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Antivirals for HIV
Yasir Waheed, PhD
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Some HIV Facts
• HIV – the Human Immunodeficiency Virus is the retrovirus that causes AIDS
• HIV belongs to the retrovirus subfamily lentivirus.
• HIV attaches to cells with CD4 receptors (T4 cells and macrophages).
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HIV Life Cycle1
• Step 1: Attachment of virus at the CD4 receptor and chemokine co-receptors CXCR4 or CCR5
• Step 2: viral fusion and uncoating• Steps 3-5: Reverse transcriptase makes a
single DNA copy of the viral RNA and then makes another to form a double stranded viral DNA
• Step 6: migration to nucleus• Steps 7-8: Integration of the viral DNA into
cellular DNA by the enzyme integrase• Steps 9-11: Transcription and RNA processing• Steps 12-13: Protein synthesis• Step 14: protease cleaves polypeptides into
functional HIV proteins and the virion assembles
• Step 15: virion budding• Step 16: Virion maturation
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Anti- HIV Drug Targets2
Three types of drugs are currently in clinical use:
1. nucleoside and nucleotide reverse transcriptase (RT) inhibitors
2. non-nucleoside reverse transcriptase inhibitors
3. protease inhibitors (PIs)
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Nucleoside and Nucleotide Analogs
• Nucleoside analogs (NRTI) act as chain terminators or inhibitors at the substrate binding site of RT
• NRTI’s must be phosphorylated (three steps) to their 5’-triphosphate form to become active inhibitors.
• Nucleotide analogs (NtRTI) already contain a phosphate group and only go through 2 steps to become active.
• The 5’-triphosphate of the NRTI’s compete with the 2’-deoxynucleoside’s 5’-triphosphate for binding to reverse transcriptase leading to viral DNA chain termination3.
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Nucleoside Analogs
• There are currently 7 FDA-approved NRTI’s and one nucleotide analog.
• The first anti-HIV drug approved was the NRTI known as AZT or Zidovudine (1987).
• AZT was discovered as a treatment of AIDS during a screening process for the identification of effective AIDS treatments.
• Antiviral selectivity due to higher affinity for HIV RT than human DNA polymerases.
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Non-Nucleoside Analogs
• Non-nucleoside analog reverse transcriptase inhibitors (NNRTI’s) inhibit viral DNA replication by binding at the allosteric non-bonding site of RT, causing a conformational change of the active site.
• NNRTI’s do not require bioactivation by kinases. • Three NNRTI’s are currently approved for clinical use
in combination therapy: nevirapine, delavirdine, and efavirenz.
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Non-Nucleoside Analogs
Delavirdine
BenzoxazinoneNevirapine
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Protease Inhibitors• During the reproduction cycle of HIV a specific
protease is needed to process the polyproteins into mature HIV components.
• If protease is missing non-infectious HIV is produced.
• HIV protease inhibitors are specific to HIV protease because it differs significantly from human protease.
• The 6 PI’s currently approved for clinical use were all designed by using structure-based drug design methods.
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HIV Protease
• The crystal structure of HIV protease was first obtained at Merck Laboratories.
• HIV protease is a 99 amino acid aspartyl protease that functions as a homodimer with one active site.
• The active sites of protease are hydrophobic.
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Protease Inhibitors
• ABT-378 or lopinavir was approved in 2000 for use in combination with ritonavir (a PI) (Kaletra)
• Ritonavir strongly inhibits the metabolism of ABT-378.
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Some Alternative Therapies • Virus adsorption inhibitors – interfere with
virus binding to cell surface by shielding the positively charged sites on the gp-120 glycoprotein– Polyanionic compounds
• Viral coreceptor antagonists – compete for binding at the CXCR4 (X4) and CCR5 (R5) coreceptors– bicyclams and ligands
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Virus Adsorption Inhibitors• Cosalane was originally
developed as an anti-cancer agent by researchers at Purdue University and the U.S. National Cancer Institute.
