Risk-Guided Statin Initiation in People Living with HIV: Clinical Utility of a Cardiovascular Risk Prediction Model in a Malaysian Cohort.

BackgroundOptimal statin initiation strategies for people living with HIV (PLHIV) remain uncertain. We evaluated whether the D:A:D reduced (D:A:Dr) model improves primary prevention statin initiation decisions among Malaysian PLHIV compared with non-risk-based strategies.MethodsThis retrospective cohort study followed statin-naïve PLHIV adults from an infectious diseases centre over five years for incident cardiovascular events. Decision curve analysis compared the net benefit of a D:A:Dr-guided strategy against four alternatives: LDL-cholesterol ≥3.0 mmol/L, age ≥40 years, treat-all, and treat-none.ResultsAmong 5,741 PLHIV, 48.9% were moderate-to high-risk. The 5-year event rate was 2.0%, ranging from 0.5% (low-risk) to 8-9% (high-risk). D:A:Dr-guided strategy yielded superior net benefit at >2% - 10% threshold probabilities. Age ≥40 years lost benefits as thresholds increased whereas LDL-cholesterol-based strategy offered minimal utility.ConclusionD:A:Dr risk-based statin initiation offers superior clinical utility at >2% to 10% threshold probabilities, enabling targeted, resource-efficient prescribing in resource-constrained settings.