Bisheteroarylpiperazine compounds are nonnucleoside reverse transcriptase inhibitors of human immunodeficiency virus type 1 (HIV-1). To provide a rationale for combination therapy with a second-generation bisheteroarylpiperazine, we investigated the effect of U-90152 in combination with 3'-azido-3'-deoxythymidine (AZT) or 2',3'-dideoxycytidine (ddC). HIV-1-infected cells were cultured in the presence of test compounds, and drug effects on p24 core antigen production were measured by an enzyme-linked immunosorbent assay. In a CD4+ T-cell line (H9) infected with HIV-1IIIB, the 501% effective concentrations for U-90152, AZT, and ddC were 6.0, 80.4, and 31.8 nM, respectively. In human peripheral blood mononuclear cells infected with the molecularly cloned clinical isolate HIV-lJRCSF, the 50%o effective concentrations for U-90152, AZT, and ddC were 5.3, 5.9, and 25.0 nM, respectively. Over a range of drug concentrations (U-90152 and AZT at 0.3, 1, 3, 10, and 30 nM; ddC at 3, 10, 30, and 100 nM), U-90152 in combination with AZT or ddC synergistically inhibited the replication of a laboratory-adapted strain and a clinical isolate of HIV-1.The bisheteroarylpiperazine (BHAP) class of compounds has been shown to inhibit the reverse transcriptase (RT) of human immunodeficiency virus type 1 (HIV-1) and block HIV-1 replication in culture cells (1,3,7,8,28,33). The BHAPs belong to a structurally diverse group of compounds known as the nonnucleoside RT inhibitors. These compounds inhibit the HIV-1 RT by binding to a common region of the enzyme away from the substrate binding site (8,12,33). In contrast, nucleoside analog inhibitors, such as 3'-azido-3'-deoxythymidine (AZT), 2',3'-dideoxyinosine, and 2',3'-dideoxycytidine (ddC), mimic the normal deoxynucleotide triphosphate substrate for RT and thus act as chain terminators during proviral synthesis (31). Other nonnucleoside RT inhibitors include dipyridodiazepinones (nevirapine) (18, 23), pyridinones (L-697,661) (12), thiobenzimidazolone compounds (TIBO Ro82150) (25), and the more recently reported TSAO [2',5' -bis-O-(tert-butyl-dimethylsilyl)-3' -spiro-5"-(4"-amino-1",2"-oxathiole-2",2"-dioxide)pyrimidine] and HEPT {1-[(2-hydroxyethoxy)methyl]-6-(phenylthio)thymine} compounds (2, 32).Drug