Analysis of Reverse Transcriptase and Protease Genes of HIV for Antiretroviral Drug Resistance in Treatment-Exposed Jamaican Pediatrics Adriel P. Ramkissoon, 1 Icolyn I. Amarakoon, 1 Cindy-Leigh C. Hamilton, 1 Russell B. Pierre, 2 Lindsay M. Eyzaguirre, 3 Jean K. Carr, 3, * William A. Blattner, 3 and Marcia E. Roye 1 Abstract This study reports on the drug resistance profiles for HIV-infected pediatrics in Jamaica who have been exposed to antiretroviral therapy (ART). The genetic diversity of HIV-1 found in these patients was also determined using phylogenetic analysis. The protease-reverse transcriptase (Pro-RT) region of the genome was amplified from 40 samples, sequenced, and analyzed for the identification of antiretroviral resistance-associated mutations (RAMs). All isolates belonged to subtype B and 39 possessed multiple RAMs in the reverse transcriptase genes that would compromise the efficacy of drugs being used to treat these patients. Four isolates possessed RAMs in the protease genes. The overall frequency of HIV drug resistance was 95%. The high frequency of drug resistance is supported by epidemiological data that revealed an equally high frequency of treatment failure (98%) among the study participants. The results of this study indicate the urgent need for greater access to drug resistance testing in Jamaica. H IV-1 infection became a significant concern in Jamaica in 1982 when the first case was reported, with subsequent spread, especially within certain high-risk groups. Statistical data reporting the percentage of HIV- infected pediatric patients are currently unavailable. How- ever, as of December 2013 it was reported that approximately 30,000 adults were infected, representing 1.8% of the Ja- maican adult population. It is estimated that 30% of infected persons are unaware of their status and approximately 8,000 persons died since HIV was first reported in Jamaica. 1 Most recent epidemiological data indicate a 61% reduction in AIDS deaths since 2004 when antiretroviral therapy (ART) was first introduced. 2 The introduction of the prevention of mother-to-child transmission (PMTCT) program resulted in 88% of pregnant women and 98% of HIV-exposed infants receiving ART. This initiative has resulted in a reduction in the national mother-to-child transmission rate; in 2013 this rate was <2% compared to 25% in 2002, prior to the introduction of anti- retroviral medication for PMTCT. 1 The effectiveness of ART in Jamaica has led to increased survival and improved quality of life for perinatally infected children; as a result, there is now a stable, maturing cohort of infected adolescents who must transition to adult life. 3 The corollary has been the growing population of children and adolescents with virological and immunological evidence of ART resistance. 4 There is limited public access to HIV resistance testing in Jamaica; as a result molecular epidemiological data are lacking. Currently HIV drug resistance data for Jamaican pediatric patients do not exist. However, a 2012 study of antiretroviral drug resistance in HIV-infected Jamaican adults reported a 35% and 29% prevalence in drug-experienced and drug-naive patients, respectively. 5 These figures repre- sent a significant portion of the study population; the prev- alence of ART resistance among pediatric patients is also likely to be high as these patients are known to be at high risk of developing ART resistance for multiple reasons including early exposure to ART to prevent infection during birth and having a limited range of approved ART formulations for children and pediatrics. 6 For physicians and health managers this translates into difficulty constructing salvage ART re- gimes and the risk of transmission of resistant virus in the population. 1 Biotechnology Centre, University of the West Indies, Mona, Kingston, Jamaica. 2 Department of Child and Adolescent Health, University of the West Indies, Mona, Kingston, Jamaica. 3 Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland. *Current affiliation: Alabama College of Osteopathic Medicine, Dothan, Alabama. AIDS RESEARCH AND HUMAN RETROVIRUSES Volume 31, Number 9, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/aid.2015.0122 932