Metabolic dysfunction-associated steatotic liver disease in people living with HIV: a framework for integrated screening and care

Metabolic & Liver Health Equity

Metabolic dysfunction-associated steatotic liver disease in people living with HIV: a framework for integrated screening and care

Sebastiani, Giada; Lee, Tzu-Hao; Cordie, Ahmed; Cinque, Felice; Lake, Jordan E.; Lazarus, Jeffrey V.; Rockstroh, Jürgen K.; Guaraldi, Giovanni

The Lancet HIV, 2024.

DOI: 10.1016/S2352-3018(26)00172-4

Research Topics Explored

This review examined the growing burden of metabolic dysfunction-associated steatotic liver disease (MASLD) in people with HIV, with a particular focus on liver fibrosis, screening, diagnosis, and management. We explored how HIV, antiretroviral therapy, metabolic risk factors, and chronic inflammation interact to drive liver disease, while also reviewing the epidemiology, natural history, and clinical consequences of MASLD in this population.

The review also examined emerging therapies, including weight-loss interventions and novel pharmacological treatments, and discussed how these advances can be integrated into routine HIV care. Particular attention was given to practical screening pathways, multidisciplinary care models, and current evidence gaps.

Methodologies Taken

This is a state-of-the-art narrative review that synthesizes evidence from clinical guidelines, large observational cohorts, randomized clinical trials, and recent regulatory approvals. Rather than simply summarizing the literature, we critically evaluated the quality of evidence and integrated findings across hepatology, infectious diseases, endocrinology, and cardiometabolic medicine.

We also proposed practical, evidence-based recommendations for clinicians, including screening algorithms, interpretation of non-invasive liver tests, management of metabolic comorbidities, and incorporation of emerging therapies into HIV care.

New Results Found

The review highlights how our understanding of liver disease in people with HIV has fundamentally changed.

MASLD has emerged as one of the most common chronic liver diseases in this population, yet it remains substantially under-recognized and under-screened despite effective non-invasive diagnostic tools being widely available.

We also show that the therapeutic landscape is rapidly evolving. Recent advances in obesity and MASLD treatment—including GLP-1 receptor agonists and resmetirom—have the potential to transform liver care, but people with HIV have largely been excluded from the pivotal clinical trials supporting these therapies. This creates an urgent need for HIV-specific evidence to ensure equitable access to emerging treatments.

Possible Impact Expected

For clinicians, this review provides a practical framework for integrating liver health into routine HIV care. By promoting earlier identification of advanced fibrosis using simple non-invasive tests and emphasizing management of metabolic risk factors, it can help shift practice from reactive treatment of advanced liver disease to prevention and early intervention.

For people living with HIV, earlier diagnosis means more opportunities to prevent cirrhosis, liver cancer, and cardiovascular complications. More broadly, the review highlights an important evidence gap: people with HIV should not be left behind as new MASLD therapies become available. We hope this work will encourage researchers, trial sponsors, guideline committees, and policymakers to ensure that future studies and treatment pathways are inclusive of this population.

Author Contact Information

Giada Sebastiani MD FAASLD

President, Canadian Association for the Study of the Liver
Professor of Medicine, Division of Gastroenterology and Hepatology, McGill University Health Centre

giada.sebastiani@mcgill.ca

Explore more articles

Metabolic & Liver Health Equity

Metabolic & Liver Health Equity

Metabolic dysfunction-associated steatotic liver disease in people living with HIV: a framework for integrated screening and care
Sebastiani, Giada et al.

The Lancet HIV, 2024.

10.1016/S2352-3018(26)00172-4
Read the summary
Global Metabolic & Liver Health Policy

Global Metabolic & Liver Health Policy

A global research priority agenda to advance public health responses to fatty liver disease
Lazarus, Jeffrey V. et al.

Journal of Hepatology, Volume 79, Issue 3, 618 - 634

http://doi.org/10.1016/j.jhep.2023.04.035
Read the summary

U53R_4N7H0NY2026-09-17T10:14:12+00:00

Registration fees

All applications for registration will be reviewed, and you will be notified of your invitation status and fee via email within one week.

Category	Early Bird (before 1 April)	After / onsite
Private Sector/Industry	295	350
Start-up*	95	150
Healthcare Professional, Academic, Public Health/Professional Association, NGO	75	100
Young Researcher / Trainee / PostDoc / Student / Young Person (under 25) *	45	60
Patient with lived experience *	free	free
Patient or Patient Representative *	45	50

* Registration fee scholarship offered on application, please email: lisa.rice@isglobal.org

Criteria for start-ups:

Early-stage startup (e.g., pre-seed, seed, or Series A).
Incorporated for under 5 years
Raised under $5 million in funding
Annual revenue less than $1 million
Fewer than 50 employees

What’s included in your ticket?

