mutations. The main characteristics of these patients are recorded in Table 3, 190
including information on RAL plasma levels as an indirect marker of drug adherence. 191
192
When testing EVG, 19 (47.5%) of RAL failures displayed impaired EVG sensitivity. Overall, 193
median FC was 7.71 [2.48-99.93], but it was much greater in the 11 samples harboring 194
primary INI resistance mutations than in the 8 samples without major integrase changes 195
(99.93 [46.92-99.93] vs 2.45 [2.36-2.83], p<0.001). Table 3 records the genotypic and 196
phenotypic data for EVG in these patients. 197
198
Primary INI resistance mutations led to high-level resistance to both RAL and EVG, although 199
with slight differences. Mutation Y143R conferred greater level of resistance to RAL than 200
EVG, with FC ranging from 26.5 to 58.9 vs 3.92 to 7.68, respectively. However, it is 201
noteworthy that this change, which is not considered a primary resistance mutation for 202
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EVG, significantly compromised EVG susceptibility in the presence of secondary resistance 203
mutations (T97A+V151I for one specimen and L74M for another). 204
205
Impact of minor integrase changes on RAL and EVG susceptibility 206
Comparisons of RAL and EVG FC in the presence/absence of changes at single integrase 207
positions were performed using non-parametric tests. Only samples without primary INI 208
resistance mutations were considered for this purpose, and therefore the analysis was 209
carried out in a subset of 50 specimens. Changes at 5 positions were positively associated 210
with increased FC for RAL compared to the wild type. They were as follows: S24G/N, D25E, 211
L74I, K215N and Q221H/S. On the contrary, the K156N change reduced the FC to RAL 212
compared to the wild type. Of note, mutations L74I and K215N appeared together in the 213
same specimen, as well as most S24G/N and D25E. All this information is summarised in 214
Table 4. With respect to EVG, mutations L45Q/V, V72I and R263K were associated to an 215
increased FC, while S119G/P/S/T, V126M/L and Q216H seemed to enhance EVG 216
susceptibility in comparison with the wild type. 217
218
Cross-resistance between RAL and EVG 219
Bivariate associations between FC to RAL and EVG expressed as log values resulted in a 220
significant positive correlation (r2=0.8, p<0.001), supporting that there was a high degree of 221
cross-resistance between both drugs. However, reduced susceptibility to EVG was more 222
common than for RAL, as 27/61 (44.3%) samples displayed EVG resistance in comparison 223
with only 15/61 (24.6%) of them (p=0.002). 224
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DISCUSSION 226
227
Resistance to both RAL and EVG has been described to be mainly associated with changes at 228
integrase positions 148 and 155. Our phenotypic results confirm the impact of these 229
changes, since they conferred high FC to both drugs. Mutation Y143R leads to the third RAL 230
resistance pattern, and again its impact on RAL susceptibility was confirmed in our study, 231
showing high FC values. Interestingly, this mutation also impaired EVG susceptibility, 232
showing FC of 4 to 8 when Y143R was present along with other secondary changes. This is 233
