Living with HIV means battling more than just the virus—heart disease lurks as a silent but deadly threat. Yet, shockingly few people are getting the statins they need to fight it, despite major guideline shifts revealed at the 20th European AIDS Conference (EACS 2025) in Paris. Dive in to uncover why this gap persists and what it means for millions.
Advancements in prescribing statins to those with HIV have been sluggish, and managing low-density lipoprotein (LDL) cholesterol—often dubbed the 'bad' cholesterol that can clog arteries and lead to heart attacks or strokes—remains inadequate among HIV-positive individuals facing elevated cardiovascular risks. This is according to research shared at the conference (available at https://eacs-conference.com/).
Back in 2011, the European Society of Cardiology (ESC) advised statins for HIV patients with high cholesterol levels. Fast-forward to earlier this year, and the ESC broadened their recommendation: statins now for everyone with HIV aged 40 and older, no matter their cardiovascular risk or LDL levels. This change stemmed from the groundbreaking REPRIEVE study, a large-scale international trial that demonstrated statin use cut the chance of serious heart-related events by 36% in HIV patients with moderate risk profiles. For newcomers to this topic, statins are medications that lower cholesterol production in the liver, helping prevent plaque buildup in blood vessels—think of them as a shield against heart issues, especially vital for those whose immune systems are already compromised by HIV.
Following REPRIEVE, HIV-tailored guidelines have emphasized prioritizing statin therapy for those with a 5% or higher cardiovascular risk (calculated using factors like age, smoking, blood pressure, and cholesterol). During a session at EACS 2025 examining the rollout of the European AIDS Clinical Society (EACS) statin advice, Professor Franck Boccara from Hôpital Saint-Antoine in Paris noted that for HIV patients with lower risk (under 5%), potential downsides—like new-onset diabetes or muscle aches—might eclipse the benefits. But here's where it gets controversial: are we risking harm by overprescribing to low-risk groups?
Guidelines also clash on LDL targets. The British HIV Association skips setting specific reduction goals post-statin start, while EACS and ESC push for a bold 50% LDL drop in higher-risk HIV patients (over 5%). Dr. Giovanni Guaraldi from the University of Modena highlighted how these lofty goals are tough to hit in real-world clinics, often demanding a mix of cholesterol-lowering drugs. Yet, Boccara championed these targets, stating, 'We require goals to boost patient compliance and shake up doctor hesitation.' And this is the part most people miss: could strict targets actually save lives, or do they set unrealistic expectations that frustrate both patients and providers?
What has been the real-world effect of these updates?
Three studies from Italy examined how well cardiovascular prevention strategies are being applied to HIV patients.
One, conducted at Milan's San Raffaele Scientific Institute—one of Italy's top HIV centers—compared statin prescribing under current guidelines for HIV patients over 40 who hadn't used statins before. They looked at two periods: November 2015 to 2017 versus May 2023 to February 2025.
Researchers matched participants by factors like age, gender, diabetes status, smoking habits, body mass index, lipid profiles, and blood pressure. Each period included 880 people, with an average age of 51, 18% women, 94% with undetectable viral loads (under 50 copies/ml), and a median CD4 count of 733 cells/mm³—a key immune cell measure.
The group's average atherosclerotic cardiovascular disease (ASCVD) risk score was 4.9, with 3.5% diabetic, 24% hypertensive, and 41% smokers.
In the earlier timeframe, over 1,445 person-years of observation, 65 statin prescriptions were issued (rate: 4.50 per 100 person-years). In the later period, across 1,217 person-years, 143 were prescribed (rate: 11.75 per 100 person-years), with the rate jumping 2.61 times higher (95% confidence interval: 1.9-3.5, p<0.001).
After 20 months, the chances of getting a statin rose to 17.6% from 7.4%. Breaking it down by risk level, this uptick held for low-to-moderate risk folks (16.9% vs. 6.8%), but not for high-risk ones (29.3% vs. 19.6%). For context, ASCVD risk scores predict 10-year heart disease chances, helping doctors decide on preventive steps like statins.
Another study from Milan's Luigi Sacco Hospital assessed LDL control improvements in HIV patients over 40 after EACS guidelines updated in 2024, now suggesting statins for all over 40 at low or medium risk, plus intense cholesterol management for those at high (5-10%) or very high risk (over 10%), factoring in other factors like high blood pressure.
This retrospective analysis compared goal attainment from April 2023 to April 2024 (1,379 participants) against April 2024 to April 2025 (1,198 participants).
The group was mostly male (75%) and White (85%), average age 56 at start. About three-quarters used integrase inhibitor-based HIV meds, often two-drug combos (45% in the later period).
Statin use climbed significantly post-update (44% to 54%, p<0.001), as did combined cholesterol therapies (9.6% to 18.2%, p<0.001).
Still, LDL management fell short. Median LDL hovered at 115 mg/dl (2.97 mmol/l) before and 110 mg/dl (2.84 mmol/l) after. While there's progress toward initial goals—like LDL under 2.6 mmol/l and blood pressure under 140 (or 130 for some)—advanced targets for top-risk patients didn't budge. Dr. Georgia Carrozzo from Luigi Sacco noted a hurdle: primary care doctors sometimes discontinue HIV clinic-prescribed statins. 'They often downplay HIV patients' risks,' she explained, leading to lapses that could undo progress.
A third study, a longitudinal one from the University of Modena's metabolic clinic, tracked cholesterol treatments' effects on LDL in HIV patients before and after EACS updates. It covered 1,318 HIV patients with clinic visits and lipid tests from 2022-2023 and follow-ups in 2024-2025.
Just 17% met cholesterol targets. In deeper analysis, success linked to diabetes diagnosis (odds ratio 2.82) or dual cholesterol meds (odds ratio 5.15). Higher-risk patients struggled more, underscoring the need for early combo therapies. 'Non-statin options are crucial for top-notch heart protection in HIV populations,' the team concluded.
Boldly put, these findings spark debate: Should we push statins universally for HIV patients over 40, even at the cost of potential side effects, or tailor them more carefully? And what about those ambitious LDL targets—are they empowering or overwhelming? Share your views in the comments: Do you agree with prioritizing heart health in HIV care, or is it too aggressive? Could this lead to better outcomes, or unintended harms? We'd love to hear your thoughts!
By Keith Alcorn
References
Borjesson RP et al. Impact of REPRIEVE indications on statin prescription in people with HIV in a real-life setting. (https://eacs2025.abstractserver.com/program/#/details/presentations/1001) 20th European AIDS Conference, Paris, abstract MTE1.1, 2025.
Manicardi M et al. Implementation of EACS 2023 cardiovascular prevention guidance in a real-life HIV metabolic clinic: a longitudinal cohort study from Modena. (https://eacs2025.abstractserver.com/program/#/details/presentations/389) 20th European AIDS Conference, Paris, abstract RO3.3, 2025.
Carrozzo G et al. LDL target achievement in people with HIV over 40: impact of updated EACS guidelines. (https://eacs2025.abstractserver.com/program/#/details/presentations/646) 20th European AIDS Conference, Paris, abstract RO3.4, 2025.
All official news reporting from EACS 2025 (https://eacs-conference.com/media-registration/news-reporting/)
