LDL-C target achievement in people living with HIV: impact of combination lipid-lowering therapy. A retrospective cohort analysis

BACKGROUND: Real-world low-density lipoprotein cholesterol (LDL-C) target attainment remains low in people with HIV (PWH). Updated ESC/EAS 2025 guidelines underscore the need to reassess treatment patterns in clinical practice. METHODS: Retrospective observational longitudinal study including PWH ≥40 years, evaluated twice between 2020 and 2025 at the Modena HIV Metabolic Clinic, with complete laboratory and clinical follow-up data. Objective was to evaluate the real-world use and effectiveness of different lipid-lowering therapy (LLT) regimens in achieving guideline-based LDL-C targets. RESULTS: Among 588 PWH (71.8% male), median age was 60 years (IQR 56-64) and 97.4% had suppressed HIV viral load. According to cardiovascular (CV) risk classification, 29.3% were at moderate risk, 52% at high risk, 12.4% at very high risk and 6.3% at extreme risk. LDL-C target attainment increased from 19.6% at baseline to 28.8% at follow-up. Achievement rates declined with increasing CV risk. In multivariable analysis, combination LLT was the strongest predictor of LDL-C target attainment (odds ratio 5.7, 95% confidence interval 3.7-9.0, P < 0.0001), whereas statin dose escalation was not. Diabetes was also associated with greater odds of reaching LDL-C goals. CONCLUSIONS: LDL-C control remains suboptimal in PWH, particularly among those at higher cardiovascular risk. Combination lipid-lowering therapy markedly increases the likelihood of achieving LDL-C targets, supporting broader adoption of combination strategies in routine HIV care.