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REPRIEVE Mexico
Statins in HIV? Applying the Results of the REPRIEVE Trial to My Patients Living With HIV in Mexico

Released: August 17, 2023

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Key Takeaways
  • In the REPRIEVE trial of persons living with HIV with no to moderate cardiovascular risk, pitavastatin appeared to reduce the risk of major cardiovascular events.

As recently as 2021, the second-leading cause of death in Mexico (after COVID-19) was cardiovascular disease. As such, I was very interested in the results of the REPRIEVE trial, which were reported at IAS 2023. REPRIEVE examined the effect of statins for cardiovascular disease prevention in people living with HIV.

REPRIEVE
The REPRIEVE trial, an AIDS Clinical Trials Group study that is the largest randomized HIV trial to date, recruited more than 7500 people living with HIV who were 40-75 years of age and receiving stable antiretroviral therapy. What is interesting is that participants had either no or only moderate cardiovascular risk.

The trial was stopped early because there was a 35% reduction in major cardiovascular events in a median of 5.1 years of follow-up for these patients, for whom we would not typically prescribe a statin. The results of this trial were presented IAS 2023 and published the same day in The New England Journal of Medicine. It is presumed that this study may be a game changer for HIV healthcare professionals, but for me, some questions about applying the data remain.

Based on this trial, it would appear that the benefit of pitavastatin in preventing cardiovascular events is unquestionable, with very few persons needed to treat to avoid 1 event in the overall cohort, although the overall cohort was at lower cardiovascular risk. The number compares favorably with traditional strategies for cardiovascular event prevention, such as prescribing aspirin for people with hypertension. The authors showed that the benefit was greater than merely lowering low-density lipoprotein cholesterol, which suggests that pitavastatin may decrease inflammation, resulting in this important cardiovascular benefit.

Should All Persons Living With HIV Receive a Statin?
Nevertheless, pitavastatin is an expensive statin, so the question remains for low- and middle-income countries in regions such as Latin America: Can we extrapolate this same benefit with other less-expensive statins, such as atorvastatin? The authors ask the same question.

In addition, if the guidelines were to change and recommend prescribing statins to persons living with HIV with low to moderate cardiovascular risk, would those of us in regions with high prevalence and propensity to diabetes need to be concerned? The authors noted that the frequency of diabetes was similar in both the pitavastatin and placebo groups and that this frequency was similar to that of the population of the United States for persons 45-64 years of age.

The rate of diabetes in adults 20-79 years of age is nearly 60% higher in Mexico than in the United States. Should I be concerned about prescribing statins to my patient population, particularly a statin that may increase blood glucose (such as atorvastatin or rosuvastatin)? That is a question with which I will grapple.

Including Transgender People in HIV Trials
Finally, it is very important to highlight that these results include sex at birth and current gender identity, which normally are not reported in HIV clinical trials. The results indicate that the benefit of pitavastatin was similar in those who were male and female at birth but that the results in those who were female at birth did not reach statistical significance.

Although the percentage of transgender persons included was small (1.6%), including transgender people and their statistics in the baseline demographics allows us to have more information about this group, which usually is underrepresented in research. Therefore, reporting gender identity is something for which we should advocate in upcoming HIV clinical trials.

Your Thoughts?
What did you think about the results of the REPRIEVE trial? Are you ready to prescribe a statin for your patients living with HIV? Join the conversation by leaving a comment.