Entry to lunch main agenda sessions 1pm-7pm on 26 May and evening reception

5. Strengthen the capacity of community health services to prevent and treat MASLD through social prescribing

Primary care has a well-established network of health centres across Spain. In the last years, there has been an increase in the number of community-based activities promoting well-being and reducing the metabolic risk profile through social prescribing. These activities usually integrate exercise through increasing physical activity.⁴⁵ Strengthened primary care systems can reinforce the role of community health services by incorporating social prescribing models to address lifestyle drivers of MASLD in vulnerable populations, such as physical activity, which is a recommended first-line therapy of people with MASLD, and can improve psychosocial health,⁴⁶ which is often reported as poor by people living with MASLD.⁴⁶ By facilitating participation in community-based activities like group exercise, arts, or wellness programs, social prescribing addresses both physical inactivity and the isolation or low mood commonly seen in this population.⁴⁷ In Catalonia, the Programa de Prescripció Social i Salut exemplifies this approach by linking patients to local community assets via an integrated system in primary care, particularly targeting conditions such as anxiety, depression, and social isolation,⁴⁴ and which may be beneficial for people living with MASLD/MASH. Elsewhere, social prescribing has demonstrated benefit for people living with diabetes.⁴⁸ Evaluation data from Catalonia show that over 70% of participants report improvements in emotional well-being and social support after engaging in prescribed community activities frequently related to physical activity.⁴⁴

5. Leverage electronic health records (EHR) through integrated automated diagnostic tools

Integrating MASLD/MASH screening algorithms into existing EHR systems can substantially enhance early detection and risk stratification in primary and secondary care. Automated tools such as intelligent liver function testing (iLFT)—which systematically interprets routine liver function tests, performs reflex testing, and identifies likely liver diseases for physicians to consider—have shown promise in improving early diagnosis and care pathways, particularly in underdiagnosed conditions like MASLD and MASH.⁴³ In the Spanish context, where nearly 10 million individuals may be living with MASLD by 2030,³ embedding such tools in the primary care EHR systems used across autonomous communities could standardise assessment, reduce diagnostic delays, and promote timely secondary referrals. Moreover, this approach complements digital transformation priorities already outlined in Spain’s National Health System and aligns with the objectives of the Strategic Framework for Primary and Community Care (2019).^26,44

4. Increase awareness and education of MASLD/MASH among at-risk groups and healthcare professionals

Enhancing awareness of MASLD/MASH among both at-risk populations—such as those living with obesity, diabetes, and metabolic syndrome—and frontline healthcare workers is critical for early identification, appropriate risk stratification and timely intervention. Given its silent clinical course, MASLD is often underdiagnosed until advanced stages, particularly in primary care settings where patients with obesity, diabetes, or metabolic syndrome are commonly managed.

Spain’s Strategic Framework for Primary and Community Care (2019) already emphasises chronic disease prevention, making it an ideal entry point for MASLD/MASH education.²⁶ Yet, existing knowledge gaps among primary care providers regarding liver disease etiology, progression, and appropriate screening necessitate awareness or education campaigns and professional training modules that build the knowledge and clinical skills needed to manage MASLD in frontline settings.^24,41 A cohesive and comprehensive educational strategy is essential and could begin with the integration of MASLD/MASH-specific content into undergraduate, specialty, and continuing medical education curricula to foster competency in metabolic hepatology across the care continuum. A national interdisciplinary training strategy could bring together professionals from family medicine, endocrinology, cardiology, nephrology, internal medicine, endoscopy, clinical nutrition, and hepatology to address MASLD/MASH as a complex, multisystemic disorder.

A comprehensive communication and engagement health literacy strategy should position MASLD/MASH as serious, progressive, and multisystemic conditions. This involves dismantling the minimising narrative of “fatty liver” and clearly linking MASLD to major outcomes such as cardiovascular, renal and metabolic disease. Such a campaign should incorporate the concept of MetALD, which captures the under-recognised harm of moderate alcohol use in people with MASLD. Establishing a national MASLD/MASH patient platform would also enable the co-design of care pathways, educational materials, public campaigns, and research priorities, ensuring patient-centered policy and practice.

Finally, it is critical to explicitly position MASLD within the cardio-renal-metabolic axis, evolving toward a CHRM model (cardiovascular-hepatic-renal-metabolic).⁴² This paradigm recognises the liver as a pivotal organ in systemic metabolic dysfunction. The CHRM paradigm reflects the shared pathophysiology and clinical trajectories of MASLD, T2DM, chronic kidney disease, and cardiovascular disease. Scientific societies and patient organisations in Spain must collectively support and disseminate this integrative model, aligning MASLD policy with broader strategies for non-communicable diseases.

