Addressing ASCVD Risk in HIV: An Update to the DHHS HIV Guidelines

Addressing ASCVD Risk in HIV: An Update to the DHHS HIV Guidelines Posted By:
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The incidence of atherosclerotic cardiovascular disease (ASCVD) is estimated to be twice as high in persons living with HIV compared with those without HIV. However, guidelines for primary ASCVD risk reduction are based mostly on data in persons without HIV. If guidelines don’t reflect our patients, how should we address cardiovascular risk in persons living with HIV?

The American College of Cardiology (ACC)/American Heart Association (AHA) pooled risk estimator provides a 10-year estimate for developing cardiac disease. Factors such as age, gender, blood pressure, total cholesterol, HDL, LDL, tobacco use, and presence of diabetes are included in the calculation, but the presence of HIV is not. So, although this risk estimator should help healthcare professionals determine when to prescribe statin therapy to lower a patient’s risk of ASCVD, until recently there were no definitive recommendations on how to adapt the ACC/AHA guidelines to persons living with HIV.

This all changed in February 2024, when the US Department of Health and Human Services (DHHS) updated the HIV antiretroviral treatment guidelines to reflect findings from the large, international, randomized, placebo-controlled REPRIEVE trial. This study enrolled 7769 persons living with HIV 40-75 years of age with low to intermediate ASCVD risk. The intervention group received 4 mg of pitavastatin (a moderate-intensity statin) daily, and the control group received placebo. After a median of 5.1 years of follow-up, the study was stopped early because it was found that there was a 35% hazard reduction of major cardiac events in the intervention group. This statistically significant reduction provided evidence for early initiation of statins for primary prevention of ASCVD in persons living with HIV.

The updated DHHS guidelines now state that all persons living with HIV 40-75 years of age with an ASCVD risk score between 5% and 20% should receive a moderate-intensity statin (either pitavastatin 4 mg, atorvastatin 20 mg, or rosuvastatin 10 mg). If the ASCVD risk score is >20%, treatment with a high-intensity statin should be started.

For persons with a risk score <5%, although members of the DHHS guidelines panel favor initiating moderate-intensity statins for this group, data from REPRIEVE suggest that the overall benefit in persons with a risk score <5% is modest. Therefore, the DHHS guidelines state that other factors affecting ASCVD should be considered to determine the benefit of starting statin therapy in persons with a risk score <5%.

There currently are insufficient data for persons living with HIV who are younger than 40 years of age. For persons living with HIV who meet existing ACC/AHA criteria (eg, those with diabetes or LDL ≥190 mg/dL), the standard ACC/AHA guidelines for the general population should be followed.

Although pharmacologic therapy has a significant effect on ASCVD, it is important to remember the benefits of nonpharmacologic interventions, such as tobacco cessation, diet, and exercise. The shift toward prevention of ASCVD is significant given that the population of persons living with HIV is aging and at higher risk of developing multiple comorbidities.

NPs and PAs are in an ideal position to manage chronic diseases in persons living with HIV. For further information on the updated treatment guidelines, please consult the “Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV” at clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/whats-new, as well as the CDC’s HIV Nexus website (cdc.gov/hiv/clinicians/index.html) for additional resources on HIV care and treatment.


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Filed under: Infectious Diseases , Preventive Medicine , Public Health , Cardiometabolic , NPs & PAs

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