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Primary prevention of atherosclerotic cardiovascular disease in an adult with HIV — ABIM Board MCQ

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HardLow-Density LipoproteinPrimary prevention of atherosclerotic cardiovascular disease in an adult with HIVABIM Board

A 52-year-old man with HIV infection presents for cardiovascular risk assessment. HIV was diagnosed 17 years ago; his nadir CD4 count was 72 cells/mm3, and he previously had several periods of detectable viremia. For the past 4 years, his HIV RNA has been undetectable while taking bictegravir-emtricitabine-tenofovir alafenamide. He has no history of atherosclerotic cardiovascular disease, diabetes mellitus, hypertension, chronic kidney disease, or tobacco use. Blood pressure is 118/72 mm Hg and BMI is 24.1 kg/m2. Laboratory studies show LDL cholesterol 108 mg/dL, HDL cholesterol 56 mg/dL, triglycerides 92 mg/dL, and normal aminotransferase and creatine kinase levels. His 10-year PREVENT-ASCVD risk is 2.8%. At his request, coronary artery calcium scoring was performed and showed a score of 0. Which of the following is the most appropriate lipid-management strategy?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Initiate moderate-intensity statin therapy with pitavastatin 4 mg daily

Explanation lettering: D = shown as B · E = shown as C · B = shown as D · C = shown as E

This patient should begin moderate-intensity statin therapy. He is age 40–75 years and has HIV, a population for whom the 2026 ACC/AHA dyslipidemia guideline recommends lipid-lowering therapy for primary prevention regardless of LDL cholesterol or calculated PREVENT-ASCVD risk. His prolonged HIV duration, low nadir CD4 count, and prior viremia further support treatment because conventional risk equations may underestimate risk in people with HIV. Pitavastatin 4 mg daily is a recommended moderate-intensity regimen and reduced major adverse cardiovascular events in low-to-moderate-risk adults with HIV in the REPRIEVE trial. Lifestyle therapy alone (A) inadequately addresses the independent risk associated with HIV. A coronary artery calcium score of 0 (C) can support deferring statins in selected low- or intermediate-risk adults without important cardiovascular comorbidities; it does not override the specific recommendation to treat adults with HIV. High-intensity therapy targeting LDL cholesterol below 70 mg/dL (D) is not required because he has neither clinical ASCVD, LDL cholesterol of at least 190 mg/dL, nor high calculated risk. Ezetimibe monotherapy (E) is not first-line therapy when a statin is tolerated; it is generally used when statins are contraindicated or insufficient to achieve the applicable LDL goal.

Reference: ACC, AHA Release New Clinical Guideline For Managing Dyslipidemia (March 13, 2026) — https://www.acc.org/latest-in-cardiology/journal-scans/2026/03/13/15/20/acc-aha-release-new-clinical-guideline-for-managing-dyslipidemia Statin Therapy as Primary Prevention for Persons With HIV: A Synopsis of Recommendations From the U.S. Department of Health and Human Services Antiretroviral Treatment Guidelines Panel (May 27, 2025) — https://pubmed.ncbi.nlm.nih.gov/40418812/ Pitavastatin to Prevent Cardiovascular Disease in HIV Infection (August 24, 2023) — https://pubmed.ncbi.nlm.nih.gov/37486775/