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Primary ASCVD prevention in HIV with ritonavir-boosted protease inhibitor therapy — ABIM Board MCQ

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HardComorbiditiesPrimary ASCVD prevention in HIV with ritonavir-boosted protease inhibitor therapyABIM Board

A 52-year-old man with HIV infection is evaluated for cardiovascular risk reduction. He has had sustained viral suppression for 8 years, and his CD4 count is 680/mm³. His antiretroviral regimen consists of tenofovir alafenamide–emtricitabine, darunavir, and ritonavir. He has no history of atherosclerotic cardiovascular disease, diabetes mellitus, chronic kidney disease, hypertension, or tobacco use. Blood pressure is 118/72 mm Hg, and BMI is 24 kg/m². Laboratory studies show an LDL cholesterol level of 108 mg/dL, HDL cholesterol level of 58 mg/dL, triglyceride level of 105 mg/dL, and normal hepatic aminotransferase and creatine kinase levels. His calculated 10-year cardiovascular risk is 2.8%. Because he is reluctant to take another medication, coronary artery calcium scoring is performed and the score is 0. Which of the following is the most appropriate lipid-lowering strategy?

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

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Correct answer: B — Initiate pitavastatin, 4 mg daily

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

The most appropriate strategy is pitavastatin, 4 mg daily. Current US dyslipidemia guidance recommends initiating lipid-lowering therapy for primary prevention in adults aged 40–75 years with HIV, regardless of LDL cholesterol level or calculated short-term risk. A coronary artery calcium score of 0 can support deferring treatment in selected low-risk patients, but not when a high-risk comorbidity such as HIV is present. The REPRIEVE trial directly demonstrated fewer major cardiovascular events with pitavastatin in adults with HIV receiving antiretroviral therapy and having low-to-moderate predicted risk. Pitavastatin is particularly suitable because ritonavir-boosted darunavir does not require pitavastatin dose adjustment. Simvastatin (B) is contraindicated with ritonavir-boosted protease inhibitors because markedly increased exposure can cause severe myopathy or rhabdomyolysis. Atorvastatin (C) is a plausible statin choice, but darunavir/ritonavir substantially increases its exposure; the recommended maximum is 20 mg daily, making 40 mg inappropriate. Ezetimibe (E) can be used when additional LDL lowering is required or statins are not tolerated, but it does not replace first-line statin therapy in this statin-naive patient. Deferring therapy (A) incorrectly allows the low calculated risk and calcium score to override the HIV-specific treatment indication.

Reference: Lower Sooner: How the 2026 Dyslipidemia Guideline Changes Practice (July 1, 2026) — https://www.acc.org/Latest-in-Cardiology/Articles/2026/07/01/01/Prioritizing-Health Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents With HIV (2026) — https://www.ncbi.nlm.nih.gov/books/NBK586306/bin/antiretroguide.pdf Pitavastatin to Prevent Cardiovascular Disease in HIV Infection (2023) — https://www.nejm.org/doi/full/10.1056/NEJMoa2304146