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The Dominance of CRF01_AE and the Emergence of Drug Resistance

Mutations Among Antiretroviral Therapy- Experienced, HIV-1-infected
Individuals in Medan, Indonesia

Article  in  Acta medica Indonesiana · December 2020

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 ORIGINAL ARTICLE

The Dominance of CRF01_AE and the Emergence of Drug

Resistance Mutations Among Antiretroviral Therapy-
Experienced, HIV-1-infected Individuals in Medan, Indonesia

Dwi W. Indriati 1,2 , Adiana M. Witaningrum 2 , M. Qushai Yunifiar 2 ,

Siti Q. Khairunisa 2, Shuhei Ueda 2,3, Tomohiro Kotaki 3, Nasronudin 2,4,
Masanori Kameoka3
1
Department of Health, Faculty of Vocational Studies, Universitas Airlangga, Surabaya, Indonesia.
2
Indonesia-Japan Collaborative Research Centre for Emerging and Re-emerging Infectious Diseases, Institute
of Tropical Disease, Universitas Airlangga, Surabaya, Indonesia.
3
Department of Public Health, Kobe University Graduate School of Health Sciences, Hyogo, Japan.
4
Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia.

Corresponding Author:
Masanori Kameoka. Department of Public Health, Kobe University Graduate School of Health Sciences, 7-10-2
Tomogaoka, Suma-ku, Kobe, Hyogo 654-0142, Japan. email: mkameoka@port.kobe-u.ac.jp.

ABSTRAK
Latar belakang: infeksi human immunodeficiency virus tipe 1 (HIV-1) adalah ancaman kesehatan masyarakat
yang serius di seluruh dunia. Medan merupakan salah satu kota besar di Indonesia dengan prevalensi infeksi
HIV-1 yang tinggi; namun, penelitian yang terbatas untuk mendeteksi peredaran subtipe HIV-1 di Medan. Selain
itu, faktor serius yang dapat berimplikasi pada pengobatan orang yang terinfeksi HIV-1 adalah munculnya
mutasi yang resisten terhadap obat. Oleh karena itu, informasi tentang infeksi HIV-1 penting untuk meningkatkan
pengobatan bagi individu yang terinfeksi. Metode: enam puluh tujuh orang yang berpengalaman dengan terapi
antiretroviral, orang yang terinfeksi HIV-1 diikutsertakan pada penelitian ini. Gen HIV-1 pol yang mengkode
protease (gen PR) dan reverse transcriptase (gen RT), serta gen env dan gag, diamplifikasi dari DNA yang
berasal dari sampel darah tepi. Subtipe HIV-1 dilakukan untuk mempelajari subtipe HIV-1 dominan yang beredar
di wilayah tersebut. Selain itu, munculnya mutasi yang resisten terhadap obat dianalisis berdasarkan pedoman
yang diterbitkan oleh International Antiviral Society-United States of America (IAS-USA). Hasil: subtipe HIV-1
yang dominan ditemukan di Medan adalah CRF01_AE (77,6%). Selain itu, subtipe dan virus rekombinan lain
seperti rekombinan pada CRF01_AE dan subtipe B (12,2%), subtipe B (4,1%), dan CRF02_AG (4,1%) juga
ditemukan. Mutasi utama terkait resistensi obat ditemukan pada 21,6% (8/37) gen RT dan 3,1% (1/32) gen PR
yang diteliti. Kesimpulan: penelitian ini menunjukkan bahwa subtipe dominan yang ditemukan pada orang yang
berpengalaman dengan ART, orang yang terinfeksi HIV yang tinggal di Medan adalah CRF01_AE. Munculnya
mutasi yang resisten terhadap obat dalam gen RT dan PR menunjukkan pentingnya memantau prevalensi mutasi
yang resisten terhadap obat di antara orang yang terinfeksi HIV-1 di Medan.

Kata kunci: HIV-1, CRF01_AE, terapi antiretroviral, resistensi obat, Medan.

