Steatotic Liver Disease Subtypes in People Living with HIV: Mortality and Cardiovascular Risks in

Background and aims

Steatotic liver disease (SLD) is an emerging comorbidity among people living with human immunodeficiency virus (PLWH). The relative frequency of SLD subtypes and their associations with mortality, cardiovascular disease, and liver cirrhosis in PLWH were unclear. This study evaluated the prevalence of SLD and subtype-specific relationships with all-cause mortality, incident cardiovascular diseases, and liver cirrhosis in a national Korean cohort.

Methods

This retrospective cohort study used National Health Insurance Service data covering 2013–2022. The analytic cohort included 4,597 Korean PLWH. Steatotic liver disease was defined using the fatty liver index (FLI) ≥30. SLD cases were categorized into three subtypes: metabolic dysfunction–associated SLD (MASLD), alcohol-associated liver disease (ALD), and metabolic dysfunction–associated ALD (MetALD).

Outcomes of interest were all-cause mortality, incident cardiovascular diseases, and incident liver cirrhosis (LC). Time-to-event analyses used multivariable Cox proportional hazards models for mortality and Fine-Gray competing risk models for outcomes where competing risks were relevant. The study compared SLD prevalence in PLWH with matched controls from the same database. The abstract reports adjusted effect estimates; the full set of covariates included in multivariable models is not detailed in the abstract.

Results

Prevalence and subtype distribution

• Among 4,597 PLWH, the overall prevalence of SLD was 45.7%.
• Within the SLD group, the majority had MASLD (86.5%), with MetALD comprising 9.7% and ALD 3.8%.
• The prevalence of SLD in PLWH was not higher than that observed in matched control subjects from the same dataset.

Outcomes over follow-up

• Median follow-up was 6 years. Over this period, presence of SLD in PLWH was associated with increased all-cause mortality. The adjusted hazard ratio (aHR) for mortality in participants with SLD was 1.53 (95% confidence interval [CI], 1.03–2.29).

Subtype-specific cardiovascular and hepatic outcomes

• ALD subtype was associated with an increased risk of stroke in competing risk analysis: adjusted subdistribution hazard ratio (aSHR) 3.10 (95% CI, 1.04–9.20).
• MetALD was associated with an increased risk of liver cirrhosis: aSHR 5.72 (95% CI, 1.48–22.10).

Analytic approaches reported in the abstract included multivariable Cox proportional hazards models for mortality and Fine-Gray competing risk models for other outcomes; the abstract provides the key adjusted effect estimates above.

Conclusions

In this national cohort of Korean PLWH, nearly half had steatotic liver disease by fatty liver index criteria, with metabolic dysfunction–associated disease representing the large majority of cases. Presence of SLD was independently associated with higher all-cause mortality over a median 6-year follow-up. Subtype-specific risks were observed: ALD carried a higher risk of stroke, and MetALD conferred a substantially increased risk of progression to liver cirrhosis. The authors emphasize the need for integrated management that addresses liver health, metabolic dysfunction, and alcohol use among PLWH to mitigate adverse outcomes.

Clinical implications and recommendations

• Screening for fatty liver using validated indices such as the fatty liver index may identify a substantial proportion of PLWH with SLD; in this cohort 45.7% met the FLI threshold used.
• Given the association between SLD and increased all-cause mortality, clinicians caring for PLWH should consider assessing liver steatosis and metabolic risk factors as part of routine care.
• Subtype recognition matters: those with alcohol-related disease may have elevated cerebrovascular risk, and those with combined metabolic and alcohol-related features (MetALD) may be at particular risk for progression to liver cirrhosis.
• Integrated interventions targeting metabolic dysfunction, alcohol use, and liver health are indicated to reduce the burden of adverse cardiovascular and hepatic outcomes in this population.

Limitations and data gaps

• The abstract does not report the specific covariates included in multivariable adjustment, detailed baseline characteristics, event counts for each outcome, or sensitivity and subgroup analyses; these details would require review of the full text.
• SLD classification relied on a fatty liver index threshold (FLI ≥30); diagnostic performance of this threshold and potential misclassification are not discussed in the abstract.
• Information on antiretroviral therapy regimens, HIV disease markers (e.g., CD4 count, viral load), and temporal relationships between HIV care and SLD onset are not provided in the abstract and therefore were not available for inclusion here.

Overall, the study supports that SLD is common among PLWH and that subtype-specific assessment and management—particularly addressing metabolic dysfunction and alcohol use—are important to reduce mortality and organ-specific complications.