Human immunodeficiency virus type 1 plasma viruses from 29 entry inhibitor-naive patients were characterized for their susceptibilities to T-20, AMD3100, and RANTES. A strikingly wide range of susceptibilities to T-20 was observed that was influenced by coreceptor usage but not by the susceptibilities of the viruses to inhibitors that target the chemokine receptors or by polymorphisms in the gp41 N helix.The human immunodeficiency virus type 1 (HIV-1) entry process (2,19,27) can be inhibited by several drugs (3,14,22,23), which belong to three groups according to the step they inhibit: (i) inhibitors of the interaction between the viral surface glycoprotein (gp120) and CD4, which target the CD4-binding site on gp120; (ii) inhibitors of the interaction between gp120 and CCR5 or CXCR4 (e.g., chemokines and their derivatives or small organic molecules that antagonize chemokine receptor activity); and (iii) fusion inhibitors, which are peptides derived from the sequence of the viral transmembrane glycoprotein (gp41) that prevent the formation of a hairpin structure required for membrane fusion. One of these peptides, T-20 (enfuvirtide), is currently being evaluated in phase III clinical trials (15,25,26). The optimization of treatment strategies that include entry inhibitors will rely on the availability of methods capable of determining baseline viral susceptibility and acquired resistance to these drugs. In addition, the characterization of the determinants of baseline susceptibility and of acquired resistance to entry inhibitors may provide valuable information on the viral entry process and on the precise mechanism of action of these drugs.We have developed a recombinant virus assay that permits the assessment of viral susceptibility to entry inhibitors. We modified a pNL4-3 molecular clone by deleting the region of the envelope gene encoding gp120 and the ectodomain of gp41 (positions 6480 to 8263) and replacing it with a linker that contains a unique MluI restriction site (vector 43-⌬env). Recombinant virus was produced by cotransfection of 293-T cells with the MluI-linearized 43-⌬env vector and a reverse transcription-PCR product, amplified from patient plasma samples, which encompasses the deleted region and carries short overlaps that allow homologous recombination. Virus-containing supernatants were used to infect subconfluent U373MG-CD4 cells expressing either CCR5 or CXCR4 (17), in the absence or in the presence of increasing concentrations of entry inhibitors. These target cells carry an HIV-1 long terminal repeat-lacZ cassette, which allows the quantification of single cycle infectivity by a colorimetric assay based on HIV-1 Tat-induced expression of -galactosidase (24). The concentrations inhibiting 50% of virus infectivity (IC 50 s) were calculated by using the median-effect equation (6).The recombinant virus assay was first used to determine the baseline susceptibilities of subtype B primary viruses to the fusion inhibitor T-20 (American Peptide Company, Inc., Sunnyvale, Calif.). Plasma samples sel...