HIV-1 Gag contributes to susceptibility of protease inhibitors (PIs) in the absence of known resistance mutations in the protease gene. For the majority of HIV-infected patients worldwide, PIs are the second, and last-line of therapy. Clinically, only around 20% of individuals who fail PI regimen develop major resistance mutations in protease. We previously showed that full-length Gagprotease-derived phenotypic susceptibility to PIs differed between HIV-1 CRF02_AG and subtype G-infected patients who went on to successfully suppress viral replication versus those who experienced virological failure of boosted lopinavir monotherapy as first-line treatment in a clinical trial. We hypothesised therefore that baseline PI susceptibility by Gag-protease phenotyping could be used to predict treatment outcomes for patients on second line, boosted-PI treatment in the real-world clinical setting in Nigeria, where subtypes CRF02_AG/G dominate the epidemic. We used clinical and demographic data; HIV-1subtype, sex, age, viral load, duration of treatment and baseline CD4 count to match individuals who experienced second-line failure with ritonavir-boosted PI-based ART (‘baseline failures’) to those who achieved virological response (‘baseline successes’) with virological failure defined by viral load <400 copies of HIV-1 RNA/mL by week 48. Using a single replication-cycle assay, we carried out in vitro phenotypic susceptibility testing of patient-derived viruses from these two groups. We found no impact of baseline HIV-1 Gagprotease-derived phenotypic susceptibility on outcomes of PI-based second-line ART, treatment outcome could not be predicted using baseline susceptibility alone. Secondly, we sought to explore the role of mutation in Gag-protease genotypic and phenotypic changes within patients who failed PI-based regimens without known drug resistance-associated protease mutations in order to identify novel determinants of PI resistance. We used longitudinal samples collected at baseline, and at virological failure to explore the role of Gag mutations. Using target enrichment and next-generation sequencing (NGS), followed by haplotype reconstruction and phenotypic drug assays and phylogenetic analysis, we reported for the first time a four-amino acid mutation signature in HIV-1, CRF02_AG matrix (S126del, H127del, T122A and G123E) which confer reduced susceptibility to the PI, lopinavir and atazanavir. Our multi-pronged genotypic and phenotypic approach to document emergence and temporal dynamics of a novel protease inhibitor resistance signature in HIV- 1 matrix domain reveals the interplay between Gag associated resistance and fitness
