Cholesterol and HIV

Cholesterol is a fatty substance that is found in different parts of the body. We all need some cholesterol because it’s used in our bodies to do important things, such as making hormones and repairing cells. But having too much of some types of cholesterol can be harmful.

Cholesterol moves through your blood attached to proteins. When cholesterol and proteins join together, they are called lipoproteins. There are different types of lipoproteins.

• High-density lipoproteins (HDL) take cholesterol to your liver where it can be removed from your body. This is sometimes called 'good' cholesterol.
• Non-HDL cholesterol can build up in your arteries and cause problems. This is sometimes called 'bad cholesterol'.
• Low-density lipoproteins (LDL) carry cholesterol from your liver to your cells. This used to be the only type of lipoprotein that was labelled as 'bad cholesterol'. We now know that other types of non-HDL cholesterol are also harmful.

It’s better to have higher levels of HDL and lower levels of non-HDL. This is because non-HDL cholesterol is linked to a thickening and hardening of your arteries (called atherosclerosis). This can lead to conditions such as heart attack and stroke.

If your cholesterol and other blood fats (lipids) aren’t in the healthy range this is sometimes called ‘dyslipidaemia’.

Your lifestyle and cholesterol

Changes to your lifestyle are an important way that you can improve your cholesterol levels.

• Eat a healthy, balanced diet that contains plenty of fruits, vegetables, and whole grains such as brown rice.
• Eat fewer foods that contain saturated fats, such as butter, cheese, and coconut oil. Instead, replace them with foods that contain unsaturated fats, such as vegetable oils and nuts.  
• Avoid highly processed foods wherever possible as these tend to contain large amounts of salt, sugar, and trans fats.
• Get regular exercise. Try to aim for 150 minutes of moderate-intensity exercise, such as cycling or brisk walking, each week. If you have very high blood pressure you should speak to a doctor about what type of exercise is safe for you.
• Don’t smoke. If you are a smoker, you can get support to stop smoking from your doctor.
• Limit your intake of alcohol. In the UK, the recommended limit is no more than 14 units a week. You should also try and avoid drinking too much coffee or other drinks and foods that contain a lot of caffeine.
• Manage your weight. If you're overweight try to lose weight in a safe and healthy way by eating a healthy balanced diet and getting enough exercise.

Who is at risk?

You’re more likely to have higher cholesterol as you get older.

Some people are at a higher risk of developing high cholesterol, including people:

• who have a close family member who has had high cholesterol, heart disease or a stroke
• with certain health conditions, such as an underactive thyroid or type 2 diabetes.

High cholesterol in people living with HIV

Living with HIV can affect your levels of cholesterol and other blood fats (lipids). There is also evidence that HIV increases your risk of heart problems more generally.

If you’re not taking effective anti-HIV treatment, this can cause you to have higher levels of non-HDL cholesterol, and lower levels of HDL cholesterol which increases your risk of heart disease. This means it is very important to take anti-HIV treatment.

However, even if you are taking effective HIV treatment, you might find that your cholesterol levels are higher than the healthy range. This could be because of the effect that HIV is having on your body or as a side effect of your anti-HIV medication. It could also be for reasons that are not related to HIV, such as ageing, your diet, or how much exercise you do.

Some anti-HIV medications are more likely to affect your blood lipids than others. These are:

• efavirenz (Sustiva, also in Atripla)
• elvitegravir (Vitekta) when taken with cobicistat, including in the combination pills Stribild (with cobicistat, tenofovir disoproxil fumarate and emtricitabine) and Genvoya (with cobicistat, tenofovir alafenamide and emtricitabine)
• protease inhibitors such as darunavir (Prezista, also in Rezolsta and Symtuza), atazanavir (Reyataz, also in Evotaz) and lopinavir (Kaletra) when they are taken with ritonavir (Norvir) or cobicistat (Tybost). You might take a booster separately, or it may be included in a combination pill.

Some people find that if they switch to tenofovir alafenamide (TAF) from tenofovir disoproxil fumarate (TDF) their lipid levels increase. However, switching back from TAF to TDF can help to improve them again.   

If the amount of cholesterol or other fat in your blood has increased because of your anti-HIV treatment you might be advised to switch treatments, be given cholesterol-lowering medication, or both.  

Diagnosis and monitoring

High cholesterol doesn’t usually cause any symptoms, so it’s important that your cholesterol levels are monitored by your doctor. Your cholesterol will be checked when you are first diagnosed with HIV. After that, you should have regular checks as part of your routine HIV care.

A cholesterol test is sometimes called a lipid panel or lipid profile. This is because it measures the fats (lipids) in your blood.

Cholesterol can be measured in two ways. The first way is using blood taken from your vein which is tested in a laboratory. The second way is testing a finger-prick blood sample, which can give you a result straight away. Eating can affect some types of cholesterol tests, so you might be told to fast (not eat or drink) before your test.

Cholesterol test results include different numbers for different types of cholesterol. Cholesterol is usually measured in units called millimoles per litre of blood, which is shortened to mmol/l. Healthy levels are usually thought to be:

• total cholesterol of 5 or under
• HDL (good) cholesterol of 1 or more
• non-HDL (bad) cholesterol of 4 or under
• a total cholesterol to HDL cholesterol ratio (the amount of HDL cholesterol in your blood compared to the amount of total cholesterol) of 5 or under.

LDL cholesterol isn’t usually measured on its own anymore. If your LDL is measured, it should be under 3mmol/l.

