A Maraviroc-Resistant HIV-1 with Narrow Cross-Resistance to Other CCR5 Antagonists Depends on both N-Terminal and Extracellular Loop Domains of Drug-Bound CCR5

CCR5 antagonists inhibit HIV entry by binding to a coreceptor and inducing changes in the extracellular loops (ECLs) of CCR5. In this study, we analyzed viruses from 11 treatment-experienced patients who experienced virologic failure on treatment regimens containing the CCR5 antagonist maraviroc (MVC). Viruses from one patient developed high-level resistance to MVC during the course of treatment. Although resistance to one CCR5 antagonist is often associated with broad cross-resistance to other agents, these viruses remained sensitive to most other CCR5 antagonists, including vicriviroc and aplaviroc. MVC resistance was dependent upon mutations within the V3 loop of the viral envelope (Env) protein and was modulated by additional mutations in the V4 loop. Deep sequencing of pretreatment plasma viral RNA indicated that resistance appears to have occurred by evolution of drug-bound CCR5 use, despite the presence of viral sequences predictive of CXCR4 use. Envs obtained from this patient before and during MVC treatment were able to infect cells expressing very low CCR5 levels, indicating highly efficient use of a coreceptor. In contrast to previous reports in which CCR5 antagonist-resistant viruses interact predominantly with the N terminus of CCR5, these MVC-resistant Envs were also dependent upon the drug-modified ECLs of CCR5 for entry. Our results suggest a model of CCR5 cross-resistance whereby viruses that predominantly utilize the N terminus are broadly cross-resistant to multiple CCR5 antagonists, whereas viruses that require both the N terminus and antagonist-specific ECL changes demonstrate a narrow cross-resistance profile.Small-molecule CCR5 antagonists are a relatively new class of drugs that block HIV entry into target cells, with the first member of this class, maraviroc (MVC), having been approved for the treatment of HIV-infected patients. These drugs bind to a hydrophobic pocket formed by the transmembrane helices of CCR5, inducing conformational changes in the extracellular loops (ECLs) of the receptor (18, 31, 39, 40, 58, 62, 64). These conformational changes can vary with different drugs, as evidenced by differential chemokine binding and HIV resistance profiles, and block the ability of HIV to use drug-bound CCR5 as a coreceptor for entry (59, 64).As with other antiretroviral agents, HIV can develop resistance to CCR5 antagonists. One pathway by which HIV can become resistant to CCR5 antagonists is via mutations in the viral envelope (Env) protein that enable it to recognize the drug-bound conformation of the coreceptor. Most of our information on this pathway has come from in vitro passaging of HIV-1 in the presence of increasing concentrations of inhibitor (2, 4, 5, 33, 41, 44, 61, 66). In most instances, the viral determinants of resistance are localized to the V3 loop of gp120 (5, 33, 41, 44, 46, 63, 66). This is as expected: the base of the V3 loop interacts with O-sulfated tyrosines in the N terminus of CCR5, while the tip of the V3 loop is thought to contact the ECLs of the receptor (14, 15, 17, 19, 26, 29, 37). Viral resistance to one CCR5 antagonist commonly results in cross-resistance to other drugs in this class, although this is not universally the case (33, 41, 60, 63, 66). Mechanistically, a number of CCR5 antagonist-resistant viruses have been shown to have increased dependence on the N-terminal domain of CCR5 (5, 34, 44, 45, 48), which is largely unaffected by drug binding and may allow viruses to tolerate drug-induced changes in ECL conformation.In contrast to several well-characterized viruses that have evolved resistance to CCR5 antagonists in vitro, few examples of patient-derived CCR5 antagonist-resistant viruses have been reported. One mechanism of resistance that has been described in patients is the outgrowth of CXCR4-tropic HIV isolates that were present at low frequencies prior to the initiation of therapy (22, 23, 35, 36, 42, 65). Due to this finding, patients undergo tropism testing prior to treatment with CCR5 antagonists, with only those harboring exclusively R5-tropic viruses considered candidates for therapy. Patient-derived viruses capable of using drug-bound CCR5 have been reported in studies using vicriviroc and aplaviroc (45, 60, 63). The aplaviroc-resistant viruses were determined to utilize the drug-bound form of the receptor by interacting primarily with the N terminus of CCR5, similar to the viruses derived by serial in vitro passaging (48).In the present study, we report the isolation of MVC-resistant Envs from a treatment-experienced patient who had a viral load rebound while on a regimen containing MVC. Viral Envs isolated from this patient at the time MVC therapy was initiated were fully sensitive to drug. However, resistance evolved over the course of 224 days, culminating in Envs that were completely resistant to inhibition but continued to use CCR5 for entry. The emergence of resistance was dependent upon changes within the V3 loop of the virus, while changes in the V4 loop modulated the magnitude of resistance. The MVC-resistant Envs studied here exhibited several unusual properties. First, while they were cross-resistant to TAK779, they remained sensitive to all other CCR5 antagonists tested, including vicriviroc and aplaviroc. Second, the Envs were particularly adept at utilizing low levels of CCR5 to mediate infection of cells. Third, and in contrast to several recent reports of CCR5 antagonist-resistant viruses, these Envs were dependent upon residues within both the N terminus and ECLs of CCR5 for efficient entry in the presence of drug. When considered in the context of other reports, our data suggest a model in which resistance to multiple CCR5 antagonists can arise if an Env protein becomes highly dependent upon the N-terminal domain of CCR5, the conformation of which appears to be unaffected by drug binding. A more narrow resistance profile results from changes in Env that enable it to use both the N-terminal domain of CCR5 as well as the drug-induced conformation of the CCR5 ECLs.