Interaction analysis of statistically enriched mutations identified in Cameroon recombinant subtype CRF02_AG that can influence the development of Dolutegravir drug resistance mutations

Sub-Saharan Africa (SSA) remains one of the regions highly burdened by HIV infection at 70% of the global epidemic. SSA has a particularly high HIV-1 genetic diversity and it is documented that diverse subtypes may affect the clinical treatment outcome in patient management [1]. The HIV-1 CRF02_AG strain continues to be the predominant subtype causing majority of infections in Cameroon, while other strains, including groups N, O and P, account for a minor proportion of infections [2‐4]. Furthermore, different mutational pathways account for subtype specific differences in drug resistance [5‐7]. Additionally, other studies have also reported that natural occurring polymorphisms (NOP) which are associated with the occurrence of resistance to Integrase (IN) strand-transfer inhibitors (INSTIs) and IN activity, are subtype-dependent [6‐8]. These subtype-specific polymorphic mutations in the IN gene have been shown to affect IN DNA binding affinity, in the presence of resistance-associated mutations (RAMs) [6‐8]. Computational modelling of RAMs against INSTIs, across different HIV-1 subtypes compared to subtype B, showed that the presence of M50I in subtypes A and C, L74I in subtypes A and CRF02_AG, G163R in CRF01_AE, and V165I in subtypes F and CRF01_AE are associated with a lower genetic barrier to resistance in non-B clades [9]. Cameroon has seen a substantial reduction of HIV infection, since the introduction of combination antiretroviral therapy (cART), especially with the rolling-out of programmes like prevention of mother-to-child transmission (PMTCT) and the implementation 90–90-90 strategy to end the AIDS pandemic by 2030 [10]. The ability of the HIV-1 virus to mutate during therapy, can lead to the emergence of HIV-1 drug resistance and this necessitates the need for more effective cART regimens with higher genetic barriers [1]. In Cameroon, the HIV-1 drug resistance rates among cART-initiators stand at approximately, 10% of the Cameroon infected population [11, 12].

The United States of America (USA) Food and Drug Administration (FDA) has approved four HIV-1 INSTIs, including raltegravir (RAL), elvitegravir (EVG), dolutegravir (DTG) and bictegravir (BIC) [13]. However, the high cost of INSTIs, has resulted in restricted access to this class of drugs in resource-limited countries [14]. Despite the cost, the World Health Organization (WHO) has given the green light to include DTG to an alternative 1st-line regimen [14, 15]. The strand transfer reaction catalyzed by HIV-1-expressed IN enzyme is blocked by the activity of INSTIs which bind to the catalytic site in the catalytic core domain (CCD) of the IN protein [16, 17]. Mutations that confer resistance to INSTIs (for example G140S, Q148H and N155H) have been structurally mapped in close proximity to the IN catalytic active site [18, 19]. Primary resistance to INSTIs, along with residues associated with catalytic activity among different subtypes are highly conserved. HIV-1 sequence and structure-based analyses have shown that polymorphic residues can cause subtype-specific effects, which significantly affect the native protein structure, function and activity important for drug-mediated inhibition of enzyme activity [9]. There is limited information available on the IN structure of CRF02_AG [9, 20] and even less on the effect of mutations on the protein structure. There is therefore a need to continue monitoring patients to identify additional RAMs and polymorphic mutations that might affect the genetic barrier to the development of RAMs against INSTI [9]. The goals of this study was to analyse the Cameroonian CRF02_AG IN gene sequences obtained from the Los Alamos National Laboratory (http://​www.​hiv.​lanl.​gov/​) HIV-1 database to assess the occurrence of mutations and natural occurring polymorphisms (NOPs). NOPs are categorized under secondary mutations which on their own play a limited role in resistance [14]. However, their pre-existence might favour a more rapid evolution towards resistance when additional mutations are selected under therapy [21]. In this study, the possible impact caused by statistically enriched NOPs found in CRF02_AG subtype was modelled within the context of a three-dimensional (3D) protein structure of the HIV-1CRF02-DNA-MG-DTG IN complex. Subsequently, stability predictions was performed using the mutation cut-off scanning matrix server (mCSM) to assess change in Gibbs free energy of mutations on the protein structure followed by interaction analysis to assesses the loss or gain of DTG interactions to Wild type and six mutated HIV-1CRF02-DNA_MG IN structures. Molecular modelling of HIV-1 CRF02 integrase sequences and DTG interaction analysis will help determine which mutations could affect the genetic barrier to the emergence of DTG drug resistance.