ABSTRACT
Background: human immunodeficiency virus type 1 (HIV-1) infection is a serious public health threat
worldwide. Medan is one example of big cities in Indonesia with a high prevalence of HIV-1 infection; however,
quite a limited study had conducted for detecting the circulation of HIV-1 subtypes in Medan. In addition, a serious

366 Acta Med Indones - Indones J Intern Med • Vol 52 • Number 4 • October 2020
Vol 52 • Number 4 • October 2020 The dominance of CRF01_AE and the emergence of drug resistance

factor that can implicate the treatment of HIV-1-infected individuals is the emergence of drug resistance mutations.
Thus, the information on HIV-1 infection is important to improve the treatment for infected individuals. Methods:
sixty-seven antiretroviral therapy-experienced, HIV-1-infected individuals were recruited for this study. HIV-1
pol genes encoding protease (PR genes) and reverse transcriptase (RT gene), as well as env and gag genes, were
amplified from DNA derived from peripheral blood samples. HIV-1 subtyping was conducted to study the dominant
HIV-1 subtype circulating in the region. In addition, the emergence of drug resistance mutations was analyzed
based on the guidelines published by the International Antiviral Society-United States of America (IAS-USA).
Results: the dominant HIV-1 subtype found in Medan was CRF01_AE (77.6%). In addition, another subtype and
recombinant viruses such as recombinants between CRF01_AE and subtype B (12.2%), subtype B (4.1%), and
CRF02_AG (4.1%) were also found. Drug resistance-associated major mutations were found in 21.6% (8/37) of
RT genes and 3.1% (1/32) of PR genes studied. Conclusion: our study showed that the dominant subtype found in
ART-experienced, HIV-1-infected individuals residing in Medan was CRF01_AE. The emergence of drug resistance
mutations in RT and PR genes indicated the importance to monitor the prevalence of drug resistance mutations
among HIV-1-infected individuals in Medan.

Keywords: HIV-1, CRF01_AE, antiretroviral therapy, drug resistance, Medan.

INTRODUCTION 3TC with EFV or nevirapine (NVP); and 2). TDF,

The number of reported HIV-1-infected cases 3TC or FTC with NVP.
in Indonesia has increased in the last decade, Recently, the prevalence of drug resistance
2010-2018 with the highest number reported in has increased among individuals on ART in
2016-2018. The data from the Ministry of Health Indonesia.3,4 This drug resistance can decrease
showed that, in 2017, there were 48,300 HIV-1 the efficacy of ART. Meanwhile, it is known
infection cases. Meanwhile in 2018, the number that there are two types of drug resistance which
dropped to 46.659 cases. In North Sumatera, the acquired drug resistance and transmitted drug
number of reported HIV-1 infection in 2017 and resistance (TDR), and TDR is believed to have
2018 was 1,891 and 1,999 cases, respectively, greater impact on ART.5 The prevalence of drug
and it was ranked seventh in the number of resistance mutations was also found in Surabaya
HIV-1-infected individuals among provinces in and Maumere, Indonesia, in our previous
Indonesia.1 Since Medan is the capital city of studies.6,7 Thus, it is important to monitor the
North Sumatera province, it is important to study effectiveness of ART and prevalence of drug
the HIV-1 infection in this city. resistance mutations in other cities in Indonesia.
H I V- 1 i n f e c t i o n w a s s u c c e s s f u l l y We aimed to monitor the prevalence of drug
suppressed by the antiretroviral therapy (ART). resistance mutations among HIV-1-infected
Recommended first-line regimens by WHO in individuals on ART. In addition, to reveal
2019 are dolutegravir (DTG) in combination the prevalence of drug resistance mutations,
with a nucleoside reverse transcriptase (RT) molecular epidemiological study to determine
inhibitor (NRTI) backbone, and efavirenz the dominant HIV-1 subtype is also needed.
(EFV) in combination with an NRTI backbone A dominant HIV-1 subtype in Indonesia is
as the alternative first-line regimen for HIV- CRF01_AE8; however, it cannot rule out the
infected adult. For infants and children, WHO emergence of other subtypes in Medan since the
recommends raltegravir (RAL)-based regimen.2 information on prevalent HIV-1 subtype is quite
The first-line ART regimens recommended by scarce in this region.
the Indonesian Ministry of Health are tenofovir
(TDF), lamivudine (3TC) or emtricitabine METHODS
(FTC) with efavirenz (EFV). Alternative first- Sixty seven HIV-1-infected individuals
line regimens which can be applied for HIV-1 on ART (33 male and 34 female, the mean
infected individuals are 1). Zidovudine (AZT), age of 31 years old) were recruited from VCT

