HIV CCR5 antagonists select for env gene mutations that enable virus entry via drug-bound coreceptor. To investigate the mechanisms responsible for viral adaptation to drug-bound coreceptor-mediated entry, we studied viral isolates from three participants who developed CCR5 antagonist resistance during treatment with vicriviroc (VCV), an investigational small-molecule CCR5 antagonist. VCV-sensitive and -resistant viruses were isolated from one HIV subtype C-and two subtype B-infected participants; VCV-resistant isolates had mutations in the V3 loop of gp120 and were cross-resistant to TAK-779, an investigational antagonist, and maraviroc (MVC). All three resistant isolates contained a 306P mutation but had variable mutations elsewhere in the V3 stem. We used a virus-cell -lactamase (BlaM) fusion assay to determine the entry kinetics of recombinant viruses that incorporated full-length VCV-sensitive and -resistant envelopes. VCV-resistant isolates exhibited delayed entry rates in the absence of drug, relative to pretherapy VCV-sensitive isolates. The addition of drug corrected these delays. These findings were generalizable across target cell types with a range of CD4 and CCR5 surface densities and were observed when either populationderived or clonal envelopes were used to construct recombinant viruses. V3 loop mutations alone were sufficient to restore virus entry in the presence of drug, and the accumulation of V3 mutations during VCV therapy led to progressively higher rates of viral entry. We propose that the restoration of pre-CCR5 antagonist therapy HIV entry kinetics drives the selection of V3 loop mutations and may represent a common mechanism that underlies the emergence of CCR5 antagonist resistance.
Human immunodeficiency virus entry is a competition at the target cell membrane between viral inactivation and successful binding to CD4 and a coreceptor, either CCR5 or CXCR4 (16,30,32,33,37,38). Engagement of receptor and coreceptor by gp120 and the subsequent rearrangement of gp41, the HIV fusion glycopeptides, leads to fusion (18,21,29,57,60,63). Smallmolecule antagonists that bind CCR5 and inhibit gp120-CCR5 binding through an allosteric mechanism have been developed (9,23,51,53,56,61). Maraviroc (MVC) is an FDA-approved CCR5 antagonist, and vicriviroc (VCV) is an investigational compound whose development has been halted (10, 47).HIV can escape CCR5 antagonism through the outgrowth of preexisting CXCR4-using populations or by the selection of resistance mutations (2, 52, 58). Mutations in the third hypervariable loop (V3 loop) of HIV-1 gp120 most commonly cause CCR5 antagonist resistance, but no canonical sites or amino acid substitutions have been identified; resistance mutations from one isolate generally do not confer resistance when transferred into unrelated env backbones (12, 17, 24, 26, 27, 34-36, 49, 54). This varied nature of HIV CCR5 antagonist genotypic resistance contrasts with resistance patterns established in other antiretroviral drug classes, for which canonical mutations (M184V in r...