Statins and lifestyle changes recommended for more people living with HIV by European experts

Keith Alcorn, reporting from HIV Glasgow, 15 November 2024
 
The European AIDS Clinical Society (EACS) has recommended that everyone with HIV with a 5% or higher risk of a heart attack or stroke in the next 10 years should receive statin treatment, Dr Jasmini Alagaratnam of London’s Chelsea and Westminster Hospital told the HIV Drug Therapy Glasgow 2024 conference this week. Statins should also be offered to people with HIV under the age of 50 who have a 2.5% or higher risk of a cardiovascular event within 10 years. The guidance follows the completion of the REPRIEVE study in 2023, which found that treatment with pitavastatin reduced the risk of a major cardiovascular event by 35% in people with HIV who had low-to-moderate cardiovascular risk over five years of follow-up.

The new guidance from EACS recommends that people with high cardiovascular risk (over 10% risk of a cardiovascular event within 10 years) should be offered a high-intensity statin. For those with moderate cardiovascular risk (5-10% risk score), a moderate-intensity statin should be offered. People with HIV who have a 10-year cardiovascular risk below 5% should be encouraged to consider the risks and benefits of statin treatment. For people with HIV under the age of 50, the thresholds are lower. A moderate-intensity statin is recommended for anyone under the age of 50 who has a 10-year cardiovascular risk of at least 2.5%, and a high-intensity statin is recommended for anyone under the age of 50 with a 10-year risk score of at least 7.5%.

The British HIV Association recommends that all people with HIV 40 years or older should be offered a statin for primary prevention of CVD irrespective of lipid profile or estimated CVD risk, and that people with a 10-year CVD risk of 5% or greater should be prioritised.

US federal guidelines recommend that all people with HIV with a 10-year CVD risk between 5% and 20% should receive a moderate-intensity statin and that if the risk is over 20%, a high-intensity statin is recommended. For people with a 10-year CVD risk estimated to be below 5%, physicians should consider HIV-related risk factors that may further increase CVD risk.

In addition to pitavastatin, EACS recommends atorvastatin and rosuvastatin. The guidance points out that there are no problematic drug interactions between them and any non-boosted integrase inhibitor, rilpivirine or either formulation of tenofovir.

In a session reviewing the management of cardiometabolic risk in people with HIV, Dr Esteban Martínez of the Hospital Clinic, Barcelona, noted that cardiovascular risk is 1.5 – 2 times higher risk in people living with HIV than the general population at all ages and that the relative risk is higher in younger people, despite lower cardiometabolic scores in general scoring tools. These scores under-predict risk, especially in women with HIV, because they do not incorporate HIV-related risk factors. Although women with HIV had lower baseline cardiovascular risk scores in the REPRIEVE study (1.9% vs 5.4% in men), female sex was not protective against major cardiovascular events after controlling for other risk factors in study participants. People with HIV who smoke have a higher risk of cardiovascular disease than non-smokers but the D:A:D study in people with HIV found that within three years of stopping, ex-smokers had experienced a substantial reduction in their risk, Dr Martinez pointed out. All physicians should talk to patients about their willingness to quit. “If the person who smokes has already considered stopping, this is a good starting point,” he said. Support in the forms of medication and cognitive behavioural therapy can improve the chances of quitting and should be offered, the EACS guidelines note.

Optimising cholesterol levels, blood pressure and glucose control through lifestyle changes and medication are also important interventions, especially for people at the highest risk of cardiovascular disease. But for physicians and people with HIV, one of the biggest challenges in managing cardiovascular risk is maintaining a healthy weight. “The first part of my career was dealing with the loss of weight due to AIDS,” said Professor Cristina Mussini of the University of Modena, Italy. Weight gain in people with HIV is positive when it is a return to health or during pregnancy, she told the conference. However, increases in weight on antiretroviral treatment can exceed 10% of body weight in a minority of people. Weight gain of this magnitude affects glucose control, greatly increasing the risk of developing type 2 diabetes. It also increases blood pressure and promotes inflammation, both contributors to heart attack and stroke risks.

Until recently, weight management required diet and exercise, but the increasing availability of GLP-1 agonists such as semaglutide has transformed the prospects for weight loss. Developed for diabetes control, GLP-1 agonists have shown numerous beneficial metabolic effects, including substantial weight loss and reductions in cardiovascular events and chronic kidney disease, Professor Christian Delles of Glasgow University explained. Most of these benefits appear to be driven by weight reduction. In people with HIV, there are limited large-scale data on the safety and efficacy of GLP-1 agonists, but early studies show benefits. Most recently, a randomised study in people with HIV with lipohypertrophy (visceral fat accumulation) found that once-weekly treatment with semaglutide significantly reduced central fat and overall body fat. But GLP-1 agonists alone cannot permanently reverse weight gain. “For those who think they can take these drugs without doing other important things, the drugs don’t work,” said Professor Delles. GLP-1 agonist treatment must be accompanied by changes in diet and exercise to achieve its maximum effect. “Unless you make these dramatic changes to your lifestyle”, the weight comes back when treatment stops, he said.

References
J Alagaratnam. Co-morbidities: update on cardiovascular and metabolic risk, including statins recommendations and other co-morbidities. HIV Glasgow 2024.
Congress delegates can view the presentation here.
E Martínez. Managing cardiovascular disease risk in HIV. HIV Glasgow 2024.
C Delles. GLP-1 agonists to mitigate cardiometabolic risk. HIV Glasgow 2024.
C Mussini. Managing ART-associated weight gain in HIV. HIV Glasgow 2024.
Congress delegates can view these presentations here.
 
Reporting from HIV Glasgow 2024 by Keith Alcorn, Gus Cairns and Roger Pebody has been financially supported by the Congress. The writers are editorially independent of the Congress and the presenting speakers.

Photo credit: Alan Donaldson Photography