What is the recommended antiretroviral therapy (ART) regimen for a patient with Human Immunodeficiency Virus (HIV) and hyperlipidemia, considering potential cardiovascular risk factors?

HIV Antiretroviral Therapy for Patients with Hyperlipidemia

For HIV-infected patients with hyperlipidemia and cardiovascular risk, switch to newer generation antiretroviral regimens—specifically dolutegravir-based therapy—and avoid abacavir-containing regimens due to increased cardiovascular events. 1

Antiretroviral Selection Strategy

First-Line Regimen Modifications

Prioritize dolutegravir-based regimens as they demonstrate non-inferiority in maintaining viral suppression while achieving 7.7% LDL-C reduction compared to ritonavir-boosted protease inhibitors. 1

Avoid abacavir-containing regimens in patients with established cardiovascular disease or significant cardiovascular risk factors, as contemporary US guidelines specifically recommend switching away from these due to their association with increased cardiovascular events. 1

Protease Inhibitor Considerations

If protease inhibitors are necessary:

• Use atazanavir-ritonavir regimens with lower ritonavir boosting doses, which have more favorable lipid profiles compared to other protease inhibitor combinations 1
• Recognize that ritonavir-boosted protease inhibitors are the primary drivers of severe hypertriglyceridemia (not seen with NRTIs alone) 2

Critical Principle: Maintain Viral Suppression

Never interrupt antiretroviral therapy for lipid management—the SMART trial demonstrated that episodic antiretroviral use increased MI rates from 0.8 to 1.3 per 100 person-years and increased death from all causes. 1 Higher CD4 counts and lower HIV RNA levels directly correlate with lower ASCVD risk. 1

Lipid-Lowering Medication Selection

Statin Therapy

For moderate-to-high intensity LDL-C reduction:

• Atorvastatin (start 10 mg daily) or rosuvastatin are preferred when intensive LDL-C lowering is needed in patients with coronary disease, despite drug interactions 1, 3
• Start with low doses and monitor closely for myopathy 3

For patients on protease inhibitors or when minimizing drug interactions:

• Pravastatin (20-40 mg daily) is the first choice as it has minimal CYP3A4 metabolism and fewer interactions 1, 3
• Fluvastatin (20-40 mg daily) is an alternative with fewer interactions 3

Absolutely avoid:

• Lovastatin and simvastatin with protease inhibitors—these are metabolized by CYP3A4 and concomitant use dramatically increases rhabdomyolysis risk 1

Fibrate Therapy

For triglycerides 200-500 mg/dL with elevated non-HDL cholesterol:

• Use gemfibrozil or fenofibrate 1, 3

For triglycerides >500 mg/dL:

• Fibrates are first-line to prevent pancreatitis 1

Critical warning: Avoid combining statins with fibrates due to substantially increased rhabdomyolysis risk; if combination is absolutely necessary, use extreme caution with intensive monitoring for myopathy. 1, 3

Monitoring Protocol

Obtain fasting lipid profile:

• Before starting any antiretroviral therapy 1, 3
• Within 3-6 months after starting or changing regimens 1, 3

Calculate 10-year cardiovascular risk if ≥2 risk factors present (age >45 years men/>55 years women, smoking, hypertension, low HDL-C, family history of premature CHD). 1, 3

Additional Drug Interaction Considerations

Antiplatelet therapy: Avoid ticagrelor with protease inhibitors due to CYP3A metabolism, which increases bleeding risk. 1

Multidisciplinary care: Patients should receive coordinated care from infectious disease specialists and cardiology/lipid specialists given the complex pharmacological interactions. 1

Lifestyle Interventions

Implement aggressively before or alongside pharmacotherapy:

• Dietary consultation with registered dietician 1, 3
• Regular aerobic exercise 1, 3
• Smoking cessation (particularly critical as smoking rates are extremely high in HIV populations) 1, 3
• Weight reduction if obese 1, 3