Few people with HIV in England starting statins despite new recommendations

Six poster presentations at last month’s British HIV Association (BHIVA) Conference in Brighton found that only a minority of people with HIV are being offered and starting to take the cholesterol-lowering statin drugs. This is despite a November 2023 recommendation by BHIVA that “All people living with HIV aged 40 years or older should be offered a statin for primary prevention of cardiovascular disease”.

Several barriers to obtaining statins were identified. A surprisingly low proportion of HIV doctors had discussed statins with their patients; clinics were still, in the main, using CVD risk scores to prioritise who over 40 should get them; and some people were turning them down due to fear of side effects.

The biggest barrier, however, was that statin prescription is generally done by GPs, and only a minority of people had asked their GPs for them or been offered them by their GP. Statins are the first drugs recommended to be part of routine care for the majority of people with HIV that are expected to be prescribed by GPs, not by HIV clinics.

A pilot study in north London in which a network of GP practices proactively contacted their patients to suggest statins found higher takeup levels. This was one of several studies at BHIVA to find that primary care physicians were starting to get more involved in HIV patient care. 

Background

Two years ago, the REPRIEVE study found that people with HIV taking a statin drug were 35% less likely to experience a major adverse cardiovascular event (MACE) such as a heart attack or stroke than people on placebo.

REPRIEVE’s findings were particularly striking because its participants had a low to moderate cardiovascular risk. The threshold for recommending statins to people in the UK is a 10% risk of MACE within the next 10 years. Though all were aged over 40, among REPRIEVE participants the average 10-year risk was 4.5%.  

The statin used in REPRIEVE, pitavastatin, is not yet available in the UK, though has recently come off patent and hopefully will become available this year. Until then BHIVA is recommending a daily 20mg dose of atorvastatin, which is as safe and nearly as effective.

Studies from HIV clinics

One poster, from the HIV clinics run by Buckinghamshire Healthcare NHS Trust, outlined eight steps that have to be taken to establish one of their patients on regular statin therapy.

In this ‘statin cascade’, the HIV clinician must first assess which of their patients are eligible for statin therapy. In principle, this should be easy, if doctors follow the BHIVA guidelines and recommend them for all patients over 40. In practice, as the studies showed, most HIV clinics are only recommending statins for patients with a cardiovascular risk (as determined by the QRISK3 algorithm) of over 5%. To calculate QRISK3, a range of data, such as cholesterol, blood pressure and smoking status, need to be regularly measured and recorded.

The HIV clinician then has to take the time to discuss statin therapy with each eligible patient. The patient has to agree to it (and quite a few do not). If they do, a letter is written to the patient’s GP, who needs to invite the patient to an appointment. The patient gets a prescription which, unlike the free antiretrovirals provided by the hospital, will need to be paid for – unless they are unemployed, over 60 or exempt for other reasons. They may then have regular monitoring appointments, and need to know how to order a repeat prescription.

The Buckinghamshire study looked at all 320 patients over 40 who attended their clinics in 2023. Of them, it found that 72% had a QRISK3 score of over 5%, so should have been on statins even if HIV-negative, but only 30.5% already were.

This study did not follow-up patients to find out if they started on statins, but several others did.

A study by Barts Health NHS Trust looked at all its HIV patients between 40 and 50 attending in the first half of 2024. In this patient group of 60 people, 65% were women, who are less often prescribed statins. The study found that 46 patients were eligible by QRISK3 score or because they were taking the antiretroviral drug abacavir, which also increases cardiovascular risk, but could only find nine people – 20% of those eligible – where it was positively recorded that statins were recommended and only five (11%) who had started. Two of the others declined statins, and the GP took no action for two others.

Given the lack of recording, it’s impossible in this case to tell whether doctors were failing to recommend statins, or failing to record recommending them, but given the low numbers starting them, it looks like the former.

Another study looked at all HIV patients attending St Mary’s Hospital in April 2024 and followed them up six months later. Of 358 patients, 205 (57%) were eligible for statins (excluding those already on them). However, records show only half of these (104 patients) were recommended statins, only half of those (50 people) agreed to start them and only 58% of those (29 people) actually started them, meaning only 14% eligible for statins started them. Of those, nine people got them directly from their HIV clinic, so only 10% of patients ended up getting statins from their GP.

Barriers identified by this study included failure by HIV doctors to raise the subject of statins, possibly because only half of patients had an up-to-date QRISK3 assessment. In addition, 14% of those asked about statins declined them.

A study by Manchester University NHS Foundation Trust, the largest in the country, looked at a random sample of 271 people with HIV seen in March 2024 and also followed them up six months later. This trust did not restrict statin availability by QRISK3 score – they were recommended for everyone over 40 – but it is noted that the average QRISK3 score, including people already on statins, was very high at 10.3%.

Of the 203 patients (75%) not already on statins, 111 (54%) were recommended them, but 28 (25%) declined them. Where a reason was recorded, about half were worried about side effects and half did not want an additional daily pill.

Of the other 83 – 41% of those eligible to start statins – only 19 (9% of all eligible to start) had started, and remained on, statins by the six-month follow-up date.

One more study, from St Thomas’ Hospital in south London, looked at all patients over 40 years old seen in clinic in May 2024. This study found that only 84 of 118 patients (70%) had records complete enough to determine statin eligibility. Forty-eight per cent of them were already on statins. Of the ones who were not, 27 (60%, nearly half of them with a QRISK3 of over 10%) had a discussion about starting statins, but a high proportion of them (11 of the 27 or 41%) declined. Sixteen ended up with a letter to their GP recommending statins but by March 2025, ten months later, only four people had actually started and remained on statins.

Although the studies show different things, only just over a third of patients are known to have been recommended statins by their doctor; just over half of those who were recommended them ended up with a referral to their GP; and in the four studies which gave this information, only 57 of 497 eligible patients initiated statins (11.5%).

As mentioned above, use of the older antiretroviral abacavir is known to increase the risk of heart attack. In the REPRIEVE cohort, former abacavir usage was associated with a 50% raised risk of MACE and current use with a 42% raised risk. However, a study from the Royal Free Hospital in London found 111 of its patients were still taking abacavir and of these, over 40% were not on statins. In most cases it was unclear why not, but 28% of them had refused statins.

Should GPs be assessing people with HIV for statins, not HIV clinics?

Given these poor figures for statin initiation via HIV clinics, one more study at BHIVA – and the only one selected for oral rather than poster presentation – looked at direct initiation of statins by GPs.

The presenter was Dr Samantha Preston, who is one of the GP HIV champions for Fast-Track Cities London, meaning that she has undertaken additional training in HIV and works to disseminate HIV knowledge through primary care practices, with the aim of improving the quality of life for people living with HIV in the local area.

The scheme involved using the electronic medical records of seven GP practices in the borough of Islington to assess MACE risk in those living with HIV. A training session on REPRIEVE for doctors, pharmacists and other staff was organised and in the end five practices became fully involved.

Among these five practices, 297 patients with HIV aged over 40 were identified, 103 of them (35%) already on statins, with two-thirds of those already initiated by the GP for reasons other than HIV, such as high cholesterol.

Of 194 patients not yet on statins, 142 (73%) were offered a consultation with a pharmacist, and in the end 44 (23% of all eligible) started statins. This is twice as many eligible patients prescribed statins as in the HIV clinic studies.

A short feedback questionnaire was sent to patients following the consultation to try and gain some qualitative feedback. Although the response rate was low, all who replied agreed that the experience improved their confidence in discussing their HIV status with their GP surgery – a bonus in the UK, where HIV is not often dealt with in primary care.