A U.S. Department of Health and Human Services (HHS) panel has issued updated clinical guidelines, published online May 27 in the Annals of Internal Medicine, recommending broader use of statins for people with HIV (PWH) to prevent atherosclerotic cardiovascular disease (ASCVD). These guidelines, developed by a 10-member writing group led by Craig Beavers, Pharm.D., from the University of Kentucky College of Pharmacy, lean heavily on findings from the landmark Randomized Trial to Prevent Vascular Events in HIV (REPRIEVE).
The HHS Panel for the Use of Antiretroviral Agents in Adults and Adolescents with HIV (ARV Guidelines Panel) now strongly recommends initiating at least moderate-intensity statin therapy for PWH aged 40 to 75 years with a 10-year ASCVD risk score of 5 percent or higher. Notably, the panel also favors statin therapy for those in the same age group with an ASCVD risk score below 5 percent, urging patient-clinician discussions that consider additional HIV-related risk factors known to elevate ASCVD risk. These factors can include the duration of HIV infection, a history of low CD4 T lymphocyte cell counts (e.g., <350 cells/mm³), prolonged periods of detectable HIV viremia, and exposure to older antiretroviral regimens with more cardiometabolic side effects. For PWH aged 40-75 with a high 10-year ASCVD risk (≥20%) or those aged 20-75 with very high LDL cholesterol (≥190 mg/dL), high-intensity statin therapy is recommended.
The REPRIEVE trial, a large, global study, demonstrated that daily pitavastatin (a moderate-intensity statin) significantly reduced the risk of major adverse cardiovascular events by 35 percent in PWH aged 40 to 75 with low-to-moderate traditional ASCVD risk who were on antiretroviral therapy. Crucially, the trial included a diverse population, with approximately 43-45 percent of participants identifying as Black or African American, making its findings particularly relevant for this group.
“There remain important clinical questions in the management of CVD risk among PWH, including further improvements in risk stratification, as well as additional ASCVD prevention strategies focused on reducing residual risk associated with inflammation,” the authors of the guideline summary acknowledged. Several authors of the summary disclosed ties to the pharmaceutical industry.
Impact on Black American Patients with HIV
These new guidelines carry profound implications for Black Americans living with HIV, a population disproportionately affected by both HIV and cardiovascular disease. Data indicates that Black PWH experience higher rates of CVD-related hospitalizations compared to their white counterparts. The reasons for this disparity are multifaceted, stemming from a confluence of traditional risk factors, HIV-specific factors, and significant social determinants of health.
Elevated Underlying Risk: Black Americans, in general, have a higher prevalence of traditional ASCVD risk factors such as hypertension, diabetes, and obesity. When compounded with HIV-specific risk factors—chronic inflammation, immune dysregulation, and potential long-term effects of some antiretroviral therapies—the risk for cardiovascular events in Black PWH can be substantially amplified. The HHS guidelines acknowledge that standard ASCVD risk calculators may underestimate risk in PWH, emphasizing HIV itself as a risk-enhancing factor.
Statin Access and Utilization Disparities: Despite the clear need, studies have consistently shown that Black PWH are less likely to be prescribed statins than their white counterparts, even when clinically indicated. These updated, stronger recommendations may help to address this underprescription. However, access to consistent, quality healthcare remains a critical barrier. Social determinants such as socioeconomic status, health insurance coverage, housing stability, and transportation can significantly impact an individual’s ability to engage in regular HIV care, receive appropriate screenings, and afford medications, including statins.
Patient-Clinician Communication and Trust: The guidelines emphasize shared decision-making, especially for patients with lower calculated ASCVD risk. For Black PWH, who may experience medical mistrust due to historical and ongoing systemic inequities, culturally competent communication and trust-building between patients and providers will be paramount. Providers will need to be proactive in discussing these guidelines and the individual benefits for their Black patients.
For Black Americans living with HIV, these guidelines underscore the urgent need for equitable access to preventive care, diligent risk assessment that accounts for HIV-specific factors, and a healthcare system that actively works to dismantle the barriers hindering optimal health outcomes.