A randomized trial demonstrates that even those PWH at low-to-moderate risk for cardiovascular disease benefit from starting pitavastatin.

People with HIV (PWH) are at higher risk for cardiovascular disease (CVD) than those without HIV; moreover, the ASCVD risk score used to decide when to start a statin may underestimate the likelihood of CVD events in PWH. To assess whether statins should be used for primary prevention in PWH with risk scores below those recommended for the general population, investigators conducted the REPRIEVE trial in 7700 PWH aged 40–75 who were receiving antiretroviral therapy and had low-to-moderate CVD risk. All enrolled patients had 10-year ASCVD risk scores <15% (mean, 4.5%), and nearly all had LDL <160 mg/dL (median 108 mg/dL).

Patients were randomized to receive pitavastatin (chosen because it does not interact with antiretrovirals commonly used in the past, such as protease inhibitors) or placebo. The study was stopped early after a median 5.1 years’ follow-up because the statin group had a 35% lower rate of major cardiovascular events (e.g., myocardial infarction, stroke) than the placebo group (4.81 vs. 7.32/1000 person-years). Incidence of diabetes was slightly higher in the statin group (1.13/100 person-years) than the placebo group (0.84/100 person-years) but both rates were similar to that in the general population (1.01/100 person-years) for people of comparable age.

Comment

This landmark trial has changed my practice: I now recommend starting a statin to my patients with HIV who are at low-to-moderate risk for CVD. The authors estimate that 106 is the number needed to treat to prevent one major CVD event, which compares favorably with other primary prevention interventions (e.g., treating hypertension). The number needed to treat is even lower in those who have an ASCVD of ≥5% — so even though I am broadly advising use of statins, I am especially strong in my recommendation in those patients in this moderate-risk group. Pitavastatin was used in REPRIEVE, but if that agent is not available, I think it’s reasonable to recommend a different statin with attention to potential drug interactions if the patient is receiving a protease inhibitor.