Table: Key stroke prevention strategies in HIV.

Primary prevention should focus on early initiation of ART and accurate assessment and optimization of vascular risk factors. Secondary prevention for non-cardioembolic strokes includes aspirin, high-intensity statin, and aggressive management of vascular risk factors. Carotid revascularization should be considered for moderate/severe stenosis. Cardioembolic strokes should be treated with anticoagulation.

Primary Prevention	Strategy
	Antiretroviral Therapy *
	Assess and optimize vascular risk factors (e.g., hypertension, hyperlipidemia, diabetes mellitus)
	Lifestyle modification (e.g., tobacco cessation)
Secondary Prevention	Ischemic Stroke Subtype	Strategy	Comments
	Small vessel disease	Aspirin	Consider short-term dual antiplatelet therapy Minor stroke/high-risk TIA: 21 days Symptomatic severe intracranial stenosis: 90 days Statin therapy: Atorvastatin or rosuvastatin: initiate at lowest recommended dose and monitor for adverse effects Pitavastatin: an alternative without significant DDI
	Intracranial stenosis	High-intensity statin** (atorvastatin or rosuvastatin)
	Carotid Atherosclerosis	Carotid revascularization for moderate/severe stenosis	CEA is preferred revascularization procedure for most patients
		Aspirin	Carotid stenting may be alternative to CEA for select patients (i.e. younger or low risk of endovascular complications)
		High-intensity statin** (atorvastatin or rosuvastatin)
	Atrial Fibrillation	Anticoagulation**	Integrase inhibitors do not have any significant DDI with DOACs
			Dabigatran is preferred for PLWH on PIs or NNRTIs
			Warfarin and Factor Xa inhibitors have DDI with ARVs that inhibit or induce CYP450 pathways

^*Careful selection of cART to avoid DDI and minimize vascular risk factors (consider avoiding abacavir if high baseline CVD risk)

^**Caution with DDI

CEA, carotid endarterectomy; TIA, transient ischemic attack; DDI, drug-drug interactions; DOACs, direct oral anticoagulants