Distance from low-density lipoprotein cholesterol targets across cardiovascular risk strata in people living with HIV: a multicentre cohort study

Introduction: Previous studies have described the gap between statin indication and prescription among people living with HIV (PLWH) using binary measures, which fail to capture the magnitude of residual lipid burden. Objectives: To quantify lipid burden in PLWH by measuring the distance from recommended LDL-cholesterol (LDL-C) targets ("LDL-C excess") across cardiovascular risk categories. Design: Multicentre, nationwide, prospective cohort study. Methods: We analysed data from 2,190 PLWH enrolled in the SCOLTA cohorts between 2015 and 2025, contributing 13,512 clinical observations (visits). Cardiovascular risk was assessed using SCORE2. LDL-C targets were defined according to the minimum thresholds recommended by historical European AIDS Clinical Society guidelines. LDL-C excess was calculated as the difference between observed LDL-C and the corresponding target and summarised as mean values with 95% confidence intervals (CI). Results: The proportion of visits meeting statin therapy criteria increased from 64.6% in 2015 to approximately 80% after 2021, whereas statin prescription rose only from 12.5% to 25.4%. LDL-C targets were achieved in 9.7% of visits. Mean LDL-C excess was 18 mg/dL in low-risk, 40 mg/dL in the intermediate, and 51 mg/dL in high-risk individuals. The excess was lower but remained substantial even among statin-treated PLWH. Conclusions: LDL-C excess highlights a clinically meaningful gap between guidelines and practice, particularly among intermediate- and high-risk PLWH, underscoring the urgent need for systematic lipid-lowering in the post-REPRIEVE era.