• Cosalane was developed from a chemical known as ATA (aurintricarboxylic acid), which has long been known to have anti-HIV activity.
• The result was cosalane.• Cosalane binds to the HIV
gp-120 protein.
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Viral Coreceptor Antagonists • Bicyclams are a type of viral
coreceptor antagonist.• They are very specific and potent
X4 coreceptor antagonists.• Bicyclams belong to a
class of macrocyclic polyamines consisting of two cyclam units linked by an aliphatic bridge
• Bicyclams with an aromatic linker apparently had higher antiviral activity.
• One such compound is AMD3100.
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Combination Therapy
• Combination therapy often called HAART is standard care for people with HIV.
• Monotherapy created virus resistance to the individual drug. Some combination therapies increase the time it takes for the virus to become resistant.
• Combinations of a PI or NNRTI with one or two NRTI’s is often recommended.
• Combination therapy may reduce individual drug toxicity by lowering the dosage of each drug
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Drug Toxicity and Side Effects
• All available antiretroviral drugs are toxic.• Side effects of nucleoside analogs are lactic
acidosis and severe hepatomegaly with steatosis (enlarged fatty liver).
• Other side effects of anti-HIV drugs include pancreatitis, myopathy, anemia, peripheral neuropathy, nausea, and diarrhea.
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Reducing Drug Toxicity
• The use of combination therapy:– Combining agents with favorable synergistic
properties allows a decrease in dose or dosing frequency
– Ritonavir alone cause gastrointestinal side effects but when used in combination with other PI’s it can be administered at a lower dose.
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10 Million Patients on Antiretroviral Therapy
2013 Global AIDS Response Progress Reporting (WHO/UNICEF/UNAIDS)
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Principles of HIV Drug Resistance
• Not all drug failure is due to resistance • Partial HIV suppression promotes resistance • Resistance may fade but not disappear when
a drug is stopped
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Principles of Resistance (2)
• Some mutations allow certain viruses to resist the effects of one or more antiretroviral drugs.
• Each infected person has a mixture of viruses, some of which are resistant to some medications.
• The drug resistant virus usually grows faster and better than the drug susceptible virus.
• The drug resistant virus replaces the drug susceptible virus in the patient.
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Resistance Testing
• Two types:– Genotyping• Less expensive• Can usually be completed in 1-2 weeks
– Phenotyping• More expensive• Generally takes 2-3 weeks to complete
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Suspect Resistance in the Setting of Treatment Failure
• Due to HIV’s high transcription error rate and high level of replication, mutant HIV variants constantly generated.
• These variants often contain mutations that confer variable levels of resistance to antiretroviral agents.
• Poor adherence or suboptimal regimens can lead to resistance and ‘viral breakthrough’.
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How Does Resistance Develop?
• Results from changes (mutations) in the genetic information in the virus.
• These changes occur whenever HIV is replicating.
• Every possible mutation occurs tens of thousands of times each day.
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Resistance Mutations
• For some drugs (NNRTIs and 3TC), a single mutation causes high-level resistance. – Resistance to these drugs occurs very quickly
• For other drugs (most NRTIs and PIs), many mutations must occur before high-level resistance is observed. – Resistance to these drugs occurs more slowly
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Cross-Resistance
• Resistance to one drug can cause resistance to others of the same class– NNRTI: complete cross-class resistance– NRTI: partial cross-class resistance– PI: partial cross-class resistance• Partly overcome by ritonavir boosting
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Minimize Emergence of Viral Resistance
• Never prescribe ARVs in the absence of adherence counseling and support
• Never prescribe monotherapy or dual therapy• Ensure optimal serum drug concentrations– Avoid drug interactions – Diagnose and manage malabsorption
• If ARV medications are to be discontinued, stop all drugs at the same time– Possible exception: NNRTI-based regimen
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2003 vs. 2005 WHO Guidelines
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