Background
Statin use will likely increase in persons with HIV (PWH) at low-to-moderate CVD risk given the cardiovascular disease (CVD) prevention benefit demonstrated by the REPRIEVE trial. However, real-world benefit of statins may be lower than expected with insufficient low-density lipoprotein (LDL) reductions. Older studies reported that few PWH on statins experienced timely LDL reductions, but more recent evidence is needed. We examined LDL changes among PWH initiating statins for primary prevention in a clinical cohort at 8 US sites.
Methods
We included PWH without CVD who had a first statin prescription between 2014 and 2022 (baseline). In intention-to-treat analyses ignoring statin therapy changes and discontinuations, we estimated (1) the mean 1-year change (absolute and relative) in LDL from baseline using generalized estimating equations, and (2) the 1-year cumulative incidence of an LDL reduction ≥30% from baseline using Kaplan Meier curves. Secondary analyses were stratified by baseline LDL and statin intensity. Person-time was censored at death, loss to follow-up (12 months with no HIV visit or lab), or data end date, whichever occurred first. We used multiple imputation for PWH missing baseline LDL values (17%).
Results
We included 4334 PWH (80% men, 46% Black, 41% white). At baseline, median age was 54 years (IQR 47, 59), median CD4 count 638 cells/µL (417, 905), median LDL 125 mg/dL (97, 153), 25% had diabetes mellitus, and 92% had a viral load <200 copies/mL. The most commonly prescribed initial statins were atorvastatin (64%), pravastatin (16%), and rosuvastatin (16%). At 6 sites with dosage data (N=2979), 8%, 72%, and 21% initiated low-, medium-, and high-intensity statin therapy, respectively. After 1 year, among all PWH, the mean absolute change in LDL was -33.5 mg/dL (95% CI -35.2, -31.9), or a relative change of -21.8% (95% CI -23.0%, -20.6%), and 35.5% (95% CI 34.0%, 37.0%) of PWH had an LDL reduction ≥30% (Table 1). PWH with higher baseline LDL and those initiating higher-intensity statin therapy had greater LDL reductions and cumulative incidence of LDL reduction ≥30% at 1 year (Table 1).
Conclusions
In this US sample of PWH initiating statins, about one-third overall and 60% of those with high baseline LDL had a 1-year LDL reduction ≥30%. Efforts are needed to elucidate and address drivers of inadequate LDL reductions among PWH, which may include patient non-adherence, lack of statin dose up-titration, and true statin non-response despite adherence.