Statins, Aspirin per Guidelines Grossly Underused in HIV: US Study

December 06, 2017

LOS ANGELES, CA — Statins and aspirin are far less likely to be prescribed per guidelines in patients with HIV than in those not infected with HIV, suggests an analysis of US healthcare visits[1]. It didn't find the same disparity for antihypertensive meds.

"It may be that physicians aren't widely aware there are statins that can be safely and effectively used with essentially little to no concern about drug interactions in patients with HIV," Dr Joseph A Ladapo (David Geffen School of Medicine, University of California, Los Angeles) told | Medscape Cardiology.

"It's just that those concerns aren't particularly well founded anymore with current antiretroviral therapy," said Ladapo, lead author on the study published November 14, 2017 in the Journal of the American Heart Association.

But concern about drug-drug interactions was likely not the only explanation for the differences, which were substantial, he noted. In the adjusted analysis of doctor visits by US patients with cardiovascular risk factors from 2006 to 2013, those with HIV were 47% less likely than those without HIV to be prescribed aspirin or other antiplatelets (P=0.03) and 49% less likely to be prescribed a statin (P<0.01).

Ladapo said the doctor visits included a range of healthcare delivery settings and specialties, and a sensitivity analysis limited to primary-care visits yielded much the same result.

Adding to the challenge of undertreatment, people with HIV have "about one to one-and-a-half-fold higher risk for heart attack compared with uninfected people, even after appropriate adjustment for clinical and demographic factors," according to Dr Matthew J Feinstein (Northwestern University Feinberg School of Medicine, Chicago, IL), who isn't connected with the study.

"They also have higher risk for heart failure, atrial fib, and stroke," he said in an interview. "So they're more likely to get cardiovascular disease than uninfected controls, and once they have it or are high risk for it, they may be less likely to get some forms of therapy."

Indeed, Feinstein agreed, "there have been a lot of concerns about drug-drug interactions with certain HIV meds and statins, which may have led to statins being underutilized among HIV-infected people."

Small studies have suggested that the concern is appropriate for lovastatin and simvastatin, he said, but pravastatin, atorvastatin, and rosuvastatin, for example, "all seem to be reasonably safe in HIV."

So a cardiologist prescribing for a patient with HIV may aim for "the bare minimum, because they don't want to interfere with antiretroviral drugs, which traditionally we cardiologists don't know that much about," Feinstein said.

Fragmentation of care may be a cause of such misunderstandings leading to undertreatment. "We may be doing an inadequate job, in our part of the medical community, of communicating across silos."

In people with HIV and CV risk factors, "There's a lot of residual benefit that we're missing out on. And I think pushing statin dose further will probably be helpful," he said. "But we don't have the hard outcomes data to tell us that yet."

Another possible source of undertreatment: changing health needs as the HIV-positive population ages, Ladapo observed. Perhaps a quarter in the US are older than 55, he said.

"There's been a big shift in the demography of patients with HIV in this country, and I think it's catching people flat-footed."

A lot of the focus in their care is on antiretroviral therapy, he observed; that is, getting them to take and adhere properly to the meds with the goal of achieving an undetectable viral load.

In the process, "It's possible other important primary care—not only cardiovascular care but also things like colorectal cancer screening, mammography, and other things that we know are evidence-based and improve outcomes—are kind of taking a back seat," he said.

"Whereas that was probably not a big problem when most people with HIV were still very young, we're now at a point where more are older, and it's becoming more important."

Feinstein proposed, in addition, that "a lot of people with HIV may be marginalized and may systematically not have the same access to multispecialty care that people without HIV have."

In the analysis that accounted for 1631 physician visits by people with CV risk factors and HIV and 226,862 such people without HIV infection, a statin prescription was ensured for only 23.6% of HIV patients who had diabetes, CV disease, or dyslipidemia. The corresponding figure for patients without HIV was 35.8% (P<0.01).

Odds Ratio (OR)a for Guidelines-Appropriate CV Treatment Prescription in People with HIV vs Without HIV

CV treatment OR (95% CI) P
Aspirin or other antiplatelet 0.53 (0.30–0.94) 0.03
Statin 0.51 (0.32–0.82) <0.01
Antihypertensive meds 0.88 (0.48–1.58) 0.66
Diet and exercise counseling 0.78 (0.51–1.21) 0.27
Smoking-cessation advice or medicationsb 1.51 (0.90–2.53) 0.12
a. Propensity-adjusted for age, sex, ethnicity, Medicaid vs uninsured, urban/rural setting, obesity/overweight, smoker, dyslipidemia, diabetes mellitus, hypertension, CVD, and a year-based time trend
b. Smoking cessation meds include nicotine-replacement therapy, varenicline, and bupropion

The problem of undertreatment with cardiovascular meds isn't unique to people with HIV, Lapado pointed out. So there may be tried and true solutions, such as building CV care in HIV into electronic health record prompts and the reimbursement infrastructure.

"Some sort of economic incentive to single it out, essentially make it more economically feasible for physicians to address preventive cardiovascular care and potentially other preventive primary care in patients with HIV," he proposed.

The authors have no relevant financial relationships, nor does Feinstein.

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