The British HIV Association (BHIVA) has recommended that everyone living with HIV aged 40 and over should take a statin to reduce their risk of heart disease, even if they do not have raised cholesterol or a high risk of heart disease.
The new guidance, issued this week, is the first in the world to respond to the results of the REPRIEVE study, presented at the International AIDS Society Conference on HIV Science in July. The study showed that taking pitavastatin daily reduced the risk of a major cardiovascular event such as heart attack, stroke or a clinical intervention to treat a serious heart disorder by 35% in people with HIV. Crucially, the study only recruited people with a low-to-moderate risk of serious heart disease within ten years.
The REPRIEVE study was designed to test whether a statin reduced cardiovascular risk in people with HIV. Living with HIV increases the risk of heart disease regardless of other risk factors such as smoking, raised cholesterol or high blood pressure. While people with HIV are twice as likely to develop cardiovascular disease, risk calculators used to assess cardiovascular risk in the general population may underestimate the risk of disease for people with HIV.
Statins are a class of medication that prevent the development of heart disease. They work by lowering levels of LDL cholesterol, the ‘bad’ form of fat which accumulates in arteries and leads to blockages that cause heart attacks and strokes. Statins also influence cardiovascular health by reducing inflammation and oxidative stress, as well as limiting the formation of dangerous blood clots and stabilising artery-blocking masses of fatty debris called plaques.
Statins are not recommended in the UK for people with a 10-year cardiovascular risk below 10% unless they have seriously reduced kidney function or type 1 diabetes accompanied by other cardiovascular risk factors, or where another factor might have led to an underestimated risk.
Following the results of the REPRIEVE study, BHIVA carried out a rapid review of the evidence regarding cardiovascular disease and statin use in people with HIV. The review concluded that statins should be offered to all people with HIV over 40 as part of a holistic effort to reduce cardiovascular risk factors in people with HIV.
BHIVA recommendation for statin use in people with HIV
BHIVA recommends that people aged 40 and over should be offered a statin irrespective of lipid levels or estimated cardiovascular risk.
People with HIV aged 40 and over with an estimated 10-year risk of 5% or over should be prioritised for statin treatment.
The first choice for statin treatment in people with HIV should be pitavastatin 4mg daily when it becomes available in the UK. (The branded product is not sold in the UK, but generic versions should be available in 2024). Atorvastatin 20mg daily can be used as an alternative. For people who cannot tolerate a statin, GPs should prescribe ezetimibe.
"Statin prescribing should be carried out by general practitioners, so it will be important for HIV clinics to communicate the rationale to GPs."
People already taking a low-intensity statin (normally pravastatin at a dose of 10mg-20mg a day in people with HIV) should switch to a moderate-intensity statin (a statin at a dose that lowers LDL cholesterol by 30% - 49%), providing that this can be tolerated.
Statin prescribing should be carried out by general practitioners, so it will be important for HIV clinics to communicate the rationale for statin prescribing. The BHIVA guidance contains a statement for inclusion in letters to GPs requesting they prescribe statins for patients with HIV and outlining how the recommendation conforms with NICE guidance on statin prescribing.
But as well as recommending statin use, HIV clinics and GPs should also provide advice and signposting on smoking cessation, exercise, diet, weight management and alcohol use, to address other cardiovascular risk factors.
Although pitavastatin and atorvastatin have a low risk of drug interactions with antiretrovirals, GPs should be aware of the following advice when starting people with HIV on these statins:
- For people taking atazanavir or atazanavir ritonavir, start pitavastatin at the lowest dose and increase gradually (due to the potential for raised pitavastatin levels). BHIVA says that boosted atazanavir should be avoided if at all possible when using atorvastatin.
- For people taking ritonavir- or cobicistat-boosted darunavir or elvitegravir, start atorvastatin at the lowest possible dose and monitor dose increases to 40mg maximum carefully.
- For people taking efavirenz and atorvastatin, an increase in atorvastatin dose may be required, depending on lipid responses to statin treatment.
The BHIVA guidance also recommends that antiretroviral treatment should be assessed to check whether it is suitable for people with high cardiovascular risk. BHIVA recommends avoiding abacavir and lopinavir/ritonavir in people with high cardiovascular risk. For this group of patients, BHIVA prefers the use of atazanavir/ritonavir over boosted darunavir if a boosted protease inhibitor is used.
British HIV Association. BHIVA rapid guidance on the use of statins for primary prevention of cardiovascular disease in people living with HIV. November 2023.
Update: This article was amended on 24 November 2023 to clarify the availability of pitavastatin in the UK.