Teropavimab and zinlirvimab sensitivity in people living with multidrug-resistant HIV-1: data from the PRESTIGIO Registry.

We characterized sensitivity to teropavimab (TAB) and zinlirvimab (ZAB) in people living with four-class drug-resistant HIV (4DR-PWH). This was a multicenter, observational study using plasma or peripheral blood mononuclear cells collected from 50 4DR-PWH (25 with HIV-1 RNA > 1,000 copies/mL matched by age, sex, nadir CD4+, and years on ART to 25 virologically suppressed [HIV-1 RNA < 50 copies/mL]) enrolled in the PRESTIGIO Registry (NCT04098315) with a documented 4DR (NRTIs, NNRTIs, PIs, and INSTIs). Phenotypic sensitivity to bNAbs was determined using the PhenoSense monoclonal antibody assay (Monogram), with susceptibility defined as IC₉₀ ≤ 2 µg/mL. The HIV-1 envelope was genotyped by next-generation sequencing, and sequences were analyzed for the presence of multi-position HIV-1 envelope amino acid signatures associated with in vitro phenotypic susceptibility to TAB and ZAB. Of 46/50 (92%) participants with PhenoSense mAb assay results, 35 (76%) were phenotypically sensitive to TAB, 23 (50%) to ZAB, and 19 (41%) to both bNAbs; seven (15%) were phenotypically resistant to both bNAbs. The proportion of individuals with sensitivity to both bNAbs was similar in participants with viremia (41%) and those with virologic suppression (42%; P = 0.99). We observed marginal correlations between TAB 90% inhibitory concentration (IC₉₀) values and years since HIV diagnosis at the time of sample collection (Spearman r = 0.29, P = 0.05) as well as between ZAB IC₉₀ values and CD8+ cell count (Spearman r = -0.32, P = 0.05). A significant number of the 4DR-PWH analyzed were found to have virus susceptible to TAB and ZAB. These data provide proof-of-concept that selected multidrug-resistant PWH may be candidates for future trials investigating bNAbs-containing regimens to achieve or maintain virologic suppression.IMPORTANCEMultidrug-resistant HIV presents significant challenges for treatment, often leaving individuals with a limited range of therapeutic alternatives. This study provides crucial insights into the efficacy of two promising broadly neutralizing antibodies, teropavimab (TAB) and zinlirvimab (ZAB), in individuals living with HIV who have developed resistance to multiple drug classes. The findings indicate that a significant proportion of the population remains susceptible to these novel treatments, irrespective of their viral suppression status. These results offer a promising basis for developing new therapeutic strategies to improve outcomes for individuals with multidrug-resistant HIV who have a history of extensive treatment, paving the way for future clinical trials aimed at achieving long-term viral suppression with novel drug regimens.