3. Add MASLD/MASH as an indicator to the list of Key Health System Indicators

Despite the rising clinical, social, and economic burden of MASLD, this condition is not currently included among Spain’s Key Health System Indicators, which guide monitoring, evaluation, and resource distribution across the National Health System.14 Integrating MASLD/MASH as a formal indicator would recognise the disease as a strategic health priority by integrating it into the national health information system, guiding decision-making on screening, diagnosis, and care pathways. Failure to track this disease risks underestimating its long-term economic and public health impacts. Incorporation into the indicator framework aligns with Spain’s commitment to data-driven governance and would support benchmarking across autonomous communities. To support targeted local action on MASLD, tools at the autonomous community level should be developed to guide policy and programme implementation. A MASLD risk index, combining aggregated clinical data, social determinants of health, and population-level metrics, can help identify high-need areas and inform municipal-level screening strategies. In parallel, a MASLD Impact Score should be created to assess the effectiveness of local policies related to metabolic health, food regulation, healthy environments, early detection practices, and workforce training. This metric could be implemented through municipal initiatives such as the upcoming “Santander se mueve” health promotion program, set to launch in September 2025.

2. Create a national MASLD registry, cohort, or observatory

Establishing a national MASLD registry, cohort or observatory is a critical step toward advancing clinical management, research, and policy evaluation. A national registry would enable the systematic collection of epidemiological, clinical, and sociodemographic data, essential for monitoring disease prevalence and progression, identifying high-risk subgroups, and assessing territorial disparities in access to care. While the Epidemiological sTudy of Hepatic infectiONs (ETHON) cohort estimated that 1.33%% of the Spanish population from 2015-2020 had MASH with fibrosis (stage F2-F3), these findings are limited to participants from primary care centers in Madrid, Santander and Valencia.^12,39 Additionally, while national clinical registries like HEPAmet and REGHNA (focused on hospital settings) provide important data, they are not population-based, nor are they consistently linked with public health surveillance systems.⁴⁰ A standardised and centralised MASLD registry would enable longitudinal tracking of this more prevalent disease, facilitate research on progression and treatment outcomes, and help evaluate the impact of interventions over time. Furthermore, registry data could support regional health planning and inform clinical practice guidelines aligned with Spain’s digital health transformation efforts.

1. Launch a Ministry of Health-led whole-of-government strategy

The growing prevalence of MASLD and MASH in Spain—projected to affect over 27% and 5.9% of the population, respectively, by 2030—necessitates an integrated, cross-sectoral policy response,³ led by an intersectoral working group under the leadership of the Ministry of Health. This whole-of-government initiative could facilitate the mainstreaming of MASLD/MASH into key national strategies addressing chronic diseases in general, and obesity, diabetes, and cardiovascular health specifically through a “health in all policies” approach. These strategies include the Strategy for Addressing Chronic Diseases (2012),²⁷ the Diabetes Strategy (2006)²⁸ and its 2012 update²⁹, and the Cardiovascular Health Strategy (2022),³⁰ where MASLD/MASH remain largely underrepresented despite their metabolic underpinnings. This omission contributes to fragmented care and missed opportunities for early intervention. Systematic integration of MASLD across these strategies would allow Spain to align with recommendations from the EASL–Lancet Liver Commission, which urges countries to address liver diseases through upstream, equity-based, and multisectoral policies.³²

Crucially, national leadership must be paired with urban action. Cities are where obesogenic environments, food insecurity, and social inequalities converge with high diabetes and obesity prevalence. An initiative to address this, “MASH Cities,” calls on municipalities to integrate MASLD/MASH into local health promotion, food policy, urban mobility, and primary care services to mitigate disease progression.³³ Major cities in Spain should consider joining this growing platform for sharing learned lessons and best practices. Empowering cities with the mandate and resources to act on liver health can serve as a scalable, equitable response to this growing challenge, as was proposed for Barcelona in May 2025.³⁴

Additionally, inclusion of MASLD/MASH in Spain’s Public Health Surveillance Strategy (2022)³⁵ could strengthen early detection and monitoring by enabling systematic data collection and risk assessment in both health and non-health sectors, such as urban planning and food policy. Primary care would be central to this approach, serving as the frontline for MASLD screening, risk stratification, and referral. Integration can help standardise primary care practices, including routine FIB-4 risk stratification of individuals with obesity, T2D, metabolic syndrome, or hepatic steatosis—which are often undetected until advanced stages.³⁶ Primary care should be adequately funded and equipped to screen, stratify, manage cardiometabolic risks, and refer high-risk patients, forming the backbone of MASLD/MASH prevention and control at the national, autonomous community, and city levels.^37,38