Human immunodeficiency virus type 1 (HIV-1) isolates derived from HIV-infected, treatment-naive Ugandan infants were propagated and tested for sensitivity to antiretroviral (ARV) drugs. Although most subtype A and D isolates displayed inhibition profiles similar to those of subtype B strains, a subtype D isolate identified as D14-UG displayed high-level resistance to nevirapine in peripheral blood mononuclear cell cultures (>2,000-fold) and in MT4 cell cultures (ϳ800-fold) but weaker resistance to delavirdine (ϳ13-fold) and efavirenz (ϳ8-fold) in MT4 cell cultures. To investigate the possible mechanism for this resistance to nonnucleoside reverse transcriptase (RT) inhibitors (NNRTIs), the RT coding region in pol was sequenced and compared to the consensus RT sequence of NNRTI-resistant and NNRTI-sensitive subtype A, B, and D HIV-1 isolates. D14-UG did not contain the classic amino acid substitutions conferring NNRTI resistance (e.g., Y181C, K103N, and G190A) but did have some putative sites associated with drug resistance, I135L, T139V, and V245T. Wild-type and mutated protease-RT genes from D14-UG and an NNRTI-sensitive subtype D isolate from Uganda (D13-UG) were cloned into pNL4-3 to produce recombinant viruses and to determine the effects of the mutations on susceptibility to ARV drugs, specifically, NNRTIs. The results showed that I135L and/or V245T mutations can confer high-level resistance to nevirapine and delavirdine as well as low level crossresistance to efavirenz. Finally, ex vivo fitness analyses suggested that NNRTI-resistant sites 135L and 245T in wild-type isolate D14-UG may reduce RT fitness but do not have an impact on the fitness of the primary HIV-1 isolate.Current drugs effective at inhibiting human immunodeficiency virus type 1 (HIV-1) reverse transcriptase (RT) are classified as nucleoside RT inhibitors (NRTIs) and nonnucleoside RT inhibitors (NNRTIs) (3,19). NRTIs interfere with enzyme activity following conversion to the triphosphate forms and incorporation into the growing DNA strand, which causes premature chain termination (4,8). In contrast, NNRTIs are noncompetitive inhibitors which bind a hydrophobic pocket adjacent to the polymerase active site, causing an allosteric change which effectively inhibits DNA polymerization (9). One of the impediments to the frequent use of NNRTIs in combination with at least two NRTIs is the rapid emergence of resistance.Studies of drug resistance have mainly focused on HIV-1 subtype B, which is dominant in developed countries (26). A paucity of data on the emergence of antiretroviral (ARV) drug resistance in individuals or populations infected with other subtypes (e.g., A, C, D, and CRF01) likely is attributable to limited access to ARV drug treatment in developing countries (1, 2, 13, 15, 30-32, 39, 47, 53). However, the rapid implementation of new ARV drug treatment programs in these regions likely will precede thorough investigations of ARV drug resistance in non-clade B HIV-1 isolates. Interestingly, nevirapine, as opposed to the more expensive p...