A 45-year-old man presents for primary-prevention cardiovascular (CV) risk assessment. He has a history of HIV with CD4 counts of 200 cells/mm3 and is adherent to antiretroviral therapy. He exercises regularly and eats a Mediterranean-based diet. His blood pressure is within normal limits and he has no family history of CV disease.
His laboratory study results include total cholesterol level 125 mg/dL, LDL-C level 82 mg/dL, HDL-C level 50 mg/dL, triglyceride level 45 mg/dL, non–HDL-C level 80 mg/dL, and Lp(a) level 25 nmol/dL.
His calculated 10-year PREVENT-ASCVD (Predicting Risk of Cardiovascular Disease EVENTs–Atherosclerotic Cardiovascular Disease [AHA]) risk is 0.7%. He is willing to implement any strategy that is recommended to prevent future CV events and wants to discuss his options.
The correct answer is: B. Initiate pitavastatin 4 mg QD after a shared decision-making discussion to reduce his risk of a first ASCVD event, regardless of his baseline LDL-C level.
In the REPRIEVE (Randomized Trial to Prevent Vascular Events in HIV) trial, people living with HIV who were taking stable antiretroviral therapy were randomly assigned to pitavastatin calcium 4 mg QD or placebo. The study was stopped early after a median follow-up of 5.1 years because pitavastatin significantly reduced the risk of major adverse CV events, resulting in a 35% relative risk reduction compared with placebo. These findings demonstrated that statin therapy provides CV benefit in people living with HIV, even when traditional risk estimates and LDL-C levels may not suggest a high level of risk.
On the basis of this evidence, the 2026 ACC/AHA/Multisociety Guideline on the Management of Dyslipidemia provides a Class 1 recommendation for statin therapy in adults living with HIV who are 40-75 years of age to reduce the risk of a first ASCVD event and slow the progression of coronary atherosclerosis, independent of baseline LDL-C levels. This recommendation recognizes HIV infection as a condition associated with elevated CV risk that may not be fully captured by traditional risk-assessment tools.
This patient case quiz is part of the larger Implementing the 2026 Dyslipidemia Guidelines: From Risk Stratification to Personalized Treatment initiative, supported by Merck & Co. and Eli Lilly and Company. To visit the Learn Prevention grant page and access additional educational activities on this topic, click here.
References
- Blumenthal RS, Morris PB, Gaudino M, et al. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of dyslipidemia: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2026;87(19):2624-2757. doi:10.1016/j.jacc.2025.11.016
- Grinspoon SK, Fitch KV, Zanni MV, et al. Pitavastatin to prevent cardiovascular disease in HIV infection. N Engl J Med. 2023;389(8):687-699. doi:10.1056/NEJMoa2304146
