Underutilization of Statins When Indicated in HIV-Seropositive and Seronegative Women

Abstract

Increased life expectancy of persons living with HIV infection receiving antiretroviral therapy heightens the importance of preventing and treating chronic comorbidities such as cardiovascular disease. While guidelines have increasingly advocated more aggressive use of statins for low-density lipoprotein (LDL) cholesterol reduction, it is unclear whether people with HIV, especially women, are receiving statins when indicated, and whether their HIV disease is a factor in access. We assessed the cumulative incidence of statin use after an indication in the Women's Interagency HIV Study (WIHS), from 2000 to 2014. Additionally, we used weighted proportional hazards regression to estimate the effect of HIV serostatus on the time to initiation of a statin after an indication. Cumulative incidence of statin use 5 years after an indication was low: 38% in HIV-seropositive women and 30% in HIV-seronegative women. Compared to HIV-seronegative women, the weighted hazard ratio for initiation of a statin for HIV-seropositive women over 5 years was 0.94 [95% confidence interval (CI) 0.62, 1.43]. Applying the American College of Cardiology and the American Heart Association (ACC/AHA) guidelines increased the proportion of HIV-seropositive women with a statin indication from 16% to 45%. Clinicians treating HIV-seropositive women should consider more aggressive management of the dyslipidemia often found in this population.

Evaluation of Statin Eligibility, Prescribing Practices, and Therapeutic Responses Using ATP III, ACC/AHA, and NLA Dyslipidemia Treatment Guidelines in a Large Urban Cohort of HIV-Infected Outpatients

“…8,[14][15][16][17][18][19][20][21][22][23] Studies have consistently found that compliance with the statin prescribing recommendations described in the ACC/AHA guidelines would result in greater proportions of patients being prescribed statin therapy than based on the ATP III guidelines. [17][18][19]21,23 However, in a nationally representative sample of adult patients at physician offices and hospital outpatient clinics between 2006 and 2013, only 24% of visits for HIV-infected patients with an indication for statin therapy, based on ATP III or ACC/AHA guidelines, resulted in statin prescriptions, compared with 36% of visits for HIV-uninfected patients; a similar gap in prescriptions between HIV-infected and HIV-uninfected patients was found for aspirin/antiplatelet agents. 24 Physicians in the US generally underused guidelinerecommended prescribing practices for CVD prevention medications, especially with HIV-infected patients.…”

HIV-associated cardiovascular disease: importance of platelet activation and cardiac fibrosis in the setting of specific antiretroviral therapies

“…When indicated, physicians were much less likely to prescribe aspirin or other antiplatelet agents, or hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins) to HIV-infected individuals (5.1% vs 13.8%, p=0.03 and 23.6% vs 35.8%, p<0.01, respectively) 19. Findings on the underutilisation of statins were replicated among 3453 HIV-infected women in the Women’s Interagency HIV Study20 and among a diverse population of 3312 HIV+ individuals in the dialated cardiomyopathy (DC) cohort 21. It was speculated that most HIV patient visits focus on control of HIV viraemia to the detriment of preventive CV care19 but, as highlighted here, the two areas are intimately linked.…”

Impact of the American College of Cardiology/American Heart Association Cholesterol Guidelines on Statin Eligibility Among Human Immunodeficiency Virus-Infected Individuals

“…Application of the ACC/AHA cholesterol guidelines to HIV populations remains limited. When applied to women infected with HIV, who make up a small proportion of the HIV-infected population in the United States, these guidelines may recommend statins to fewer HIV-infected women [13]. However, whether a similarly increased number of all patients infected with HIV would be recommended for statin therapy under the new guidelines has not been explored relative to a control population of all patients infected with HIV.…”