Despite INSTIs having an increased genetic barrier against resistance, studies performed from high-income countries shows that the occurrence of RAMS against INSTIs can happen, via acquired drug resistance mutations (DRM) and/or transmitted DRM, leading to reduced susceptibility to INSTIS and possible treatment failure [22, 28]. The IN mutations usually associated with reduced INSTIs susceptibility include both polymorphic mutations and non-polymorphic mutations [29, 30]. Other studies have reported that several NOPs can affect structural stability and flexibility of the IN protein structure [31, 32]. Previous researchers have reported low rates of IN mutations against INSTIs in Cameroon [15, 20]. The WHO has recommended the utilization of DTG as part of first-line regimens [16]. With the approval of INSTIs usage worldwide, it is predicted that approximately 57% of people living with HIV will be receiving DTG based regimens, including new-borns and children [33]. It is therefore imperative to screen for the presence of mutations against INSTIs which can affect treatment outcomes. Currently, there is limited data available for INSTI RAMs from studies that focuses on the SSA region, where over two-thirds of the presently infected individuals reside [34, 35]. In our previous studies we found low level of RAMSs against INSTIs [3].

In a recent study on CRF02_AG IN, we reported that accessory mutations can impact the binding of DTG with or without combination of primary resistance mutations [32, 36]. In this study we analysed the CRF02_AG IN gene sequences for the presence of polymorphic and non-polymorphic mutations. Four major INSTIs mutations were found within the database sequences: T66A, Q148H, N155H and R263K. R263K displayed moderate level resistance against EVG (12-fold) [37] and seems to confer low-level resistance against DTG. Structural analyses have suggested that DTG shares a similar interfacial mechanism of inhibition with EVG and RAL, but is able to make more intimate contacts with the viral DNA [38]. In addition, DTG can adapt its position and conformation in response to structural changes within the active site of EVG- or RAL resistant IN enzymes and in doing so avoid cross-resistance as a result of slower dissociation rates [39, 40]. Two principal mutation pathways identified from our study that reduces susceptibility to RAL are Q148H/K/R and N155H. These mutations are located in close proximity to the Integrase’s active site and each mutation significantly reduces viral fitness by 92-fold for Q148R, 30-fold for N155H [41]. Q148H and N155H mutations are thought to trigger conformational changes within the catalytic pocket that result in lower binding affinity of INSTIs to IN [42]. The variant T66A which is normally selected by EVG treatment, was detected in 0.3% of our sequence cohort. This variant is associated with 5-fold reduced susceptibility to EVG, however, T66A also bears cross-resistance to DTG and is selected by RAL [41]. Abraham et al., 2013, showed that the T66A mutant occurs within the two distal sheet from the DDE triad motif. The close proximity of the T66A/I/K variants to the viral DNA 3′ end and mutation N155H, could sterically hamper viral DNA binding and/or metal ion coordination with DTG [41]. The fact that only 1.0% of sequences analysed contained INSTI primary RAMs suggest that mutations against INSTIs will need to be monitored carefully against Cameroonians living with HIV. This result is in agreement with other studies done in Africa [20, 43‐45] Asia [46, 47], Europe [48, 49] and South America [50] where studies showed a low frequency of INSTI primary RAMs.

