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Modulation of human immunodeficiency virus type 1 synergistic inhibition by reverse transcriptase mutations.

Synergy between the anti-human immunodeficiency virus type 1 (HIV) nucleoside reverse transcriptase (RT) inhibitors (NRTIs) and nonnucleoside RT inhibitors (NNRTIs) results from a general mechanism in which NNRTIs inhibit ATP-mediated removal of NRTIs from chain-terminated primers by decreasing the maximum rate of removal, thus sustaining NRTI chain termination. With this molecular mechanism of synergy, beta-D-(+)-3'-azido-3'-deoxythymidine monophosphate (AZTMP) removal was examined in the context of clinically relevant RT mutants. The IC50 value for inhibition by nevirapine against wild-type (WT) RT in our removal assay was 3 microM, but this concentration had no effect on removal by the nevirapine-resistant Y181C mutant. Rather, a approximately 83-fold increase in nevirapine was required to decrease the rate of removal by 50% for this mutant. Efavirenz displayed a 100 nM IC50 value against WT and the efavirenz-sensitive Y181C mutant, but the efavirenz-resistant mutants K103N and K103N/Y181C required a 6-fold increase in efavirenz concentration to achieve the same effect. A newer generation NNRTI, TMC125, showed potency (55 nM) against WT and all mutants, paralleling the activity of this inhibitor relative to nevirapine and efavirenz in cell culture. When tested against the AZT-resistant mutant, all NNRTIs inhibited removal by greater than 50%, showing that this mutant is hypersensitive to NNRTIs. Altogether these results illustrate that both the NNRTI and NRTI mutations can modulate chain termination. This demonstrates that sustaining synergistic HIV inhibition in combination NRTI/NNRTI therapy requires NNRTIs that are potent against WT virus and possess favorable activity profiles against clinically relevant mutations.