In vivo selection of HIV-1 variants with reduced susceptibility to the protease inhibitor L-735,524 and related compounds.

L-735,524 is a potent inhibitor of the HIV-1 protease. In cell culture, the compound interferes with virus replication by causing production of noninfectious immature viral particles containing an unprocessed gag-pol polyprotein. Initial human clinical studies demonstrated that treatment with the inhibitor caused circulating viral levels to decline and this decline was associated with increases in the CD4 count of varying magnitude. However, in most patients, antiviral activity is lost as viral variants with reduced susceptibility to the inhibitor are selected. The resistant phenotype appears to require an amino acid substitution at protease codon 82. However, this amino acid alteration alone is insufficient for expression of the resistance phenotype. Co-expression of various additional alterations seems to be required, but the nature of these additional substitutions differs among resistant isolates. HIV-1 variants, cross-resistant to a panel of structurally diverse protease inhibitors, were isolated from patients following prolonged L-735,524 therapy.