*Article* **Spectrum of Atazanavir-Selected Protease Inhibitor-Resistance Mutations**

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**Soo-Yon Rhee 1,\*, Michael Boehm 2, Olga Tarasova 3, Giulia Di Teodoro 4, Ana B. Abecasis 5, Anders Sönnerborg 6, Alexander J. Bailey 1, Dmitry Kireev 7, Maurizio Zazzi 8, the EuResist Network Study Group † and Robert W. Shafer 1**


**Abstract:** Ritonavir-boosted atazanavir is an option for second-line therapy in low- and middleincome countries (LMICs). We analyzed publicly available HIV-1 protease sequences from previously PI-naïve patients with virological failure (VF) following treatment with atazanavir. Overall, 1497 patient sequences were identified, including 740 reported in 27 published studies and 757 from datasets assembled for this analysis. A total of 63% of patients received boosted atazanavir. A total of 38% had non-subtype B viruses. A total of 264 (18%) sequences had a PI drug-resistance mutation (DRM) defined as having a Stanford HIV Drug Resistance Database mutation penalty score. Among sequences with a DRM, nine major DRMs had a prevalence >5%: I50L (34%), M46I (33%), V82A (22%), L90M (19%), I54V (16%), N88S (10%), M46L (8%), V32I (6%), and I84V (6%). Common accessory DRMs were L33F (21%), Q58E (16%), K20T (14%), G73S (12%), L10F (10%), F53L (10%), K43T (9%), and L24I (6%). A novel nonpolymorphic mutation, L89T occurred in 8.4% of non-subtype B, but in only 0.4% of subtype B sequences. The 264 sequences included 3 (1.1%) interpreted as causing high-level, 14 (5.3%) as causing intermediate, and 27 (10.2%) as causing low-level darunavir resistance. Atazanavir selects for nine major and eight accessory DRMs, and one novel nonpolymorphic mutation occurring primarily in non-B sequences. Atazanavir-selected mutations confer low-levels of darunavir cross resistance. Clinical studies, however, are required to determine the optimal boosted PI to use for second-line and potentially later line therapy in LMICs.

**Keywords:** HIV-1; antiviral therapy; drug resistance; protease inhibitor; protease; mutation; atazanavir