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Dwi W. Indriati Acta Med Indones-Indones J Intern Med

program in community health centers in Padang (nt 2611 to 2592). The viral env gene
Bulan Medan, North Sumatera, Indonesia. was amplified by nested PCR with the
Ten milliliters of ethylenediaminetetraacetic primers M5, 5’-CCAATTCCCATACAT
acid (EDTA)-anticoagulated peripheral blood TATTGTGCCCCAGCTGG-3’ (nt 6858
samples were collected from participants using to 6889), and M10, 5’-CCAATTGTCCCT
BD vacutainer®CPT (BD Bioscience, San CATATCTCCTCCTCCAGG-3’ (nt 7661
Jose, USA) in July 2017. Peripheral blood to 7632), in the first round, and M3,5’-
mononuclear cells (PBMC) were isolated using GTCAGCACAGTACAATGIACACATGG-3’
density gradient centrifugation with histopaque (nt 6948 to 6973), and M8, 5’-TCCTTCCATGGGA
(Sigma Aldrich, USA). After centrifugation at GGGGCATACATTGC-3’ (nt 7547 to 7521), in
2,000rpm for 20 minutes, blood samples were the second round. The viral gag gene was amplified
separated into plasma, PBMC and red blood by nested PCR with the primers H1G777,
cells. After the centrifugation, thin layer ring or 5’-TCACCTAGAACTTTGAATGCATGGG-3’
buffy coat containing PBMC was formed. DNA (nt 1231 to 1255), and H1P202,
was extracted from PBMC using the QIAamp 5 ’ - C TA ATA C T G TAT C AT C T G C T
DNA Mini kit (Qiagen, Hilden, Germany). G C T C C T G T- 3 ’ ( n t 2 3 5 2 t o 2 3 2 5 ) ,
This study was conducted with an approval in the first round, and H1Gag1584,
from the Ethics committees of Universitas 5’-AAAGATGGATAATCCTGGG-3’ (nt
Airlangga and Kobe University Graduate 1577 to 1595), and G17, 5’-TCCACATTTC
School of Medicine. All study participants were CAACAGCCCTTTTT-3’ (nt 2040 to 2017),
requested to sign an informed consent prior to in the second round. PCR products were
sample calculation. All participants agreed to then visualized by ethidium bromide staining
provide blood samples for this study. under UV light following 1.5% agarose gel
Polymerase Chain Reaction (PCR) and
electrophoresis. All successfully amplified
Sequence analysis samples for PR, RT, gag and env genes were
The partial fragments of viral pol gene then subjected to sequencing analysis using the
encoding protease (PR gene) and RT (RT gene), BigDye Terminator v3.1 Cycle Sequencing kit
as well as gag and env genes, were amplified from (Applied Biosystems, Foster City, CA, USA)
DNA extracted from PBMC samples by a nested with an ABI PRISM 3500 xl genetic analyzer
PCR using Ex Taq (Takara Bio, Shiga, Japan) and following purification step using ExoSap-IT
the following primers. For the amplification of (ThermoFisher Scientific, Waltham, USA).
RT gene, the primers for the first PCR were RT1L, Sequencing data were then assembled and
5’-ATGATAGGGGGAATTGGAGGTTT-3’ aligned using Genetyx version 10 software
[corresponding to nucleotide (nt) 2388 to 2410 of a (Genetyx, Tokyo, Japan). As the results, the
HIV-1 reference strain, HXB2 (GenBank accession sequencing data of 32 PR genes (297-bp), the
no. K03455)] and GPR2M, 5’-GGACTACA N-terminus of 37 RT genes (762-bp), 34 env
GTCYACTTGTCCATG-3’ (nt 4402 to 4380), genes spanning C2-V3 region of gp120 (389-
and the primers for the nested PCR were RT7L, bp) and 28 gag genes encoding a part of Gag
5’-GACCTAC ACCTGTCAACATAATTGG-3’ p24 (382-bp) were obtained from 67 blood
(nt 2485 to 2509) and GPR3L, samples. The nucleotide sequences of these PR,
5’-TTAAAATCACTARCCATTGYTCTCC-3’ RT, gag and env genes have been deposited in
(nt 4309 to 4285). For the amplification of PR the GenBank database under accession numbers
gene, the primers for the first PCR were PRO5F, MT163520-MT163650.
5’-AGAAATTGCAGGGCCCCTAGGAA-3’ HIV-1 Subtyping and the Detection of Drug
(nt 2022 to 2044) and DRPR02L, Resistance Mutations
5’-TATGGATTTTCAGGCCCAATTTTTGA-3’ HIV-1 subtyping was carried out using
(nt 2716 to 2691), and the primers for the recombinant identification program (RIP),
nested PCR were PRO5F and DRPR06, available at the website of the HIV sequence
5 ’ - A C T T T T G G G C C AT C C AT T C C - 3 ’ database (www.hiv.lanl.gov/). In addition,

