title: Protease inhibitor associated mutations compromise the efficacy of therapy in human immunodeficiency virus-1 (HIV-1) infected pediatric patients: a cross-sectional study.
abstract: BACKGROUND
  Although the introduction of combined therapy with reverse transcriptase and protease inhibitors has resulted in considerable decrease in HIV related mortality; it has also induced the development of multiple drug-resistant HIV-1 variants. The few studies on HIV-1 mutagenesis in HIV infected children have not evaluated the impact of HIV-1 mutations on the clinical, virological and immunological presentation of HIV disease that is fundamental to optimizing the treatment regimens for these patients.
  
  
  RESULTS
  A cross sectional study was conducted to evaluate the impact of treatment regimens and resistance mutation patterns on the clinical, virological, and immunological presentation of HIV disease in 41 children (25 male and 16 female) at the Robert Wood Johnson Pediatric AIDS Program in New Brunswick, New Jersey. The study participants were symptomatic and had preceding treatment history with combined ARV regimens including protease inhibitors (PIs), nucleoside reverse transcriptase inhibitors (NRTIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs). Fifteen (36.6%) children were treated with NRTI+NNRTI+ PI, 6 (14.6%) with NRTI+NNRTIs, 13 (31.7%) with NRTI+PIs, and the remaining 7 (17.1%) received NRTIs only. Combined ARV regimens did not significantly influence the incidence of NRTI and NNRTI associated mutations. The duration of ARV therapy and the child's age had no significant impact on the ARV related mutations. The clinico-immunological presentation of the HIV disease was not associated with ARV treatment regimens or number of resistance mutations. However, primary mutations in the protease (PR) gene increased the likelihood of plasma viral load (PVL) > or = 10,000 copies/mL irrespective of the child's age, duration of ARV therapy, presence of NRTI and NNRTI mutation. Viremia > or = 10,000 copies/mL was recorded in almost all the children with primary mutations in the PR region (n = 12/13, 92.3%) as compared with only 50.0% (n = 14/28) of HIV infected children without (PR-), P < 0.008. However, CD-4 T cells were not affected by the mutations in the PR gene of the HIV-1 isolates.
  
  
  CONCLUSIONS
  Primary PR resistance mutations significantly increase the likelihood for high viral replication in pediatric patients with moderate/severe HIV-1 infection, which may affect the long-term clinical prognosis of the HIV infected children.
authors.affiliation: Department of Pediatrics, Division of Infectious Disease, University of Medicine and Dentistry of New Jersey (UMDNJ)-Robert Wood Johnson Medical School, New Brunswick, New Jersey 08903, USA. malhotam@umdnj.edu
authors.forename: Amisha
authors.initials: A
authors.lastname: Malhotra
authors.forename: Sunanda
authors.initials: S
authors.lastname: Gaur
authors.forename: Patricia
authors.initials: P
authors.lastname: Whitley-Williams
authors.forename: Caitlin
authors.initials: C
authors.lastname: Loomis
authors.forename: Anna
authors.initials: A
authors.lastname: Petrova