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Background Based on recent guidelines, people with HIV (PWH) aged ≥40 years are candidates for statins. However, updated data on statin use and tolerability in this population are scarce.Material and Methods Retrospective, observational study involving PWH aged ≥40 years at 5 clinical centers in Italy. PWH were followed from baseline (BL, first visit after release of DHHS recommendations on statins in February 2024) until the last available visit [follow-up (FU) truncated after 18 months]. SCORE2 was used to estimate the 10-year cardiovascular disease risk. We explored rates of statin recommendation (SR) by physicians, statin acceptability among PWH, statin discontinuation (SD), and their predictors using Cox regression models. Furthermore, variables associated with achieving the LDL target (defined according to ESC/EAS) were studied.Results A total of 1,390 PWH were included (72.1% males, median age 58 years, 93.1% with HIV-RNA<50copies/mL, median CD4 737 cells/µL, 57% with a SCORE2≥5%). Statin use and achievement of LDL target, stratified by cardiovascular risk, are detailed in figure 1. At BL, 461 (33.2%) PWH were already taking a statin. Among those not on statin at BL and without previous intolerance (n=879), only 36.5% (n=321) (27% vs 46.1% with SCORE2 <5% vs ≥5%, p<0.001) were offered a statin during FU; older age (aHR 1.24 per +10 years, p=0.017), higher LDL (aHR 1.16 per +10 mg/dL, p<0.001) and a SCORE2≥5% (aHR 1.52, p=0.010) were independent predictors of SR by physicians. Among PWH who were offered a statin, 222 (69.2%) accepted the therapy. During FU, 14 (6.3%) PWH discontinued statin (mainly for myalgias), with an estimated SD rate of 10.6% at 12 months: protease inhibitors (PI) use was an independent predictor of SD (aHR 15.48, p=0.015). In statin-treated PWH with available FU, LDL target was reached by only 167/604 PWH (27.6%) (44.6% vs 19.2% with SCORE2 <5% vs ≥5%, p<0.001). Injecting drug use (aHR 0.52, p=0.046), PI use (aHR 0.41, p=0.024), higher LDL at BL (aHR 0.82 per +10 mg/dL, p<0.001) and a SCORE2 ≥5% (aHR 0.18, p<0.001) were associated to a lower probability of reaching LDL target.Conclusions In our multicenter cohort, statin use is increasing but statin recommendation by physicians is still suboptimal, especially in PWH with SCORE2 ≥5%. Counselling should be strengthened to improve patient acceptance of statins. Statin tolerability was good with low discontinuation rates. Lipid-lowering therapy adjustments should be pursued during follow-up to improve LDL target achievement.Abstract OC66 Figure 1Flow chart detailing statin use in the cohort, stratified by cardiovascular risk. Abbreviations: BL, baseline; PWH, people with HIV