Barriers and facilitators to statin adherence in people with HIV: a qualitative study

Background Cardiovascular disease (CVD) risk is almost twice as high for people with HIV (PWH) compared to the general population. US and European guidelines now recommend initiating or considering statin therapy in all PWH aged ≥40. However, recent studies found that poor adherence to statins is common in PWH. Regular HIV care visits provide opportunities to promote statin adherence, but PWH-specific evidence on determinants of statin adherence is needed to inform interventions, given PWH’s unique clinical and social context. Purpose To identify barriers and facilitators to statin adherence in PWH. Methods In 2024 in North Carolina, US, we recruited PWH aged ≥18 with an active statin prescription from a safety-net tertiary care center with ~2000 active patients with HIV from across the state. We conducted in-depth, semi-structured interviews in English and Spanish. Interviews were transcribed verbatim and coded by 2 people based on both emergent and a priori themes, informed by prior medication adherence studies in people with and without HIV. We mapped themes to the Capability-Opportunity-Motivation shape Behavior (COM-B) framework, which can be linked to specific intervention strategies. Results We interviewed 31 PWH (3 in Spanish) with a median age of 58 (IQR 50-63), including 22 cisgender men, 7 cisgender women, and 2 transgender women. A majority (65%) were Black, 19% White, and 13% Hispanic. Participants had been on statins for a median of 5.2 years (IQR 1.9-8.3), 57% had LDL >100 mg/dL (2.6 mmol/L), and 29% had a history of CVD. Table 1 shows salient themes mapped to COM-B components. Several PWH discussed the lack of information they received at statin initiation and during follow-up to explain and reinforce the indication for a statin, how cholesterol works, and how they are doing with cholesterol control. Most PWH’s statin was partially or fully covered by private or public insurance, financial aid programs, or a combination thereof; Several PWH expressed concerns with maintaining coverage and managing out-of-pocket costs. PWH discussed the importance of interactions with their HIV care provider in several ways, including trust in the provider’s knowledge and good intentions, ability to ask the provider questions, and positive feedback from the provider. Some PWH whose statin therapy was managed by another provider cited coordination with their HIV provider as important to them, in part to ensure viral suppression was not compromised. Conclusions Statin adherence barriers and facilitators in this sample were largely factors that can be addressed during routine health care encounters, for example by reinforcing CVD prevention knowledge, statin therapy goals, and PWH’s success with cholesterol control. Leveraging PWH’s relationship with their HIV provider may be an effective strategy to address statin adherence barriers. Maintaining programs that cover statins’ cost for PWH is also essential to promote statin adherence.Table 1.Themes and COM-B components.For image description, please refer to the figure legend and surrounding text.