A useful case study for examining how steatotic liver disease can be addressed in people living with HIV

Yet even in a strong system like Spain’s, SLD in this population is rarely framed as a condition requiring systematic recognition or monitoring.

– Juan M Pericàs, MD MPH PhD, Leader, Liver & Metabolism Team, Vall d’Hebron University Hospital, VHIR

Spain provides a useful case study for examining how steatotic liver disease (SLD) can be addressed in people living with HIV. In high-income countries like Spain, the HIV care system is well established with long-term follow-up; there are often high rates of people on antiretroviral therapy and with suppressed viral loads. Yet, beyond viral suppression, people living with HIV tend to experience more multimorbidity.

People living with HIV tend to age faster than those without HIV, facing distinct and amplified risks, often including the onset of SLD. People living with HIV are more likely to develop SLD earlier, with faster progression driven by metabolic dysfunction, chronic inflammation, and some behavioural risks. Furthermore, multiple cardiometabolic risk factors, past or present viral infections potentially leading to chronic hepatitis, as well as alcohol consumption are frequently observed in routine HIV care. As such, the prevalence of liver conditions within the SLD spectrum is high in this population.

Yet even in a strong system like Spain’s, SLD in this population is rarely framed as a condition requiring systematic recognition or monitoring. How to overcome this gap offers lessons that extend beyond the country.

Depending on the country, the prevalence of SLD in people living with HIV is often higher than that of the general population (e.g., particularly those older than 50 years). For this reason, it is important to consider this group as a distinct sub-population, given both their risk of developing SLD and the higher likelihood of more aggressive disease in a subset of patients. 

However, in most settings, including HIV clinics, SLD is still not systematically screened for, much as viral hepatitis was for many years, even after curative treatments for HCV became available. In Spain, healthcare providers are increasingly aware of the significant risk of liver disease associated with the notable metabolic burden and other non-communicable diseases affecting people living with HIV.

However, we still have room for improvement when it comes to education, health promotion and prevention, and screening for SLD and liver fibrosis. We must shift the paradigm to extend our focus beyond viral hepatitis to newer forms of liver disease that require a more nuanced approach to assessment. This, of course, takes time for both health systems and patients to become aware of this transition and adapt accordingly. But it is critical. 

Beyond this, we should also comment on addressing the gaps in the available scientific knowledge of SLD in people living with HIV. This sub-population has been almost systematically excluded from the largest SLD cohort studies and clinical trials because of the presence of those specific risk factors that relate to the development of a steatotic liver: progression towards steatohepatitis, advanced fibrosis and cirrhosis; as well as cardiometabolic, neoplastic and liver-related complications. Furthermore, we could do more to elucidate the role of the social and commercial determinants of health and equity, such as gender, socioeconomic position or food insecurity in shaping the distribution and outcomes of SLD in people living with HIV. In Spain, citizens and legal residents are guaranteed access to healthcare services, which closes much but not all of the gap on treatment and management. 

Although most care provided to people living with HIV, including managing cardiometabolic and behavioural risks such as smoking and alcohol use is centralised in HIV clinics, each point of contact with the healthcare system, including routine health checks in both primary and HIV care, should be used as an opportunity to assess risk, provide counselling and treatment to address risk factors, and, when indicated, screen for SLD and liver fibrosis. Screening tools such as serum biomarkers (e.g., FIB-4, ELF) and imaging techniques (e.g., transient elastography, ultrasound) should be widely available to use in the routine clinical care of people living with HIV to enable early detection of liver disease, risk stratification, and timely preventive interventions before progression to advanced fibrosis or cirrhosis. 

Currently, Spain offers an emerging example for improving the integration and monitoring of SLD in HIV care, with early efforts to begin strengthening collaboration between HIV clinics and endocrinology and hepatology services to enable systematic screening and multidisciplinary management. While not without limitations, it highlights the potential of a model that could be replicable across different levels of care, particularly primary care, supported by a broad education and training strategy and effective labs that can automate testing.

Most importantly, the central takeaway is clear: addressing steatotic liver disease as a public health threat cannot rely solely on data from the general population.

Groups with earlier onset of SLD, faster progression, and distinct risk profiles, such as people living with HIV, are essential if we are to understand the true burden of the disease and implement impactful change in management and care. Making SLD visible in people living with HIV is not a niche concern. It is necessary in building equitable, preventive, and effective responses to SLD at a population level.

This expert commentary was reviewed by Anthony Armenta, Trenton White and Jeffrey Lazarus.

Further reading