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neighbor-joining (NJ) trees with a Kimura Table 1. General Characteristic of HIV-1-infected

two-parameter model were constructed using Individuals in Medan.

MEGA6.2 software13 with Bootstrap values Characteristics Value (n=67)

(1,000 replicates) as comparison with those Age, mean (SD), years 31.0 (10.8)
results analyzed with RIP. Viral subtyping was Gender, n (%)
carried out based on the successfully sequenced -- Male 33 (49.3)
PR, RT, env and gag genes, and if there were an -- Female 34 (50.8)
incompatibility in the subtype or CRF among the Marital Status, n (%)
PR, RT, gag and env genes, the viral gene was -- Married 48 (82.8)
considered to be a recombinant form of HIV-1. -- Single (Divorced/Widowed) 10 (17.2)
Drug resistance-associated mutations were Ethnic group, n (%)
studied according to the International Antiviral -- Batak 26 (38.8)

Society-United States (IAS-USA) report.9 We -- Malay 5 (7.5)

analyzed drug resistance-associated mutations -- Javanese 23 (34.3)

on RT and PR genes which were the targets of -- Chinese 5 (7.5)

the first line and the second line ART regimens -- Dayak 1 (1.5)

in Indonesia, respectively. -- Indian 1 (1.5)

-- Karo 1 (1.5)

RESULTS -- Mandailing 1 (1.5)

-- Minang 2 (3.0)
Medan is one of the big cities in Indonesia.
-- Nias 2 (3.0)
The majority of HIV-1-infected individuals
Transmission risk category, n (%)
were Batak and Javanese. HIV transmission in
-- Heterosexual 34 (50.8)
Medan was spread dominantly through sexual
-- Injecting drug use (IDU) 7 (23.9)
intercourse while most (82.8%) study participants
-- Men having sex with men 16 (23.9)
were married (Table 1). All study participants
-- Mother to Child Transmission
had experienced ART more than a year. They (MTCT)
8 (12.0)
were treated with the first line ART regimen as -- Blood transfusion 2 (3.0)
it is suggested for primary treatment by Ministry Types of ART used, n (%)
of Health in accordance with WHO regulations. -- AZT+3TC+NVP 24 (35.8)

CRF01_AE was the Dominant HIV-1 Subtype -- AZT+3TC+EFV 10 (14.9)

Found in Medan -- TDF+3TC+EFV 21 (31.3)
HIV-1 subtypes detected among HIV-1- -- TDF+3TC+NVP 10 (14.9)
infected individuals in Medan were CRF01_AE Duration of ART, n (%)
(41 samples), recombinants between CRF01_AE -- < 1 year 3 (4.5)
and subtype B (6 samples), CRF02_AG (2 -- 1 – 3 years 24 (35.8)
samples), and subtype B (2 samples) (Figure -- > 3 years 40 (59.7)
1). The result showed that the dominant HIV-1
subtype in Medan was CRF01_AE, indicating
that the dominant subtype found in this region was Recombinants between CRF01_AE and subtype
similar to that in other regions in Indonesia. Since B as well as CRF02_AG were found among
its first appearance in 1990s,10 CRF01_AE has individuals with heterosexual transmission. In
been continuously found as a dominant subtype in addition, subtype B was found in MSM and
Indonesia. CRF01_AE was found in 3 individuals individuals with heterosexual transmission.
with IDU, 4 wives with heterosexual transmission Major and Minor Drug Resistance Mutations
from husband with IDU, 17 individuals with Detected in RT Genes
heterosexual transmission, 13 homosexual Most study participants were on ART with
individuals (men who have sex with men or first-line regimens, AZT, 3TC and NVP/EFV;
MSM), 6 pediatric patients transmitted from or TDF, 3TC and NVP/EFV. Drug resistance
mother, and an individual with blood transfusion. mutations were detected among 9 out of 37

