Pitavastatin cuts hypertension risk in PLWH

In the secondary analysis of the REPRIEVE trial presented at CROI 2026, pitavastatin reduced the risk of developing incident hypertension in people living with HIV (PLWH).

Over a median follow-up of 5 years, 11.7 percent of participants receiving pitavastatin developed incident hypertension. In the placebo arm, the corresponding rate was 13.3 percent. According to study author Dr Esteban Martinez from the Hospital Clinic of Barcelona, Spain, the reduced risk with pitavastatin was  ‘modest but significant’ (hazard ratio [HR], 0.83; p=0.017).

This effect was consistently observed across most prespecified subgroups, with the most pronounced effects in the Southeast/East Asia (HR, 0.54) and South Asia geographic regions (HR, 0.57). [CROI 2026, abstract 118]

“PLWH have increased cardiovascular (CV) risk despite effective viral suppression … Statins can lower aldosterone levels in the general population, but the key gap is we do not know the effect of statins in PLWH, particularly on incident hypertension,” Martinez pointed out.

“[As such, we sought] to evaluate the effect of pitavastatin on incident hypertension and its association with subsequent major adverse CV events (MACE), and to identify risk factors for hypertension,” he said.

The trial comprised 4,989 PLWH (median age 49 years, 70 percent men) who were free of hypertension at baseline. They were randomized 1:1 to receive pitavastatin 4 mg or placebo. Incident hypertension was defined as clinically diagnosed hypertension (systolic blood pressure [BP] ≥140 mm Hg or diastolic BP ≥90 mm Hg) based on standard methods captured as time to first site-reported diagnosis, with death as a competing event. The median systolic and diastolic BPs were 120 and 76 mm Hg, respectively.

Approximately half of the overall cohort were on an antiretroviral therapy (ART) regimen of a nucleoside reverse transcriptase inhibitor (NRTI) plus a non-NRTI, while a quarter were on a regimen containing an NRTI and an integrase strand transfer inhibitor. The median ART duration was 9.2 years.

Other outcomes

Even below diagnostic thresholds, elevated BP was the strongest predictor of incident hypertension after adjusting for demographic, clinical, metabolic, and HIV-related factors, including randomized treatment (incidence rate ratio [IRR], 2.41; p<0.001).

Other key independent risk factors were older age (IRRs, 1.69 and 1.36 for ≥60 and 50–59 years, respectively), obesity (IRR, 1.59), Black race within high-income countries (IRR, 1.35), and elevated fasting glucose (IRR, 1.32).

“Importantly, HIV-related variables were not independently associated with incident hypertension after adjustment. Therefore, the risk is primarily driven by cardiometabolic factors, reinforcing the need for integrated prevention in HIV care,” Martinez noted.

After adjusting for atherosclerotic CV disease risk, incident hypertension was associated with a twofold higher risk of MACE (first primary: HR, 2.16; p=0.0021, first confirmed: HR, 2.25; p=0.0042, and first hard: HR, 2.35; p=0.011). “Clinically, this supports hypertension as a major prognostic marker in PLWH, even in a primary prevention population,” Martinez said.

Benefits beyond lipid-lowering

Martinez acknowledged several limitations. Apart from being a secondary analysis, hypertension was based on site-reported diagnoses. Moreover, BPs were evaluated annually, and subgroup analyses were underpowered.

Nonetheless, this was a large, global study with a double-blind, randomized design that evaluated normotensive participants at baseline, with centrally adjudicated CV outcomes, Martinez noted. “The randomized design and consistency across analyses support the robustness of the main findings.”

“The results emphasize both the preventive effect of statins on hypertension development and the prognostic significance of incident hypertension for CV outcomes in PLWH,” he said.

“The findings suggest that statin benefits may extend beyond lipid-lowering. These findings support integrated CV disease prevention in HIV care, with proactive BP screening and early management alongside [lipid-lowering] strategies,” Martinez concluded.