Imagine a world where a simple pill could significantly reduce the risk of heart attacks and strokes for people living with HIV. That's the promise of statins, but shockingly, many who could benefit aren't getting them. Studies presented at the 20th European AIDS Conference (EACS 2025) in Paris reveal a concerning gap between medical guidelines and real-world practice: despite evolving recommendations, statin use remains inadequate, leaving many individuals with HIV vulnerable to cardiovascular disease.
Let's break down why this is such a big deal. People living with HIV often face a higher risk of cardiovascular issues compared to the general population. This is due to a complex interplay of factors, including inflammation caused by the virus itself and potential side effects from certain antiretroviral medications. To combat this, medical organizations like the European Society of Cardiology (ESC) have issued guidelines recommending statins, drugs designed to lower cholesterol levels in the blood.
Initially, in 2011, the ESC recommended statins for people with HIV who already had elevated cholesterol. But here's where it gets controversial... Earlier this year, spurred by the groundbreaking REPRIEVE study, the ESC broadened its recommendation to include all people with HIV aged 40 and over, regardless of their existing cardiovascular risk or LDL ('bad') cholesterol levels. The REPRIEVE study, an international randomized trial, demonstrated a remarkable 36% reduction in major cardiovascular events among people with HIV taking statins, even those considered to be at low-to-intermediate risk. This was a game-changer, suggesting that statins could be a powerful preventative measure for a much wider population.
Following the REPRIEVE study, HIV-specific guidelines have emphasized prioritizing statin treatment for individuals with a cardiovascular risk score of 5% or higher. But is this enough? Professor Franck Boccara, from Hôpital Saint-Antoine in Paris, speaking at the EACS conference, raised an important point: in people with HIV who have a low cardiovascular risk (below 5%), the potential side effects of statins, such as diabetes and muscle pain, might outweigh the benefits. This highlights the importance of careful consideration and personalized treatment plans.
To understand the impact of these guidelines, researchers in Italy conducted several studies. One study, from the San Raffaele Scientific Institute in Milan, compared statin prescriptions before and after the updated guidelines. They found a significant increase in statin prescriptions after the guidelines were implemented, with the incidence rate more than doubling. Specifically, over a follow up period, the probability of receiving a statin prescription was significantly higher in the period after the guideline changes (17.6% vs 7.4%). And this is the part most people miss... This difference was significant in those with low-to-intermediate cardiovascular risk, but not in those with high cardiovascular risk, suggesting that individuals at the highest risk still weren’t getting statins at a significantly higher rate.
Another study, from Milan’s Luigi Sacco Hospital, looked at whether LDL cholesterol control improved after the EACS guidelines were updated in 2024. The study showed an increase in both statin use (44% to 54%) and the use of combination lipid-lowering treatments (9.6% to 18.2%). However, despite these increases, LDL cholesterol control remained suboptimal. The median LDL cholesterol level only decreased slightly, and achieving second-step goals for those at the highest cardiovascular risk didn't improve. This suggests that simply prescribing more statins isn't enough; more aggressive and targeted interventions may be needed.
Dr. Georgia Carrozzo from the Luigi Sacco Hospital pointed out a critical challenge: ensuring that general practitioners continue statin prescriptions initiated by HIV clinics. She noted that GPs often underestimate the cardiovascular risk in people with HIV and discontinue the prescriptions, which undermines the efforts of specialized HIV care providers.
A third study, a longitudinal cohort study from the University of Modena, examined the impact of lipid-lowering treatment on LDL cholesterol levels. The study found that only 17% of participants achieved the lipid-lowering target. Achieving the target was associated with having diabetes or being prescribed two lipid-lowering treatments. Interestingly, individuals with high or very high cardiovascular risk scores were less likely to achieve the target, reinforcing the need for earlier and more comprehensive use of combination lipid-lowering therapies. The researchers concluded that "beyond-statin approaches should be considered essential for optimal cardiovascular prevention in people with HIV."
So, what does all this mean? While the updated guidelines are a step in the right direction, real-world implementation is lagging. Statin use is increasing, but LDL cholesterol control remains suboptimal, particularly for those at highest risk. Several factors contribute to this gap, including physician inertia, a potential underestimation of cardiovascular risk by general practitioners, and the need for more aggressive lipid-lowering strategies beyond statins alone.
But Boccara defended the use of LDL targets. “We need targets to increase the adherence of patients and to overcome the inertia of physicians,” he said. This sparks a debate: are strict LDL targets necessary to drive action, or are they unrealistic and potentially harmful?
Ultimately, improving cardiovascular health in people with HIV requires a multi-faceted approach. This includes raising awareness among both patients and healthcare providers, ensuring consistent statin prescriptions, and considering combination lipid-lowering therapies for those who don't achieve adequate LDL control with statins alone. Furthermore, addressing modifiable risk factors like smoking, diet, and exercise is crucial.
What are your thoughts on this? Should statin guidelines for people with HIV be even more aggressive? Are LDL targets helpful or harmful? Share your perspective in the comments below! Let's discuss how we can bridge the gap between guidelines and practice to protect the cardiovascular health of this vulnerable population.