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Dwi W. Indriati Acta Med Indones-Indones J Intern Med

Figure 1. Phylogenetic tree analysis of HIV-1 RT, PR, env, and gag genes derived from infected individuals
residing in Medan, Indonesia. Phylogenetic trees were constructed for the HIV-1 RT (A), PR (B), env (C),
and gag genes newly sequenced in the present study (D). The corresponding viral genes of reference
HIV-1 strains representing subtypes A1, A2, B, C, D, and G as well as CRF01_AE (01_AE), CRF02_AG
(02_AG), CRF15_01B (15_01B), CRF33_01B (33_01B), and CRF34_01B (34_01B) were included in the
analyses (shown in bold letters). Sequence IDs are presented as a GenBank accession number, sample
ID, or the ID of the reference HIV-1 strain, and the subtype or CRF of the reference strain (shown in
parentheses) in that order. Bootstrap values were shown if they were >70.

individuals (24.3%) on long-term ART. Major A Major and Several Minor Drug Resistance
drug resistance mutations detected in RT Mutations were Detected in PR Genes
genes were E138G (33.3%), K103N (22.2%), Protease inhibitor is used for the second-line
and M184V (22.2%). Meanwhile, minor drug regimens in combination with 2 NRTI drugs in
resistance mutations detected in RT genes were Indonesia; however, no study participants in
V106I (33.3%), V90I (11.1%) and V179D the present study were on ART with protease
(11.1%) (Table 2). inhibitor. Therefore, drug resistance mutations

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Vol 52 • Number 4 • October 2020 The dominance of CRF01_AE and the emergence of drug resistance

Figure 1. Phylogenetic tree analysis of HIV-1 RT, PR, env, and gag genes derived from infected individuals
residing in Medan, Indonesia. Phylogenetic trees were constructed for the HIV-1 RT (A), PR (B), env (C),
and gag genes newly sequenced in the present study (D). The corresponding viral genes of reference
HIV-1 strains representing subtypes A1, A2, B, C, D, and G as well as CRF01_AE (01_AE), CRF02_AG
(02_AG), CRF15_01B (15_01B), CRF33_01B (33_01B), and CRF34_01B (34_01B) were included in the
analyses (shown in bold letters). Sequence IDs are presented as a GenBank accession number, sample
ID, or the ID of the reference HIV-1 strain, and the subtype or CRF of the reference strain (shown in
parentheses) in that order. Bootstrap values were shown if they were >70.

in PR genes were studied to find TDR in this minor mutations, M36I/K, H69K and L89M/I/V,
study. A major drug resistance mutation, I50V, were detected in all samples (Table 3).
was found in PR gene from a study participant.
This major mutation is correlated with the DISCUSSION
resistance to darunavir/ritonavir (DRV/r), The dominant HIV-1 subtype, CRF01_AE
lopinavir/ritonavir (LPV/r), and fosamprenavir/ prevalent in Medan, was consistently detected
ritonavir (Table 3). In addition, 12 minor drug in Jakarta, Bali, East Java, West Nusa Tenggara
resistance mutations were detected. Especially, and other parts of Indonesia in previous

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Dwi W. Indriati Acta Med Indones-Indones J Intern Med

Table 2. Genotypic Characteristics and Drug Resistance Mutations Detected in RT Genes Derived from 9 Individuals on
ART in Medan.
Drug Resistance
Sample Subtype* ART status Mutations** Drug Resistance
nRTIs NNRTIs
MED 11 CRF02_AG*** 3TC, AZT, EFV V90I ETR
MED 12 CRF01_AE TDF 3TC, EFV V106I DOR, ETR
A62V****
K103N ABC, FTC, 3TC TDF, ddI, d4T, EFV,
MED 17 CRF01_AE 3TC, AZT, NVP K65R
E138G NVP, RPV, ETR
M184V
MED19 CRF01_AE 3TC, AZT, EFV E138G ETR, RPV
MED 25 CRF01_AE TDF, 3TC, NVP E138A ETR, RPV
K103N
MED 42 CRF01_AE TDF, 3TC, EFV EFV, NVP, DOR, ETR
V106I
MED 46 CRF01_AE TDF, 3TC, NVP V106I DOR, ETR
E138G
MED 48 CRF01_AE 3TC, AZT, NVP ETR, RPV
V179D
MED 65 CRF01_AE 3TC, AZT, NVP M184V Y181C ABC, FTC, 3TC, EFV, ETR, NVP, RPV

* The subtype of RT genes was assigned based on RIP and phylogenetic analyses.
**The determination of drug resistance mutations was based on the guidelines published by the International Antiviral
Society-United States (IAS-USA).
***Recombinants CRF02_AG
****The letter written in bold was showing major mutation.

