title: Transient antiretroviral therapy selecting for common HIV-1 mutations substantially accelerates the appearance of rare mutations.
abstract: BACKGROUND
  Highly selective antiretroviral (ARV) regimens such as single dose nevirapine (NVP) used for prevention of mother to child transmission (PMTCT) in resource-limited settings produce transient increases in otherwise marginal subpopulations of cells infected by mutant genomes. The longer term implications for accumulation of further resistance mutations are not fully understood.
  
  
  METHODS
  We develop a new strain-differentiated hybrid deterministic-stochastic population dynamic type model of healthy and infected cells. We explore how the transient increase in a population of cells transcribed with a common mutation (modelled deterministically), which occurs in response to a short course of monotherapy, has an impact on the risk of appearance of rarer, higher-order, therapy-defeating mutations (modelled stochastically).
  
  
  RESULTS
  Scenarios with a transient of a magnitude and duration such as is known to occur under NVP monotherapy exhibit significantly accelerated viral evolution compared to no-treatment scenarios. We identify a possibly important new biological timescale; namely, the duration of persistence, after a seminal mutation, of a sub-population of cells bearing the new mutant gene, and we show how increased persistence leads to an increased probability that a rare mutant will be present at the moment at which a new treatment regimen is initiated.
  
  
  CONCLUSIONS
  Even transient increases in subpopulations of common mutants are associated with accelerated appearance of further rarer mutations. Experimental data on the persistence of small subpopulations of rare mutants, in unfavourable environments, should be sought, as this affects the risk of subverting later regimens.
authors.affiliation: School of Computational and Applied Mathematics, University of the Witwatersrand, Private Bag 3, Johannesburg, South Africa. tshiri@cam.wits.ac.za
authors.forename: Tinevimbo
authors.initials: T
authors.lastname: Shiri
authors.forename: Alex
authors.initials: A
authors.lastname: Welte
mesh_terms: D000998:Antiviral Agents / Q000494:pharmacology; D005260:Female; D016678:Genome; D015658:HIV Infections / Q000188:drug therapy* / Q000635:transmission; D015497:HIV-1 / Q000235:genetics*; D006801:Humans; D018445:Infectious Disease Transmission, Vertical; D015233:Models, Statistical; D009154:Mutation; D019829:Nevirapine / Q000494:pharmacology; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious; D012306:Risk; D013269:Stochastic Processes; D014773:Virology / Q000379:methods
chemical_list: D000998:Antiviral Agents; D019829:Nevirapine