Perspectives for the chemotherapy of AIDS.

In the design of selective inhibitors of the human immunodeficiency virus (HIV), the etiologic agent of AIDS, various steps of the virus replicative cycle could be envisaged as targets, i.e. virus adsorption to its cellular receptor (or another early event in virus replication such as penetration or uncoating), transcription of the viral RNA genome to proviral DNA (reverse transcription), trans-activation of viral mRNA transcription and translation, and, finally, virus release ("budding", or another late event in virus replication such as the assembly process). Although some potent HIV inhibitors such as heparin and dextran sulfate may interfere with an early step of the virus replicative cycle (adsorption) and others (interferon and interferon inducers) are assumed to act at a late step (budding), the majority of the anti-HIV agents appear to act at the reverse transcriptase level. Most of these reverse transcriptase inhibitors belong to the class of the 2',3'-dideoxynucleosides (ddN), and within this class of compounds a variety of 2',3'-dideoxy-, 2',3'-didehydro-2',3'-dideoxy-, 3'-azido-2',3'-dideoxy- and 3'-fluoro-2',3'-dideoxyribosides of both purines and pyrimidines have been described as potent and selective anti-HIV agents. Akin to 3'-azido-2',3'-dideoxythymidine (AZT), the sole anti-HIV compound that has so far been licensed for clinical use in the treatment of AIDS, all other ddN analogues are postulated to interact as competitive inhibitors (with respect to the natural substrates) and/or chain terminators of the HIV reverse transcriptase. To do so, the ddN analogues need first to be phosphorylated by cellular kinases to the corresponding 5'-triphosphates (ddNTPs), and together with the affinity of the ddNTPs for the HIV reverse transcriptase (relative to their affinity for the cellular DNA polymerases), the extent by which the ddNs are phosphorylated to the ddNTPs are critical determinants of their potency and selectivity as anti-HIV agents. Much more remains to be learned about the in vivo efficacy of the 2',3'-dideoxynucleoside analogues, and their pharmacokinetic and toxicological properties, before their true potential in the treatment of AIDS can be fully assessed.