Primary Cardiovascular Prevention in People Living With HIV: Rethinking Statin Therapy in the Post-REPRIEVE Era

Abstract

This review examines approaches to primary cardiovascular prevention in people with HIV (PWH), focusing on the implications of the REPRIEVE trial and the 2026 ACC/AHA multisociety dyslipidemia guideline. We discuss cardiovascular risk mechanisms, limitations of conventional prediction tools, selection and monitoring of statin therapy, and the potential roles of imaging and non-statin lipid-lowering agents. REPRIEVE demonstrated that pitavastatin reduced major adverse cardiovascular events in PWH aged 40–75 years receiving antiretroviral therapy and at low-to-moderate estimated cardiovascular risk. Absolute benefit varied substantially according to baseline risk. Current US guidance recommends statin therapy for primary prevention in PWH aged 40–75 years receiving stable combination antiretroviral therapy, while quantitative risk assessment remains important for communicating expected benefit and informing treatment intensity. REPRIEVE did not directly study PWH younger than 40 years or older than 75 years; however, cohort data suggest a higher HIV-attributable relative cardiovascular risk at younger ages despite low absolute event rates, whereas general-population evidence supports statin efficacy and acceptable tolerability in older adults. Conventional risk models show variable performance in PWH, and high-quality evidence supporting imaging-guided prevention or non-statin cardiovascular outcome reduction specifically in this population remains limited. Statin therapy is an evidence-based component of primary cardiovascular prevention in PWH aged 40–75 years, but guideline-level eligibility does not imply uniform absolute benefit. Outside the REPRIEVE age range, decisions should integrate the distinct balance of relative and absolute risk, general-population evidence, comorbidity, frailty, drug–drug interactions, treatment burden, and individual preferences rather than rely on age alone.