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- Determining the immune response in human immunodefficiency virus infection : HIV -1 diversity as tool for epidemic monitoringPublication . Carvalho, Alexandre Manuel Câmara de; Lecour, Henrique; Pedrosa, JorgeThe Human Immunodeficiency Virus type 1 (HIV-1) is characterized by extensive genetic diversity at the population level but also within a single infected individual. The swift capacity of the virus to generate extensive diversity within the human host played a central role in the origin of the disease and is also key for the current global proportions of the HIV-1 pandemic. The epidemic started in Africa with multiple zoonotic transmissions of simian immunodeficiency virus (SIV) to humans. This was followed by a period of diversification and adaptation to the human population that, enhanced by the high rates of mutation and recombination of the virus, allowed the emergence of a virus capable of efficient sexual transmission among humans. The spread of the human adapted virus is estimated to have initiated from late 1950s to the early 1960s from Africa to the rest of the world. The predominance of the subtype B HIV-1 virus in Western Europe suggests that this was the first subtype to be introduced in this region. The subtype diversity pattern of HIV-1 in Portugal resembles the ones found in Central Africa being far more complex than the viral diversity patterns observed in the rest of Western Europe highlighting the relevance of in detailed studies of the Portuguese HIV-1 epidemics. In this work we have characterized the local HIV-1 epidemic of the Portuguese city of Braga in the years from 2000 to 2012. We found that the most frequent HIV-1 subtypes were G and B and by combining epidemiological and phylogenetic analysis we were able to uncover local transmission clusters of non-B and non-G subtypes among locals in association with sexual transmission networks that initiated transmission in the early 2000s. This corroborates Portugal as an early point of introduction of non-B HIV-1 subtypes in Western Europe. Having performed this characterization at the level of this local population we then focused on analyzing the duration of infection at the level of the infected patient. For this purpose we have optimized a methodology to differentiate recent from chronic infections. It was based on the study of ambiguous nucleotide calls obtained from routine HIV-1 genotyping. We found that the analysis of these ambiguities, as an expression of intra-host HIV-1 diversity, allowed the inference of the duration of infection in this study population. Subsequently, we questioned if high HIV-1 subtype diversity found in this region correlated with higher rates of transmission of drug resistance mutations. We found that the level of transmitted drug resistance in this population was similar to other European regions and independent predictors of transmitted drug resistance (TDR) could not be identified supporting the recommendation of universal viral sequencing at patient admission. This study performed in a country that is unique in Western Europe in what regards to HIV-1 diversity supported Portugal as one of the early entry-points of non-B HIV-1 subtypes in Western Europe and also reinforced the need for more efficacious local control measures targeting sexual transmission routes. We believe this study is of general importance especially in a time when several reports suggest that the prevalence of non-B subtypes in Western Europe is increasing. The knowledge herein generated also contributed for the development of method to discriminate recent from non-recent HIV-1 infections, a step of crucial importance to validate prevention strategies. Importantly, it was also shown that the higher HIV-1 subtype diversity found in this study population does not correlate with an increase in the rate of transmission of drug resistance when compared to the rest of the Western Europe.