In our study, we observed five IN accessory RAMs; namely Q95K, T97A, G149A, E157Q and D232N. T97A mutation can reduce EVG susceptibility by 3-fold [41] and combination of T97A mutation with other INSTI RAMs lead to reduced susceptibility to RAL [51, 52] and DTG [53, 54]. E157Q acts as a compensatory mutation and individually has a negligible effect on the susceptibility to INSTIs; however, a combination of E157Q with other INSTI RAMs may lead to reduced susceptibility to INSTIs [55, 56]. Individuals containing E157Q mutation in combination with other IN RAMs showed reduced susceptibility to DTG. Moreover, another rare nonpolymorphic accessory resistance mutation Q95K confers little if any effect on drug susceptibility to INSTIs [57]. A study by Axel Fun et al., 2010, showed that this secondary mutation enhances N155H-mediated resistance and partially restores the reduced replication caused by N155H [58]. In our study, we detected L74M mutations at a frequency > 20%, which is not surprising since, nearly 10% of ARV-Naïve patients infected with CRF02_AG viruses harbours L74M mutations [59]. This L74M mutation has minimal if any effect against susceptibly of INSTIs, but in combination with mutations at positions 140 and 148, it reduces susceptibility of DTG [38, 60, 61]. Within the IN CCD, we observed 11 of the reported INSTI NOPs. This IN region is important for recognition of DNA, binding and chromosomal integration of the newly synthesized double-stranded viral DNA into the host genomic DNA [62‐64]. It contains the endonuclease and polynucleotide transferase site [62‐64]. While in the CTD, a region that helps stabilize the integrase–viral DNA complex, five other NOP mutations were observed [65]. All of the afore mentioned mutations in either the CCD and/or CTD regions have the potential to affect the IN protein function and interfere with INSTIs binding [65].

We further analysed the effect of NOPs on the stability of the structures and neighbouring residues. Most of the variants noted in our study were shown to destabilise the protein structure, except for one mutation Q95K, that showed to exert a slightly stabilising effect on the protein structure and no changes in the number of polar contacts with neighbouring residues making it unlikely to affect the IN protein structure. It is known that destabilising effects of mutations on the protein structure might reduce drug binding. This was further explored by performing interaction analysis between the drug DTG and energy minimized structures of the WT and mutants T66A, T97A, Q148H, N155H, E157Q, R263K and D232N. The findings revealed accessory mutations E157Q and D232N had the potential to reduce and or prevent DTG binding to HIV-1 CRF02_AG IN structure based on the loss of MG ion interactions, while known RAM’s does not seem to influence DTG drug binding. However, the effect of RAM’s on DTG drug binding needs to be validated using molecular dynamic simulations to calculate the change in free energy of binding between DTG and HIV-1 CRF02_AG IN. Interestingly, the mutation E157Q occurred within the stable alpha-helix secondary structure element and made more contacts with DNA (stabilizing viral DNA complex), while the D232N mutation occurred within the stable Beta-sheet secondary structure element and in close proximity to the flexible G140’s loop region suggesting that these changes can affect the protein conformation and thereby interfere with drug binding leading to resistance.

A limitation of the study is the use of online database sequences that may contain contaminated and truncated sequences leading to spurious phylogenetic tree results and also these databases are not regularly updated. Furthermore, gaps in the aligned regions between the homologous template and target sequence may result in unresolved loop regions within the protein model which is one of the limitations of 3D protein modelling that can result in inaccurate interaction prediction. Furthermore, the interaction analysis was done for only a single static structure of the protein structure and does not consider the dynamic behaviour of the protein structure that might result in the loss and under estimation of crucial interaction partners. An important finding in this study is the fact that sequence diversity amongst different subtypes may affect different folding conformations of the HIV-1 IN subtypes thereby allowing not only RAM’s but accessory mutations to result in less efficacious INSTI binding to HIV-1 IN structures.

Molecular modelling and interaction analysis provided novel insights into the effect of accessory mutations (E157Q and D232N) on HIV-1 CRF02_AG IN drug resistance. This emphasise the need to screen for the presence of INSTIs major RAM’s and accessory mutations in patients on INSTI treatment. This would help identify pathways that contribute to drug resistance and help tailor more effective treatment regimens in INSTI naïve patients.