Herein, we report the first Sc(OTf)3-catalyzed redox-neutral cascade [1,5]-hydride transfer/cyclization for the efficient synthesis of azepane-fused spiroindolenines. This structurally strained seven-membered-ring scaffold has long eluded efficient access. The reaction proceeds via Knoevenagel condensation, intramolecular hydride transfer, and cyclization, delivering the target products in good to excellent yields (up to 97%). Notably, this protocol eliminates the need for substrate pre-functionalization or external oxidants. The methodology is readily scalable to the gram scale and enables diverse downstream transformations, including late-stage coupling with zidovudine. Preliminary biological evaluation indicates that selected derivatives exhibit micromolar antiproliferative activity against ovarian cancer cells, warranting further investigation as potential anticancer agents.

The World Health Organization (WHO) recommends human immunodeficiency virus (HIV) drug resistance testing (DRT), but current tests are too complex and expensive for routine use. Genotypic DRT is challenging to interpret because of the growing list of mutations responsible for HIV drug resistance. Although phenotypic DRT is simpler to interpret, it requires slow and labor-intensive viral culture. Phenotypic tests that measure the activity of isolated HIV enzymes are faster and less labor-intensive, but none have yet met the 2023 WHO Target Product Profile (TPP) for HIV DRT. Here, we present an optimized product-enhanced reverse transcriptase (PERT) assay for sensitive and quantitative detection of HIV viral load and drug resistance. PERT combines complementary DNA (cDNA) synthesis by HIV-reverse transcriptase (HIV-RT) with cDNA amplification and detection by quantitative PCR (qPCR). We established sensitive detection down to 10 HIV-RT molecules in a 25 µL sample corresponding to a viral load of ~10 HIV RNA copies/mL. We demonstrated the assay's feasibility for phenotypic DRT using lamivudine-5'-triphosphate (3TC-TP)-to which the M184V mutation confers high-level resistance-and quantified 3TC-TP inhibition using the difference in cDNA produced between drug and no-drug conditions. We surpassed WHO minimal analytical sensitivity requirements (20% low-abundance variant detection) by differentiating 10% M184V HIV-RT fractions in heterogeneous mixtures (1,000 total HIV-RT, viral load ~2,500 copies RNA/mL). Finally, we showed that PERT could detect resistance to existing and emerging RT inhibitors, including tenofovir-diphosphate (TFV-DP), doravirine (DOR), and islatravir (ISL)-TP.IMPORTANCEAlthough antiretroviral therapy can effectively treat and prevent HIV infection, treatment efficacy and global control of the HIV epidemic are threatened by rising rates of HIV drug resistance. Inexpensive and decentralized HIV drug resistance testing (DRT) could facilitate surveillance efforts to understand the prevalence of HIV drug resistance in local and global contexts. This need is especially timely and pressing considering anticipated increased rates of HIV acquisition and drug resistance due to the reductions in global HIV services driven by recent funding cuts. Our optimized product-enhanced reverse transcriptase (PERT) assay for simultaneous viral load and phenotypic drug resistance quantification is fast (~2 h), sensitive, and accurate. We can also leverage existing RT-qPCR instruments used for viral load measurement to significantly improve access to HIV drug resistance monitoring and tailored regimen selection.

Transmitted HIV drug resistance can compromise treatment outcomes in children with vertically acquired infection, particularly when baseline resistance testing is unavailable. This case report describes the longitudinal clinical, virological, immunological, and molecular course of a male child diagnosed with vertically acquired HIV-1 subtype C infection, most consistent with mother-to-child transmission. Clinical history, viral load, CD4/CD8 profiles, HIV-1 pol sequencing, phylogenetic analysis, and interpretation were performed using the Stanford HIV Drug Resistance Database (HIVdb). The baseline viral load was 240,993 copies/mL, with a CD4:CD8 ratio of 0.40. Genotypic analysis identified major protease inhibitor resistance mutations V82A and I84I/V, together with M184V. Stanford HIVdb predicted high-level resistance to lopinavir/ritonavir, atazanavir/ritonavir, lamivudine, and emtricitabine; low-level resistance to darunavir/ritonavir and abacavir; and preserved susceptibility to tenofovir, zidovudine, and the evaluated NNRTIs. Initial lopinavir/ritonavir-based regimens failed to achieve sustained virological suppression. Following treatment optimization with an integrase inhibitor-based regimen and subsequent transition to bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF), HIV-1 RNA became Target Not Detected (TND) from November 2024 onward. At the latest follow-up, the CD4 count was 877 cells/µL, the CD8 count was 722 cells/µL, and the CD4:CD8 ratio had improved to 1.21, indicating substantial immune recovery. This single-patient case highlights the clinical value of baseline genotypic resistance testing and individualized, genotype-guided antiretroviral therapy in achieving durable virological suppression in pediatric HIV.

