Clinical guidelines from the Department of Health and Human Services recommend statin therapy for patients living with HIV who face increased risk for heart disease.

The guidance advises statin use to prevent atherosclerotic cardiovascular disease (ASCVD) in adults with HIV aged 40 to 75 years who have a 10-year ASCVD risk of at least 5%. The recommendation follows findings from the REPRIEVE trial, which demonstrated that pitavastatin significantly reduced major cardiovascular events in this population.

The trial enrolled more than 7,700 adults with HIV on antiretroviral therapy who were at low to intermediate ASCVD risk. Participants were randomized to receive pitavastatin 4 mg daily or placebo and were followed for a median of 5.6 years. Those treated with pitavastatin had 36% fewer major cardiovascular events—including heart attacks, strokes, and cardiovascular-related deaths—than those who received placebo.

In addition to lowering low-density lipoprotein cholesterol (LDL-C), statins may reduce inflammation associated with HIV, which contributes to earlier onset of cardiovascular disease. Patients with HIV often have higher rates of traditional risk factors, such as smoking and obesity, as well as HIV-specific factors like chronic immune activation and effects from antiretroviral medications.

Participants were a median age of 50 years. At baseline, the median 10-year ASCVD risk was 4.5%, and nearly half had previously experienced a very low CD4 count. The greatest benefit of statin therapy was observed in participants with a 10-year ASCVD risk of 5% or greater, where fewer patients needed treatment to prevent one cardiovascular event.

Based on these findings, the panel recommended moderate-intensity statin therapy—pitavastatin 4 mg, atorvastatin 20 mg, or rosuvastatin 10 mg—for patients with HIV and an ASCVD risk between 5% and 20%. For those with a lower calculated risk, the decision to initiate statins should be guided by clinician–patient discussions, especially when additional HIV-related risk factors are present.

The guideline authors noted the need for careful selection of statins due to potential interactions with antiretroviral medications. Pitavastatin was chosen for the trial in part because of its low risk for drug-to-drug interactions. 

Adverse events were more frequent in the statin group, including muscle-related symptoms and a modest increase in new-onset diabetes (6% vs 4.7%). However, the benefits were judged to outweigh the risks, especially in those at higher cardiovascular risk.

This marks the first U.S. guideline to specifically endorse statins for primary prevention of cardiovascular disease in patients with HIV.

Full disclosures can be found in the guideline.

Source: Annals of Internal Medicine