somewhat unexpected since prior reports had claimed that Y143R did not influence EVG 234
susceptibility (5,14,18). Altogether, our results suggest that EVG activity is compromised in 235
the presence of any of the RAL resistance patterns, including Y143R. Therefore, the 236
sequential use of these drugs is not advisable upon failure with either of them. 237
238
A few samples in our study displayed small, but potentially clinically significant, reductions 239
in the susceptibility to integrase inhibitors, based upon the established biological cut-offs of 240
2.0 and 1.9 for RAL and EVG, respectively. The reduced sensitivity was more prominent for 241
EVG in the absence of primary INI resistance mutations. One specimen from a subject failing 242
on RAL did not show any known INI resistance mutation but displayed a 2.5 FC for RAL and 243
7.71 for EVG. This sample only harboured the change R263K as potentially responsible for 244
this effect on INI susceptibility. Interestingly, R263K has previously been shown to be 245
selected in vitro by EVG conferring a 5.2 FC to the drug (15). In the present study, it also led 246
to a slight but significant decrease in RAL susceptibility. Another patient displayed a FC of 247
2.7 to RAL despite lacking primary INI resistance mutations. However, change L74I had been 248
selected in this patient failing on RAL. Given that mutation L74M is a secondary resistance 249
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mutation generally selected along with N155H in patients failing on RAL (8,15), we suggest 250
that change L74I might equally compromise RAL susceptibility. 251
252
Overall, testing of samples collected from RAL failures in the absence of primary INI 253
resistance mutations allowed the recognition of certain minor changes that might impact INI 254
susceptibility in a clinically relevant manner. This was the case for changes S24G/N, D25E, 255
L74I, K215N and Q221H/S for RAL and L45Q/V, V72I and R263K for EVG. Additional 256
resistance studies are being performed by Virco to clear up the phenotypic effect of each of 257
these changes. However, their clinical impact should be further investigated in larger groups 258
of patients experiencing INI failure. 259
260
Most patients displaying resistance to RAL in our study also exhibited a reduced EVG 261
susceptibility. The extent of cross-resistance was high for all different resistance patterns 262
and may have important clinical implications regarding the consideration of sequential use 263
of RAL and EVG. Moreover, it was intriguing that EVG showed more often increased FC than 264
RAL, given that confronting integrase changes, the FC was almost uniformly more influenced 265
for EVG than for RAL. Hypothetically, our findings could be explained by the faster 266
dissociation time from the viral integrase for EVG than RAL, with a half-life of 2.4 and 9 267
hours, respectively (9). 268
269
The variability at the viral integrase has been shown to be greater in antiretroviral-270
experienced compared to drug-naïve patients (1,7,21). All our patients, regardless of RAL 271
exposure, were antiretroviral-experienced, which might have led to a higher rate of 272
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polymorphisms, contributing to explain the relatively high proportion of subjects with slight 273
