Updated cholesterol guidelines indicate that up to two-thirds or more of U.S. veterans with HIV, hepatitis C (HCV) or both should have been taking statins. But almost one-third of statin-eligible veterans were not getting the drugs, according to the study.
Both HIV and HCV infection boost the risk of cardiovascular disease. Researchers who conducted this Veterans Affairs (VA) analysis called statins "a cornerstone" of primary cardiovascular disease prevention. But research indicates that veterans with HIV or HCV are less likely to receive statins according to guideline recommendations.
The new study aimed to compare statin indications in male veterans with three sets of cholesterol guidelines: the 2004 Adult Treatment Panel (ATP-III) guidelines, the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines and the 2014 VA/U.S. Department of Defense (VA/DoD) guidelines. The study included male veterans from 40 to 75 years old with HIV and/or HCV infection (positive HCV RNA or genotype test) and with data available in the period 2008-2010. The researchers checked the VA Clinical Case Registry to determine which veterans should have been prescribed statin therapy according to the three sets of guidelines and which veterans actually received statins at any time in 2008-2010.
The study group consisted of 13,579 veterans with HIV, 169,767 with HCV and 6628 with HIV/HCV. Median ages of those three groups were 53.9, 57.9 and 56.3 years, while respective proportions of blacks were 47%, 34% and 63.4%. More than 86% of all three groups were engaged in care, meaning they had annual visits in each of the three study years. More than two-thirds of veterans with HIV or HIV/HCV had an undetectable HIV load. Proportions prescribed statins were 39.1% in the HIV group, 31.9% in the HCV group and 23.1% in the HIV/HCV group.
According to 2004 ATP-III guidelines (the guidelines in effect during the study period), 50.6% of veterans with HIV, 45.9% with HCV and 33.8% with HIV/HCV were eligible for statin therapy. Among statin-eligible veterans, proportions not on statins were 22.7% with HIV, 30.6% with HCV and 31.5% with HIV/HCV. Multivariable logistic regression analysis determined that smoking and older age independently predicted statin underutilization (that is, statin eligibility but not on statins). Engagement in care independently predicted a lower risk of statin underutilization. Among veterans with HIV or HIV/HCV, a detectable HIV load predicted statin underutilization; and in veterans with HCV or HIV/HCV, cirrhosis predicted underutilization.
According to 2013 ACC/AHA guidelines, statin eligibility rose to 66.1% for veterans with HIV, 73.6% for those with HCV and 58.5% for those with HIV/HCV. Respective absolute eligibility increases compared with 2004 ATP-III guidelines were 15.5%, 27.7% and 24.7%. With the 2014 VA/DoD guidelines, statin eligibility rates for veterans with HIV, HCV and HIV/HCV were 57.3%, 64.4% and 49.1%. Compared with ATP-III guidelines, respective absolute eligibility increases with VA/DoD were 6.8%, 18.5% and 15.3%.
The researchers estimated the likely effect of the ACC/AHA guidelines on future cardiovascular events in veterans by applying the 10-year atherosclerotic cardiovascular disease risk score to veterans without documented cardiovascular disease who were newly eligible for statin therapy with ACC/AHA. Ten-year prevention rates by using the ACC/AHA guidelines would be 3.73% for veterans with HIV, 3.25% for veterans with HCV and 3.38% for veterans with HIV/HCV.
Although the authors did not determine underutilization rates with ACC/AHA or VA/DoD advice, they noted the ACC/AHA or VA/DoD guidelines "substantially expand statin recommendations" compared with ATP-III and thus would "widen the gap of statin underutilization in all groups." The researchers believe their findings "suggest that programs are needed to improve primary [cardiovascular] risk assessments in the clinical care of HIV- and HCV-infected veterans and to ensure statin therapy is discussed with the patient at the time of assessment."