HIV guidelines recommend a statin for all people older than 40: new BHIVA document

1 December 2023. Related: Guidelines, Coinfections and complications.

The 8-page document is in response to results from the REPRIEVE study published earlier this year that were also presented at the IAS and EACS conferences. [2]

Other evidence is also reviewed.

REPRIEVE showed that people at low risk of major cardiovascular events (MACE) who were randomised to daily pitavastatin had a significant reduction in MACE compared to daily placebo.

The BHIVA document interprets the results from REPRIEVE in order to reduce overall lifetime risk of cardiovascular events, rather than just to reduce the 10-year risk.

Recommendations

The guideline includes four graded recommendations supported by evidence.

• That all people living with HIV aged 40 years or older should be offered a statin for primary prevention of CVD irrespective of lipid profile or estimated CVD risk (Grade 1B).
• First-line choice for primary prevention should be pitavastatin 4 mg daily when it becomes available in the UK (Grade 2A).
• That atorvastatin 20 mg daily can be used as an alternative (Grade 2B).
• That a family history of high cholesterol should be excluded when assessing all people with total cholesterol > 7.5 mmol/L without clear cause or a personal/immediate family history of coronary artery disease below the age of 60 years (Grade 1C).
• To optimise ART in people at high risk of CVD in line with BHIVA treatment guidelines (Grade 1C).

Seven additional recommendations are graded as a Good Practice Point (GPP).

• That CVD risk assessment and discussion about pharmacological primary prevention is combined with a holistic approach to lifestyle modifications including smoking cessation and dietary advice. People needing further support should be signposted to or referred for appropriate multidisciplinary support (GPP).
• That CVD risk is assessed using tools recommended by BHIVA monitoring and national guidelines (GPP).
• All people living with HIV should have a baseline lipid assessment (GPP).
• That people living with HIV aged 40 years or older with an estimated 10-year CVD risk of 5% or greater are prioritised for primary prevention with a statin (GPP).
• That people currently on a low-intensity statin should switch to one of moderate intensity if clinically appropriate and tolerated (GPP).
• To offer an alternative lipid-lowering drug in line with national guidelines for people unable to tolerate a statin (GPP).
• That best practice for primary prevention is for statins to be prescribed and monitored in primary care (GPP).

Please see the full document for detailed discussion of the issues and evidence that supports these recommendations.