reductions in RAL and especially EVG susceptibility in INI-naïve patients. 274
275
In summary, our results testing phenotypic and genotypic samples from RAL failures and 276
controls support that the susceptibility to RAL and EVG is mainly impaired by resistance 277
mutations Q148H/R, N155H and/or Y143R. Slight reductions in susceptibility to any of these 278
drugs can occur in the presence of other integrase changes. The wide extent of cross-279
resistance between RAL and EVG should preclude their sequential use. 280
_______________________________ 281
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22. Verlinden Y, Vermeiren H, Lecocq P, Bacheler L, McKenna P, Vanpachtenbeke M, 373
Horvat LI, Van Houtte M, Stuyver LJ. 2005. Assessment of the Antivirogram® 374
performance over time including a revised definition of biological test cut-off values. 375
Antivir Ther., 10 (suppl):S51 376
377
378
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Table 1. Main characteristics of the study population. 1
2
Samples examined (n) 61INI naïve (%) RAL failures (%)
21 (34.4%) 40 (65.6%)
Median Plasma HIV-RNA (log copies/mL) 4.13 [3.38-4.82] Median CD4 count (cells/mm3) 242 [88-392] HIV-1 subtype (%)B 93.4 F 3.3G 1.6 CRF02_AG 1.6Time under RAL therapy*(weeks) 44.71 [22.57-70.57] 3
* Only for the 40 samples belonging to patients failing on raltegravir. 4
INI, integrase inhibitor; RAL, raltegravir 5
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Table 2. Genotypic and phenotypic results in patients naïve to HIV integrase inhibitors. 1
2
Sample ID ARV regimen Subtype FC
RALFC
EVGMinor
mutationsOther changes
N_1 ABC, AZT, TDF, DRV/r B 1,10 2,08
Q44K, I72V, T112IT, I113V, S119P, T122IT, E152G, T206S, T218S
N_2 FTC, ddI, ATV B 1,30 2,08 D6E, E11D, V32I, V37I, L101I, T125A,
I135V, V201I, S283G
N_3 NA B 1,30 2,19 I203M E11D, E13D, V31I, V32I, S39C, M50I, I60V, L101I, I113V, T122I, T124N, I208L
N_4 AZT, 3TC, NVP B 1,60 2,53 E138D V32I, D41N, I72V, L101I, T122I, T124A,
V201I
N_5 TDF, AZT, 3TC, ABC,
fAPV/r B 0,80 2,56 S230NS D6E, E11D, L28I, K34R, V37I, V201I,
L234IL, D253DE, A265AV
N_6 AZT, 3TC, fAPV/r B 1,80 2,63 T97A
E11D, S24G, D25E, L45V, M50I, L101I, T125A, F181L, T206S, D256E, S283G,
D288N
N_7 FTC, TDF, fAPV/r G 1,90 3,33
K14R, L101I, T112I, T124A, T125A, G134N, K136T, D167E, V201I, T206S, Q221H, D232E, L234I, S255N, D256E, S283G
N_8 FTC, TDF, ATV/r B 1,20 3,35
M50I, I113V, T124A, F181L, V201I, N222H, D256E
N_9 FTC, TDF, LPV/r B 2,40 1,68
E11D, S24G, D25E, S39C, M50IM, I72V, L101I, V201I, S283GS
3
FC, fold change; RAL, raltegravir; EVG, elvitegravir 4
ABC, abacavir; 3TC, lamivudine; FTC, emtricitabine; TDF, tenofovir; fAPV, fosamprenavir, 5
ATV, atazanavir; LPV, lopinavir. 6
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Table 3. Genotypic and phenotypic results in patients failing on raltegravir. 1
2
Sample ID Subtype ARV regimen Months on RAL
Detectable RAL plasma levels
FCRAL
FCEVG
Majormutations
Minormutations
Other changes
F_1 B ETR, DRV/r, RAL 8.9 - 2 1.1 D6T, K7E, E13D, V31I, V79I,
L101I, V201I
F_2 B AZT, 3TC, ATV,RAL 7.6 - 2.7 1.2 I203M E11D, V32I, S39C, L74I,
V201I, I208L, K215N
F_3 B MVC, ATV, RAL NA + 2.5 7.7 R263K M50I, I72V,S119P, T124A, V201I, I220L
