More than 40% of HIV group has hepatic steatosis, regardless of age

Mark Mascolini,

In a study of 168 US adults with HIV, 39% of those 50 or older and 49% of younger people had hepatic steatosis (fatty liver disease), a nonsignificant difference. [1]

Compared with younger people with steatosis, older people with steatosis were more likely to be women, to have cirrhosis, and to have HIV infection longer.  

Fatty liver disease – defined as 5% or greater hepatic steatosis – remains highly prevalent in HIV populations with and without hepatitis virus coinfection. A US study of 62 HIV positive adults with elevated aminotransferase while taking antiretrovirals but without chronic hepatitis infection found that 34 (55%) had nonalcoholic steatohepatitis determined by liver biopsy and predicted by insulin resistance and obesity. [2]

Using a hepatic steatosis index based on transaminases, body mass index, gender, and presence or absence of diabetes in 796 Canadian patients with HIV but without chronic hepatitis, a Montreal team charted a steatosis incidence of 6.9 per 100 person-years. [3]

Researchers from University of Texas Health in Houston and other centres noted that, as a metabolic inflammatory disease, fatty liver disease has the greatest impact on morbidity and mortality via cardiovascular disease, not progressive liver disease.   

To learn more about steatosis prevalence, risk factors, and biomarkers in people with HIV, these investigators enrolled 168 people in a cross-sectional study. All participants underwent FibroScan to determine controlled attenuation parameter (CAP, a steatosis measure) and liver stiffness measurement (LSM, a fibrosis and cirrhosis indicator).

The researchers defined significant hepatic steatosis as CAP greater than 260 dB/m. They used quantile regression to determine factors associated with CAP. A subset analysis presented at the HIV and Ageing Workshop compared outcomes in people 50 or older with outcomes in younger people.   

The study group was 58% male, 31% female, and 11% transgender women. There were 90 people 50 or older and 78 younger than 50. Overall age averaged 51 years, body mass index 29 kg/m2(near the top of the overweight range), CD4 count 640, time with HIV infection 14 years, and time taking antiretrovirals 9 years. About 96% of the group was nonwhite.  

Significant steatosis affected 39% of people 50 or older and 49% of the younger group. Among people with steatosis, average CAP was marginally and nonsignificantly lower in the older group (256 versus 266 dB/M, p >/= 0.05), while LSM was nonsignificantly higher (worse) in older participants (6.1 versus 5.4 kPa, p >/= 0.05). Average body mass index was similar in older and younger people with fatty liver disease (32.9 and 31.5 kg/m2, p=0.45).  

Older participants with fatty liver disease were more likely to be female than younger patients with fatty liver disease (43% versus 29%, p=0.005). The older group with fatty liver disease had a higher cirrhosis prevalence than the younger group with fatty liver disease (14% versus 0%, p=0.02), and the older group with fatty liver disease had a marginally higher HCV frequency (29% versus 12%, p=0.08). The older and younger groups with fatty liver disease did not differ significantly in current smoking, hyperlipidaemia, or diabetes.   

Two HIV variables differed significantly between older and younger people with fatty liver disease: The older group had a significantly longer duration of HIV infection (average 16 versus 12 years, p=0.009) and significantly more years on antiretroviral therapy (average 12 versus 7 years, p=0.0003). But the older and younger groups with fatty liver disease did not differ significantly in current CD4 count, viral load below 50 copies, history of AIDS, or type of antiretroviral therapy. Nor did the older and younger groups with fatty liver disease differ significantly in an array of markers: adiponectin, hs-IL-6, PCSK9, FGF21, fetulin A, or FABP-4.   

Compared with older people without fatty liver disease, older individuals with fatty liver disease were more likely to be obese (average body mass index 32.9 versus 26.5 kg/m2, p <0.0001) and to have higher fetulin A, a liver-derived blood protein that inhibits insulin receptor tyrosine kinase associated with insulin resistance [4] (average 836 versus 665 ug/mL, p=0.003). Older people with fatty liver disease tended to include a higher proportion of Hispanics and to have higher rates of cirrhosis and high triglycerides but less prevalent cardiovascular disease.   

The researchers underlined obesity as a major clinical factor tied to hepatic steatosis in older people with HIV. Preventing and treating obesity in older and younger people, they proposed, are crucial to preventing hepatic steatosis with advancing age.    


  1. Lake J et al. Hepatic steatosis is common in both younger and older adults living with HIV and associated with divergent immuno-metabolic profiles. 9th International Workshop on HIV and Aging, September 13-14, 2018, New York. Abstract 7.  
  2. Morse CG et al. Nonalcoholic steatohepatitis and hepatic fibrosis in HIV-1-monoinfected adults with elevated aminotransferase levels on antiretroviral therapy. Clin Infect Dis. 2015;60:1569-1578. 
  3. Sebastiani G et al. Incidence and predictors of hepatic steatosis and fibrosis by serum biomarkers in a large cohort of human immunodeficiency virus mono-infected patients. Open Forum Infect Dis. 2015;2:ofv015.  
  4. Dabrowska AM et al. Fetuin-A (AHSG) and its usefulness in clinical practice. Review of the literature. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2015 Sep;159:352-359.

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