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Risk of failure in patients with 215 HIV-1 revertants starting their first thymidine analog-containing highly active antiretroviral therapy

Violin, Michelaa; Cozzi-Lepri, Alessandrob; Velleca, Rossellaa; Vincenti, Antonellac; D'Elia, Salvatored; Chiodo, Francescoe; Ghinelli, Floriof; Bertoli, Adag; Monforte, Antonella d'Arminioa; Perno, Carlo Federicog,h; Moroni, Mauroa; Balotta, Claudiaa

Clinical Science

Objective: To investigate the impact of 215 HIV-1 revertants on the risk of virological failure of the first thymidine analog-containing highly active antiretroviral therapy (HAART).

Design: The study included 491 HIV-1 subjects of the Italian Cohort Naive for Antiretrovirals, 405 of whom received a genotypic assay before therapy and had a virological follow-up.

Methods: Pre-treatment genotypic resistance was assessed by sequencing of the whole protease (PR) and reverse transcriptase (RT) region.

Results: Three (3.2%) and 13 (3.3%) individuals with recent (n = 95) and chronic (n = 396) HIV-1 infection carried an HIV-1 strain with 215 revertants (215D/C/E/A/V), respectively. In contrast, nucleoside associated mutations were higher in the former (15.8%) compared with the latter group (6.8%) (P = 0.005). A multivariable regression model, considering pre-HAART viral load levels, use of saquinavir-hard gel as the only PI, use of zidovudine, number of other RT and PR mutations, indicated that patients carrying 215 revertants had an increased risk of virological failure compared with those not carrying such mutants (adjusted relative hazard = 2.97 95% confidence interval, 1.11–7.94, P = 0.03). Among patients with 215 revertants, who experienced virological failure, four out of seven showed the emergence of the 215Y resistant mutation. The probability of 215Y occurrence was different between patients carrying 215 revertants compared with those who did not carried these mutants (P = 0.006).

Conclusions: HIV-1 215 revertants with an increased ability for selecting 215Y mutation are associated with a higher risk of virological failure and may lead to the appearance of virus carrying 215Y/F mutation in vivo. These findings suggest that 215 revertant viruses may compromise the efficacy of the first thymidine analog-containing regimen.

From the aInstitute of Infectious and Tropical Diseases, University of Milan, Italy, the bRoyal Free and University College Medical School, London, UK, the cInfectious Diseases Department, Lucca Hospital, Lucca, the dInfectious Diseases Institute, Policlinico Umberto I, University of Rome, the eInfectious Diseases Institute, Sant'Orsola Hospital, University of Bologna, the fInfectious Diseases Unit, Arcispedale Sant'Anna, Ferrara, the gIRCCS, L. Spallanzani, Rome and the hDepartment of Experimental Medicine, University Tor Vergata, Rome, Italy.

Correspondence to Claudia Balotta, MD, Institute of Infectious and Tropical Diseases, University of Milan, Luigi Sacco Hospital, Via G.B. Grassi, 74, 20157 Milano, Italy.

Tel: +39 02 38200446; fax: +39 02 3566644;

Received: 14 February 2003; revised: 23 May 2003; accepted: 24 June 2003.

© 2004 Lippincott Williams & Wilkins, Inc.