F_4 B 3TC, MVC, RAL 9.6 + 78 99.9 Q148HQ G140GS E10D, V31I, I72V,
L101I, S119G, T122I, T125A, K156N, V201I, T206S, Q216H, Q221R, D256E
F_5 B FTC, TDF, ETR, DRV/r, RAL 5.3 + 161.2 99.9 Q148H G140S E11D, S24N, V31I,
T112IM, T206S, I208L, D253DE
F_6 B FTC, TDF, RAL 7 NA 125.3 99.9 Q148R G140A V31I, D41N,L101I, V201I, T206S, I268L, R269K
7 B FTC, TDF, RAL 7.6 + 161.2 99.9 Q148H G140S,A128AV
D6E, K14R, S17NS, V31I,L101I, K111EK, I135V, G163Q, G193E, V201I, D256E
F_8 B TDF, MVC, RAL NA + 95.9 99.9 Q148R G140A, E157Q
K14R, S24G, D25E, L45I,I113V, T124N, T125A, K160S, V165IV,
I220L, Y227F, L234V, D256E
F_9 B NA NA + 13.5 48.0 N155H S17N, L101I, T112I, V165I, H171L,
T206S, D256E
F_10 B 3TC, ABC, RAL 6.7 + 14.6 99.9 N155H L74LM E11D, K14R, K34R, D41N, P90S, L101I, K111KQ, S119RS, K156N, I208L, D256E
F_11 B AZT,
3TC,ETR,DRV/r, T20, RAL
5.2 + 27.6 46.9 N155H T97AT, E92EQ
K7R, S17N, R20K,L101I, T112V, S119P, T124A, I135V,
I220L, D232DN, D253DN
F_12 B d4T, TDF, ETR, DRV/r, RAL 21.7 + 26.5 3.9 Y143R T97AT,
V151IVS17N, V31I, M50T, I72V, V75IV,
T124A, K156N, T206S, I220IV, D232DN, D256E
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F_13 B FTC, TDF, RAL 12.8 NA 58.9 7.6 Y143R L74M K7R, V31I,L101I, T112I, T125V, K219N, N222K
F_14 B FTC, TDF, RAL 10.4 + 49.3 99.9 Y143HY,N155H
S17N, E96N, L101I, S119P, T122I, T124A, K156N,
V201I, T206S, I208L, Y227F, D253Y, D256E
F_15 B FTC, TDF, ETR, RAL 11.8 - 1.3 2.3
D6E, L28I, V37I, S39C, I84IM, L101I, T124A, T125A, I135V
F_16 B AZT, 3TC, TDF, T20, DRV/r, RAL 5.6 NA 1.5 2.4
K7KR, S17N, L101I, K111T, S119T, T124NS, I208IL, I220L, Q221S, D253E, D256E
F_17 B FTC, TDF, DRV/r, RAL 31.7 + 1.1 2.4 S230N E10D, V32I, S39C, L101I, T218S, D253E
F_18 B DRV/r, RAL NA - 0.7 2.4 D6E, S17N, V32I, L45V, T124N, I203M, D253E
F_19 B FTC, TDF, ETR, RAL 16.5 - 1.3 2.5
K7R, S17N, V31I, S39C, L101I, G163E, K173R, V201I, D232E
F_20 B 3TC, LPV/r,RAL NA NA 0.6 2.8 V31I, L45Q, L101I, T206S, N254Q
F_21 B FTC, TDF, RAL 18 + 0.6 2.8 S230N K7R, K14R, L101I, T112I 3
FC, fold change; RAL, raltegravir; EVG, elvitegravir; -, undetectable RAL plasma levels; +, detectable RAL plasma levels 4
DRV, darunavir; ETV, etravirine; MVC, maraviroc; ABC, abacavir; 3TC, lamivudine; FTC, emtricitabine; TDF, tenofovir; fAPV, fosamprenavir, ATV, 5
atazanavir; LPV, lopinavir; d4T, stavudine; T20, enfuvirtide 6
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Table 4. Phenotypic impact of minor changes at the HIV integrase gene in the absence of 1
primary resistance mutations on susceptibility to raltegravir and elvitegravir. 2
3 Integrase Inhibitor Position
FC [median, IQR] WT Mutation p
RAL
S24G/N 1.05 [0.70-1.30](n=46)
1.65 [1.27-2.25](n=4)
0.021
D25E 1.10 [0.70-1.30](n=47)
1.80 [1.20-2.40](n=3)
0.052
L74IK215N
1.10 [0.75-1.3](n=49)
2.70(n=1)
0.040
Q221H/S 1.05 [0.7-1.3](n=46)
1.4 [1.3-1.8](n=4)
0.044
K156N 1.10 [0.8-1.3](n=47)
0.7 [0.6-0.8](n=3)
0.047
EVG
L45Q/V 1.19 [0.9-2.08](n=47)
2.63 [2.43-2.80](n=3)
0.018
V72I 1.14 [0.76-1.44](n=18)
1.48 [1-2.42](n=32)
0.051
R263K 1.2 [0.92-2.22](n=49)
7.71(n=1)
0.040
S119G/P/S/T1.48 [1.09-2.45]
(n=33)1 [0.70-1.39]
(n=17)0.006
V126M/L 1.3 [0.98-2.33](n=48)
0.76 [0.70-0.76](n=2)
0.041
Q216H 1.3 [0.98-2.33](n=48)
0.62 [0.48-0.76](n=2)
0.015
4
FC, fold change; RAL, raltegravir; EVG, elvitegravir 5
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