Several studies have shown that because HIV reverse transcriptase is similar to

telomerase, AZT is more binding to the telomeric region than DNA of CHO cells (chinese
hamster ovary). Other studies also show that AZT increases aging and apoptosis and
decreases cell proliferation through the action of inhibition of telomerase and decreases
telomere size in immortal cells (Lee et al., 2019).
Although in somatic cells, the decreased levels of mRNA TERT levels by AZT can be
explained by the study of Ji et al., after AZT administration, the first activity to decrease is
the TERT sub unit and the c-Myc transcription factor that required for TERT transcription (Ji
et al., 2005). Myc works directly as a central signaling of cellular pathways in TERT
transcription settings where high Myc expression is followed by TERT mRNA expression or
high telomerase activity (Khattar and Tergaonkar, 2017).
The influence of AZT on telomerase activity not only directly works telomeric, but
also non telomeric on transcription factors. Research on the mammary adenocarcinoma
model shows that azidothymidine not only has telomeric effect, but also has non-telomeric
activity. After 15 times the administration of azidothymidine (600uM) showed inhibitory
effects on telomerase, and extra telomeric effects showed a significant reduction in
transcription of c-Myc, Cyc-D1 and TERT (Armando, et al., 2016).
Telomerase activity also decreased after AZT administration in esophageal cancer.
AZT inhibits the proliferation of TE-11 esophageal cancer cells in vitro. This growth
inhibitory effect is associated with decreased telomerase activity, cessation of cell cycles in S
and G2 / M phases and increased DNA damage (Wang et al., 2017).
Another mechanism that can explain the decrease in telomerase activity by AZT is the
regulation of telomerase activity by the protein shelterin, namely TPP1 (telomere protection
protein 1). The action of telomerase depends on the TPomer telomere protein, which recruits
telomerase to telomeres and facilitates the process of DNA synthesis (Grill et al., 2019).
TPP1 is a protein coded by the ADC gene on chromosome 16q22.1, has 544 amino
acids with a molecular weight of 57.7 kDa. In-vivo research shows this protein is needed for
telomerase recruitment. TPP1-POT1 heterodimer stimulates telomerase activity and
procession by interacting with hTERT. This shows the physical relationship between the
shelterin complex and telomerase which is needed in the mechanism of telomere synthesis
(Gomez et al., 2012b). Similarly, TPP1 directly increases telomerase activity. This protein
contains what is called TELpatch, a site that specifically interacts with the catalytic subunit
telomerase and recruits this enzyme to telomeres (Nalobin et al., 2018).
Some data on cancer cells show that AZT shortens telomere size. Once telomeres
shorten at a critical level, the proteins that make up the shelterin complex are unable to relate
to telomere sequences and lose their function, so they will not only activate the double strand
break response, DSB response, activation of DNA damage pathways and genome instability,
but also eliminates telomerase enzyme recruitment (Doksani, 2019; Turner et al., 2019).
From the description above, it can be summarized that AZT decreases telomerase
activity in at least three ways; first, AZT gives fake nucleotides to the telomeric region of
DNA, so the telomerase enzyme cannot work on telomeres to provide a nucleotide template
for the transcription process during cell division; second, AZT decreases transcription factors
such as c-Myc which are needed for transcription of TERT as catalytic subunits of the
telomerase enzyme; and third, shortening of telomeres due to the two mechanisms above will
cause the recruitment of telomerase by the protein shelterin to be disrupted so that this
enzyme cannot work on telomeres.

5.2. Telomere Size

Azidothymidine (AZT) is a thymidine nucleotide analog that works like other reverse
transcriptase inhibitors, breaking the chain of HIV replication by inhibiting the activity of the
reverse transcriptase enzyme. In the presence of a TERT component in telomerase with the
catalytic function of reverse transcriptase and structurally similar to HIV reverse
transcriptase, AZT is thought to work also as a telomerase inhibitor and shorten telomere size
(Gomez et al., 2012a).
The work of AZT with telomere targets, has been extensively studied in cancer cells
and somatic cells. In this study, we showed that the effect of AZT administration significantly
shortened the spermatozoa telomere size. Post Hoc Test continued with Least Significant
Difference (LSD), showing that the group with the optimal dosage had the most influence on
telomere shortening.
Studies in mice given AZT with concentrations close to the preventive dose of
transmission of HIV perinatal transmission show inhibition of embryo telomere lengthening,
an increase in the number of copies of LINE-1 (long interspersed nuclear element 1) after 48
hours of administration (Navarro et al., 2017). Research with antisense strategies or ALT cell
therapy in osteosarcoma and He-la cell lines shows AZT administration induces progressive
telomere shortening, cell cycle cessation in the G2 phase and finally cell death (Bondarev and
Khavinson, 2016).
To date there are no data on the effect of AZT administration on the telomere size of
spermatozoa. Earlier reports on the effects of AZT administration on male reproduction by
Chris-Ozoko et al on rodents showed that administration of AZT in three groups of treated
mice with doses of 0.3 mg / ml, 1.3 mg / ml and 2.3 mg / ml for 30 days, respectively,
resulted in histological changes. architectures that were significant to the testes compared to
controls. The study concluded that AZT causes structural abnormalities of testicular tissue
(Chris-Ozoko, et al., 2013).
Antiretroviral combinations of AZT and Lamivudine (Zidolam) cause a significant
decrease in the progressive motility of spermatozoa, spermatozoa concentrations, and their
viability. Withdrawal of this drug returns the suppressed value to its normal state. These
results indicate that zidolam triggers reversible changes in all parameters and their impact on
spermatogenesis (Osonuga et al., 2010).
The effect of antiretroviruses on sperm quality was also investigated by Leeuwen et
al. The administration of a combination antiretrovirus causes the progressive motility of
spermatozoa to decrease significantly according to WHO criteria (Leeuwen et al., 2008). In
contrast to previous studies, Dominique et al (2003) found spermatozoa motility dysfunction
in rats given Azidothymidine due to a significant decrease in cytochrome c-oxidase activity
(Dominique et al., 2003).
Several studies have shown that because HIV reverse transcriptase is similar to
telomerase, AZT is more binding to the telomeric region than the DNA of CHO cells
(Chinese hamster ovary). Other studies also show that AZT increases aging and apoptosis and
decreases cell proliferation through the action of inhibition of telomerase and decreases
telomere size in immortal cells (Lee et al., 2019).