Background and Objectives: Oral antiviral agents nirmatrelvir/ritonavir (NMV/r) and molnupiravir are recommended for the early treatment of non-hospitalized adults with COVID-19 who are at increased risk of disease progression. Real-world comparative data on these two agents remain limited. The aim of this study was to evaluate the efficacy and safety of NMV/r and molnupiravir in non-hospitalized patients with COVID-19. Materials and Methods: We conducted a retrospective, single-center study with a sample size of 122 initially non-hospitalized adults with confirmed SARS-CoV-2 infection treated at the Clinic for Infectious Diseases, University Clinical Center of Vojvodina (UCCV), Novi Sad, Serbia, during 2022. Patients were treated within the first five days of symptom onset with either NMV/r (n = 48) or molnupiravir (n = 74) for five days. Demographic characteristics, clinical presentation, comorbidities, vaccination status, laboratory parameters at baseline and on day 3, chest radiography findings, hospitalization, and mortality were analyzed. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS), version 21 (IBM Corp., Armonk, NY, USA). Results: The groups did not differ significantly in age, sex, vaccination status, or vaccine type. Between baseline and day 3, the increase in lymphocyte count (p < 0.001) was significantly greater in the molnupiravir group. Chest radiography showed no significant between-group differences. Overall, 6 patients (4.9%) were hospitalized, with no significant difference between antiviral agents (p = 1.000), and no deaths occurred. Among patient-reported symptoms effects, the incidence of dysgeusia was significantly higher in patients treated with NMV/r (p = 0.001). Conclusions: Both antivirals showed similarly low progression, hospitalization, and mortality rates.

Background: Doravirine (DOR) is a new-generation non-nucleoside reverse transcriptase inhibitor, which has emerged as an option for people living with HIV (PLWH) owing to its favorable efficacy and safety profile, unique resistance pathway and limited potential for drug-drug interactions. Methods: This retrospective chart review study aimed to better understand DOR-based treatment use in Greece, PLWH characteristics, and drivers of treatment switch. Eligible individuals were adult PLWH who were switched to a DOR-based regimen based on the physician's decision. Individuals exposed to DOR at any time prior to switching to the DOR-based regimen were excluded. Results: From 12 July 2023 to 31 October 2023, 110 PLWH were consecutively enrolled across 6 public hospital clinics. At baseline (closest prior to or on the date of first DOR prescription), the mean age of PLWH was 49.3 years, 90.9% were males, 88.2% were asymptomatic, 86.5% were virologically suppressed, 33.6% were suffering from multimorbidity (excluding infections/infestations), 45.5% were receiving comedications for their comorbidities, and 5.5% were co-infected with Hepatitis C virus. Most PLWH (98.2%) were prescribed DOR plus two nucleoside reverse transcriptase inhibitors; 87.3% were prescribed DOR/Lamivudine/Tenofovir Disoproxil Fumarate fixed-dose combination. PLWH started DOR a median of 11.7 years after first-ever antiretroviral therapy initiation, corresponding to 2nd/3rd/≥4th antiretroviral line in 33.6%/33.6%/32.7% of participants, respectively; 60.9% of them were proactively switched to a DOR-based regimen. The most common reasons for switching were 'regimen simplification' (42.7%), 'tolerability' (26.4%) and 'prevention of toxicities' (18.2%). Conclusions: This study highlights the patterns of DOR use in real-life clinical practice in Greece among treatment-experienced PLWH. Physicians switch HIV-1-infected individuals from prior ART to DOR-based regimens to offer a simplified regimen or to avoid or prevent toxicity.