title: Evidence that low-level viremias during effective highly active antiretroviral therapy result from two processes: expression of archival virus and replication of virus.
abstract: Episodes of low-level viremia (LLV), with plasma human immunodeficiency virus type 1 (HIV-1) RNA levels ranging from 50 to 400 copies (c)/ml, occur commonly during highly active antiretroviral therapy (HAART). LLV has been associated with virologic failure of HAART in some studies, while in others LLV did not appear to affect the clinical outcome. To understand the processes leading to LLV, genetic analyses were used to determine whether plasma virions emanated from archived or from newly evolved viral genomes. Episodes of LLV (plasma HIV-1 RNA, 50 to 379 [median, 77] c/ml) were detected in 21/37 (57%) HIV-1-infected children with median plasma HIV-1 RNA levels of <50 c/ml during 79 patient years of HAART. Viral sequences were derived by direct sequencing of PCR products from 21 plasma specimens diluted to end point. In phylogenetic analysis, LLV viral sequences grouped with virus from early in the course of infection in 8/11 subjects. Six specimens had multiple identical viral sequences, suggesting origin from clonally expanded infected cells. LLV plasma virus evolved over time, indicating viral replication, in 3/11 subjects. Two of these had frequent LLV, including the selection of drug-resistant mutants. In summary, plasma virus from episodes of LLV during effective HAART appeared to originate from two distinct processes, (i) clonal outgrowth from long-lived HIV-1-infected cells, presumably following activation and proliferation of these cells, and (ii) ongoing viral replication that included the selection of new drug-resistant mutants. These observations provide a plausible explanation for the divergent clinical outcomes previously associated with LLV.
authors: Department of Pediatrics, University of Washington, Seattle, WA, USA.
authors: Nicole H
authors: NH
authors: Tobin
authors: Gerald H
authors: GH
authors: Learn
authors: Sarah E
authors: SE
authors: Holte
authors: Yang
authors: Y
authors: Wang
authors: Ann J
authors: AJ
authors: Melvin
authors: Jennifer L
authors: JL
authors: McKernan
authors: Diane M
authors: DM
authors: Pawluk
authors: Kathleen M
authors: KM
authors: Mohan
authors: Paul F
authors: PF
authors: Lewis
authors: James I
authors: JI
authors: Mullins
authors: Lisa M
authors: LM
authors: Frenkel
mesh_terms: D000595:Amino Acid Sequence; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D002648:Child; D024882:Drug Resistance, Viral; D015684:Gene Products, pol / Q000235:genetics; D016679:Genome, Viral; D015658:HIV Infections / Q000188:drug therapy* / Q000821:virology*; D015497:HIV-1 / Q000235:genetics* / Q000472:pathogenicity; D006801:Humans; D008969:Molecular Sequence Data; D009154:Mutation; D010802:Phylogeny; D016415:Sequence Alignment; D017421:Sequence Analysis; D019562:Viral Load; D014766:Viremia / Q000188:drug therapy* / Q000821:virology*; D014774:Virulence
chemical_list: D044966:Anti-Retroviral Agents; D015684:Gene Products, pol