Abstract
Indian HIV-1 subtype C, infecting 2.6 million individuals, demonstrates unique geospatial diversity reflecting distinct evolution and host-pathogen interactions that may instruct the development of region-specific therapeutic strategies. An Indian PLHIV cohort was profiled for immune dysfunction, proviral load, broadly neutralizing antibody sensitivity, and drug resistance mutations in putative CD4+ T cell reservoirs. We demonstrate therapy state specific immune dysfunction, including in ART responding individuals, coincident but not correlated with stable proviral load, apparently enriched in CD4+ T memory subsets. Reservoir derived full length envs displayed distinct neutralization profiles against best-in-class broadly neutralizing antibodies, highlighting the need for a combinatorial approach to target potential breakthrough viruses. Surveillance of the archival repertoire demonstrated the occurrence of drug resistance conferring mutations (>10%) across therapy states, including instances of primary and acquired resistance to recently introduced integrase strand transfer inhibitors. Our data, underlines the need for incorporating reservoir diversity in intervention and management strategies.