February 27, 2024: The Department of Health and Human Services Guidelines Panel for the Use of Antiretroviral Agents in Adults and Adolescents with HIV (the Panel) has developed recommendations for the use of statin therapy in people with HIV, in collaboration with representatives from the American College of Cardiology (ACC), the American Heart Association (AHA), and the HIV Medicine Association.

With continuous antiretroviral therapy (ART) and viral suppression, most people with HIV achieve a life expectancy close to that of people without HIV. However, there remains a mortality gap primarily due to cardiovascular disease and cancer. REPRIEVE, a large randomized controlled trial among people with HIV aged 40 to 75 years who were receiving ART and had low-to-intermediate risk of atherosclerotic cardiovascular disease (ASCVD), showed that when compared to placebo, pitavastatin 4 mg daily was associated with a 35% reduction in major adverse cardiovascular events over a median follow-up duration of 5 years.

The recommendations below are endorsed by the organizations listed above.

For people with HIV who have low-to-intermediate (<20%) 10-year ASCVD risk estimates:

• Age 40–75 years
• When 10-year ASCVD risk estimates are 5 to <20%, the Panel recommends initiating at least moderate intensity statin therapy (AI).
• Recommended options for moderate intensity statin therapy include:
• Pitavastatin 4mg once daily (AI)
• Atorvastatin 20mg once daily (AII)
• Rosuvastatin 10mg once daily (AII)
• When 10-year ASCVD risk estimates are <5%, the Panel favors initiating at least moderate intensity statin therapy (CI). The absolute benefit from statin therapy is modest in this population; therefore, the decision to initiate a statin should take into account the presence or absence of HIV-related factors that can increase ASCVD risk.  
• Same options for moderate intensity statin therapy as recommended for 10-year ASCVD risk estimates of 5 to <20% (see above)
• Age <40 years
• Data are insufficient to recommend for or against statin therapy as primary prevention of ASCVD in people with HIV. In the general population, lifestyle modifications are recommended for people age <40 years, with statin therapy considered only in select populations (see AHA/ACC/Multisociety Guidelines).

The AHA/ACC/Multisociety Guidelines provide the following key recommendations for the general population; these recommendations should also be applied to people with HIV:

For people aged 40–75 years who have high (≥20%) 10-year ASCVD risk estimates:

• Initiate high intensity statin therapy.

For people aged 20–75 years who have low density lipoprotein-cholesterol ≥190 mg/dL:

• Initiate high intensity statin therapy at maximum tolerated dose.

For people aged 40–75 years with Diabetes Mellitus: 

• Initiate at least moderate intensity statin therapy. Perform further risk assessment to consider using a high intensity statin.

Discussions of the study results from REPRIEVE, the rationale that led to the Panel’s recommendations, the choice of which statin and what dose to use, and the potential for drug-drug interactions between statins and certain antiretroviral drugs can be found in Recommendations for the Use of Statin Therapy as Primary Prevention of Atherosclerotic Cardiovascular Disease in People with HIV.

Acknowledgment: This document has been endorsed by the American College of Cardiology, the American Heart Association, and the HIV Medicine Association.

For a list of recent updates, please see What’s New in the Guidelines. To view or download the Guidelines, go to the Adult and Adolescent Antiretroviral Guidelines section of Clinical Info’s website. The guidelines tables and recommendations also can be downloaded as separate PDF files.