High Discordance in Plasma and Genital
Tract HIV-1 Drug Resistance in Indian
Women Failing First-line Therapy
MOPDA0106
S. Saravanan, PhD
Session Code: MOPDA01
Molecular Techniques of HIV-1 Analysis
21 July 2014
Background:
 Much less work has been directed at HIV in non-blood compartments
and those compartments may be the potential sanctuary sites harboring
HIV and impacting both the transmission and pathogenesis of HIV
infection.
 It is vital to investigate tissues and compartments other than blood
for two important reasons (Cu-Uvin S., et al., 2010).
• From a patient perspective, it is important to determine
whether antiretroviral therapy can reduce viral load in non-blood
compartments.
• From a public health perspective, it is critical to know the
factors that contribute to the “infectiousness” of an individual in
order to devise strategies to reduce the likelihood of transmission.
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Materials and Methods:
 HIV-infected women (n=200) at YRG CARE in Chennai, India, who
were adherent on >6 months of first-line antiretroviral therapy were
enrolled.
 Genital tract (2 Sno-strips in 500uL of NASBA buffer) RNA levels
measured using COBAS® AMPLICOR HIV-1 MONITOR Test, v1.5 & Pol
genotyping (Saravanan et al., 2009) was conducted in paired detectable
samples from both compartments.
 Sequences were aligned (ClustalX) to an Indian subtype C reference
(C.IN.AFo67155) and examined for HIV-1 subtype (REGA v2),
nucleotide diversity (Highlighter HIV LANL, SLAC in HyPHY) and drug
resistance associated mutations (IAS-USA and Stanford HIV Resistance
Database).
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Results:
Demographic details of enrolled study subjects
Women on First-line ART (n=200)
Patient Characteristics
Viremic (n=73)
Non-Viremic (n=127)
Age(Mean) years
33.8±6.3
33.4±5.2
PVL (Median) log copies/mL
4.6 (3, 5.9)
Not Detected
CD4(Median) cells/µL
246 (15, 832)
530 (27, 1182)
Duration on HAART
(Median) Months
35 (7, 114)
34 (6, 122)
NVP
44 (60%)
87 (68.5%)
D4T/AZT
55 (75%)
114 (90%)
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Results:
STUDY SUBJECTS ENROLLED; n = 200
VIREMIC; n=73 (36.5%)
PVL >3000 Copies/mL;
n=42/73 (57.5%)
DETECTABLE GVL
n=30/42 (71%)
GVL >2000 Copies/mL
n=21/30 (70%)
NON-VIREMIC; n=127 (63.5%)
PVL <3000 Copies/mL;
n=31/73 (42.5%)
UNDETECTABLE GVL
n=12/42 (29%)
GVL <2000 Copies/mL
n=9/30 (30%)
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Results:
Genital and Plasma Sequences
(n = 21)
Concordant mutation
patterns; n = 4/21 (19%)
Discordant mutation
patterns; n = 17/21 (81%)
41%
50%
Percent of subjects
35%
40%
24%
30%
20%
10%
0%
5 NRTI – T215F,
M41L, D67DN, K70T,
K219E
7 NNRTI- K103E/N,
H221Y, V106M,
Y188H, E138A,
Y181C
Additional in
Genital
Additional in
Plasma
Diverse in both
Discordance Pattern
Total patients with additional mutations in
genital tract; n=11/21 (52%)
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Results:
p=
<0.005
r2 = 0.872 (p=ns)
 Women with detectable PVL tend
to shed virus in genital secretions
(p<0.005)
Figure 1a: Pearson’s rank correlation for comparison between PVL
and GVL in patients with discordance (n=17).
1b: Fisher’s exact test for comparison of patients with detectable and
undetectable viral load in plasma and genital compartments (n=42)
Figure 4: Phylogenetic analyses of RT
 95% have monophyletically clustered
with Indian subtype C with one sequence
clustered to CRF_02 AE
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Results:
 High prevalence of M184V
in both compartments
followed by TAMs.
Figure 5: Prevalence of various NRTI and NNRTI
DRMs in plasma and genital tract.
Figure 6: Comparison between the presence of
intermediate to high-level resistance in plasma and genital
secretions in patients with discordant mutations (n=5).
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 Genital discordant mutations
were responsible for an increase
to a predicted intermediate or
high level drug resistance to at
least one drug in 24% of women
Conclusion:
 High resistance discordance between plasma and the genital
tract among South-Indian women failing first-line antiretroviral
therapy, suggesting compartmentalization and independent
viral evolution.
 If confirmed, GVL and resistance monitoring may need to be
considered to prevent sexual and perinatal HIV-1 resistance
transmission in countries like India where sexual transmission is
the major mode of HIV infection.
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Acknowledgement
Indian Council of Medical Research (ICMR) under U.S.-India
Collaborative Research Supplement # Indo-US/35/2007-ECD-II
S. Gomathi, M.Sc
S. Sivamalar, M.Sc
G. Kausalya, M.Sc
P. Selvamuthu, MBBS
N. Kumarasamy, MBBS, PhD
P. Balakrishnan, PhD
Suniti Solomon, MD
Susan Cu-Uvin, MD
Rami Kantor, MD
Sunil S. Solomon, MPH, PhD
IAS International scholarship (S12858)
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