Table 3. Genotypic Characteristics and Drug Resistance al,14 20128 showed that CRF01_AE was more
Mutations Detected in PR Genes Derived from 32 frequently found among individuals with IDU
Individuals on ART in Medan.
rather than individuals with other transmission
Frequency (%)
Mutation* routes in Indonesia. In contrast, subtype B
CRF01_AE** CRF02_
all (n=32) were more frequently found among individuals
(n=30) AG*** (n=2)
L10I/V 4 (12.5) 4 (13.3) 0 (0) with the heterosexual transmission. However,
G16E 6 (18.8) 6 (20.0) 0 (0) interestingly in our results, recombinant viruses
K20R/I 23 (71.9) 22 (73.3) 1 (50.0) containing CRF01_AE gene fragment, rather
M36I/K 32 (100) 32 (100) 0 (0) than B subtype, were frequently detected among
I50V**** 1 (3.1) 1 (3.3) 0 (0) individuals with the heterosexual transmission.
I62V 5 (15.6) 5 (16.7) 0 (0) Our results were also in accordance with our
L63P 5 (15.6) 3 (10.0) 2 (100) previous results showing that CRF01_AE were
I64V 1 (3.1) 0 (0) 0 (0) frequently detected among female sex workers.15
H69K 32 (100) 30 (100) 2 (100) Another recombinant form, CRF02_AG, was
V77I 10 (31.3) 10 (33.3) 0 (0) found in this study. Interestingly, the emergence
V82I 2 (6.3) 2 (6.7) 0 (0) of CRF02_AG was also detected in other parts
L89M/I/V 32 (100) 30 (100) 2 (100) of Indonesia in recent studies.16–18 CRF02_AG
I93L/M 5 (15.6) 4 (13.3) 1 (50.0) was first detected from frozen serum samples
*The determination of drug resistance mutations was collected in the Democratic Republic of the
based on the guidelines published by the International
Antiviral Society United States (IAS-USA).
Congo (former Zaire) in 1976.19 Similarity could
** The subtype of PR genes was assigned based on RIP be found between CRF01_AE and CRF02_AG
and phylogenetic analyses. throughout their genome, and both of them were
*** Recombinants CRF02_AG
****The letter written in bold was showing major mutation. rapidly and largely transmitted by heterosexual
transmission. 20 However, its appearance in
studies. 6,11–14 Different transmission routes Indonesia needs to be further studied in order
could account for the transmission of different to reveal its role in the HIV-1 epidemic in
HIV-1 subtypes. Previous studies by Merati et Indonesia.

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Among the HIV-1 subtype, the difference among CRF01_AE viruses.28

in cellular tropism or coreceptor usage, CCR5
(R5) and CXCR4 (X4), was reported,21,22 and CONCLUSION
it was related to HIV-1 pathogenesis. Studies The dominant HIV-1 subtype found in
on coreceptor usage have been extensively Medan, South Sumatera, was CRF01_AE.
conducted on HIV-1 subtype B and C, but Several other subtypes and recombinant viruses
not for other subtypes and CRFs. Therefore, including CRF02_AG were also detected. In
further researches are required on subtypes and addition, antiretroviral drug resistance mutations
recombinants detected in this study. Generally, were observed in RT and PR genes. Resistance
R5 viruses were detected over the entire course of mutations against RT inhibitors were found in
disease progression after HIV-1 infection while 24.3% of ART-experienced individuals. We also
X4 viruses were usually found in the late stage detected a major mutation in a PR gene (3.1%).
of disease progression. X4 vir uses were found Our results suggest the importance of continuous
in the late stage of disease progression for most surveillance studies on HIV-1 subtypes and drug
HIV-1 subtypes except subtype C. The switch resistance mutations among ART-experienced
in coreceptor usage between R5 and X4 was individuals.
correlated with faster CD4+-T cell decline and
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