A lipid panel will also usually measure your triglyceride levels. Triglycerides are another type of fat (lipid) found in your blood. Having high triglyceride levels can increase your risk of heart disease. Levels of triglycerides in your blood change when you eat. If you were allowed to eat and drink before your blood test, a healthy triglyceride level is below 2.3mmol/l. If you have your triglycerides measured after you’ve fasted they should be below 1.7mmol/l.

Treatment and management

If you have raised lipids (dyslipidaemia) you’ll usually be advised to make some changes to your lifestyle to try and bring it down. If this doesn’t work well enough, you might be prescribed medicine to help lower your cholesterol. The most common medicines used to treat high cholesterol are called statins.

You might also be prescribed a statin even though your cholesterol levels aren’t raised. This is because doctors can also consider information, such as your family history and your blood pressure, to calculate your risk of developing heart problems. If your risk of heart attack, stroke or major heart surgery is more than 10%, it’s recommended that you take a statin.

There is some evidence that the tools used in these calculations can underestimate the risk of heart disease in people living with HIV. This means some doctors might not prescribe statins as early as they could. If you think you might benefit from a statin, discuss this with your doctor.

Statins can interact with HIV medication so it’s important that your doctor knows that you’re taking HIV treatment. Two types of anti-HIV treatment can interact with statins. These are boosted protease inhibitors and NNRTIs. There is more information about each of these below.

Boosted protease inhibitors

Protease inhibitors include darunavir (Prezista, also in Rezolsta and Symtuza), atazanavir (Reyataz, also in Evotaz) and lopinavir (Kaletra). If your HIV treatment includes a protease inhibitor, you are probably also taking a boosting agent such as ritonavir (Norvir) or cobicistat (Tybost). You might take this separately, or in a combination pill.

Boosted protease inhibitors can change the way some statins are broken down by your body. For this reason, you should not be prescribed simvastatin (Zocor, Simvador, also in Inegy) or lovastatin (Mevacor) if you are taking any protease inhibitor as part of your anti-HIV treatment. You should also not be prescribed atorvastatin (Lipitor) if you are taking atazanavir with cobicistat (Evotaz).

If you take atazanavir or darunavir and you’re prescribed atorvastatin, pravastatin, or rosuvastatin, you may be prescribed a lower dose when you first start taking it.  

Non-nucleoside reverse transcriptase inhibitors (NNRTIs)

NNRTIs include efavirenz (Sustiva, also in Atripla), etravirine (Intelence), doravirine (Pifeltro, also in Delstrigo), nevirapine (Viramune), and rilpivirine (Edurant). NNRTIs can also change the way some statins are broken down by your body.

If you’re taking efavirenz and you are prescribed atorvastatin, you may be advised to take a higher dose. If you’re taking efavirenz, etravirine, or nevirapine and you’re prescribed lovastatin or simvastatin, you may also be advised to take a higher dose.

Side effects

Like all medications, statins can cause side effects for some people, but most people taking them don’t experience any side effects. The side effects of statins don’t seem to be different for people living with HIV compared to the general population.

The most common side effects are:

• muscle pain
• joint stiffness
• feeling very tired or weak
• problems with your digestive system such as constipation and diarrhoea
• feeling sick
• headaches
• dizziness
• having trouble sleeping.

Some of these side effects are more common at higher doses. However, this doesn’t mean you will experience more severe side effects if you are prescribed a higher dose of a statin because you are taking an NNRTI. This is because NNRTIs make it harder for statins to be absorbed. The higher dose of statin you’ve been prescribed just makes sure there is enough of it for your body to use.

Other medications

Statins don’t work well for everybody. You may not be able to use statins if you have serious liver disease, or if you are pregnant or breastfeeding.

If you can’t take statins, or they haven’t worked for you, there are some other medications that lower your cholesterol levels.

• Ezetimibe (Ezetrol). This is a tablet that blocks the absorption of cholesterol. It is not as effective as statins, but it has fewer side effects and it can be used if you can’t take a statin. If you take atazanavir as part of your anti-HIV treatment, you might be prescribed a lower dose of ezetimibe.
• PCSK9 inhibitors. These are medications known as monoclonal antibodies that you take as injections. Currently, there are two types: alirocumab (Praluent) and evolocumab (Repatha). They work by helping your liver get rid of LDL cholesterol. They are often used as well as statins and ezetimibe. They don’t interact with any anti-HIV medications.
• Inclisiran (Leqvio). This is a medication that works in a similar way to PCSK9 inhibitors. It is also taken as an injection. No interactions with anti-HIV medications have been reported.
• Bile acid sequestrants (resins). These medications come as a powder and need to be mixed up with a liquid. They can affect how other medications you take are absorbed, so speak to your doctor about how soon or after taking them you can take your anti-HIV treatment.
• Bempedoic acid. This is a tablet which stops cholesterol from being made in your liver. It doesn’t interact with any anti-HIV medications.

There are also medications which are prescribed to lower your triglyceride levels.

• Fibrates. These tablets are usually used to lower triglycerides. However, they can also affect your cholesterol. They don’t interact with any anti-HIV medications.
• Omega 3 fatty acids (icosapent ethyl). This might be prescribed if your cholesterol levels are in the normal range, but your triglyceride levels are high. It doesn’t interact with any anti-HIV medications.

Other useful sources of information

You may find the British Heart Foundation and Heart UK helpful.

• Visit the British Heart Foundation website www.bhf.org or call their helpline (from the UK) on 0300 330 3311.
• Visit Heart UK’s website www.heartuk.org.uk or email ask@heartuk.org.uk

You can check for interactions between your anti-HIV medication and other medications here: www.hiv-druginteractions.org