Distinct modes of evolution drive HIV escape from two broadly neutralizing antibodies.

Broadly neutralizing antibodies (bNAbs) show promise for HIV treatment and prevention, but are vulnerable to resistance evolution. Comprehensively understanding in vivo viral escape from individual bNAbs is necessary to design bNAb combinations that will provide durable responses. We characterize viral escape from two such bNAbs, 10-1074 and 3BNC117, using deep, longitudinal sequencing of full length HIV envelope (env) genes from study participants treated with bNAb monotherapy. Improved sequencing depth and computational evolutionary analyses permit us to identify in vivo routes and parallelism underlying HIV escape from each bNAb, providing new insights into this evolutionary process. We find that 10-1074 escape is restricted to a small number of previously documented pathways seen across participants, but these escape mutations 1) emerge via extensively recurrent mutation, 2) are not equally preferred, and 3) can pre-exist at low frequency in intra-host viral populations before therapy, although their detection does not predict rebound timing. In contrast, 3BNC117 escape follows background-specific patterns in which specific escape mutations present in one intra-host population rarely emerge or spread in other populations, except among highly related viruses. Despite this, 3BNC117 escape mutations often still emerge recurrently within their host. Our findings map longitudinal in vivo antibody escape across 20 diverse clade B HIV intra-host populations and reveal clinically relevant resistance dynamics that highlight how combination bNAb therapies will need to contend with extensively recurring escape mutations and dependence on genetic background. Significance StatementUsing recently developed techniques that capture viral genetic diversity and associations between mutations at depth, we deeply sequenced HIV from two clinical trials of broadly neutralizing antibody (bNAb) monotherapies, 3BNC117 and 10-1074. We computationally characterized HIV populations longitudinally with unprecedented resolution as they escaped these therapies in people living with HIV. Intra-host tracking of individual HIV genetic backgrounds reveals extensively recurrent mutations driving escape and suggests that HIV escape routes from certain bNAbs can depend sensitively on the genetic background of the virus. Our findings highlight the difficulties in evaluating pre-treatment resistance, provide an analysis blueprint for future trials, and inform the design of emerging combination antibody therapies to maximize the likelihood of durable efficacy.