Uncovering the NAFLD burden in people living with HIV from high‐ and middle‐income nations: a meta‐analysis with a data gap from Subsaharan Africa

Abstract

Introduction Non‐alcoholic fatty liver disease (NAFLD) has become a significant concern among people living with HIV (PLHIV), albeit its burden remains unclear. The primary objective of this systematic review (SR) and meta‐analysis (MA) was to estimate the prevalence of NAFLD and significant fibrosis in PLHIV. The secondary objective was to determine the risk factors for NAFLD among PLHIV. Methods We searched MEDLINE and Scopus from inception to 30 December 2022 for peer‐reviewed studies that included PLHIV and reported the prevalence of NAFLD. MA of proportions was used to estimate the pooled prevalence of NAFLD and significant fibrosis. MA of pre‐calculated effect estimates examined risk factors for NAFLD in PLHIV. Results We included 24 articles published between 2009 and 2022, encompassing 6326 PLHIV. The pooled prevalence of NAFLD was 38% (95% CI: 31–45%) with high heterogeneity (I2 = 96.3%). The pooled prevalence of significant fibrosis was 13% (95% CI: 8–18%) with high heterogeneity (I2 = 92.09%). Subgroup analyses showed a NAFLD prevalence of 40% (95% CI: 24–57%) in the United States, 33% (95% CI: 31–36) in Asia, 42% (95% CI: 24–61%) in Europe and 33% (95% CI: 29–37) in South America. When stratifying by income level, NAFLD was 39% (95% CI: 31–48) prevalent in PLHIV from high‐income economies and 34% in both upper‐middle‐income (95% CI: 31–37%) and lower‐middle‐income economies (95% CI: 28–41%). Higher body mass index (BMI) (OR = 1.32, 95% CI: 1.13–1.55; I2 = 89.9%), increasing triglycerides (OR = 1.48, 95% CI: 1.22–2.79; I2 = 27.2%) and dyslipidaemia (OR = 1.89, 95% CI: 1.32–2.71; I2 = 15.5%) were all associated with higher risk‐adjusted odds of NAFLD in PLHIV. Discussion The burden of NAFLD and significant fibrosis in PLHIV is significant. Therefore, targeted efforts to screen and diagnose NAFLD in this population are needed. Health services for PLHIV could include ways to target NAFLD risk factors, screen for liver disease and implement interventions to treat those with significant fibrosis or more advanced stages of liver disease. Taking no action to address NAFLD in PLHIV should not be an option. Conclusions This SR and MA found a 38% NAFLD and 13% significant fibrosis prevalence in PLHIV. Increasing triglyceride levels, higher BMI values and dyslipidaemia were associated with higher risk‐adjusted odds of NAFLD among PLHIV.

Metabolic causes of liver disease among adults living with HIV from low‐ and middle‐income countries: a cross‐sectional study

“…Although liver fibrosis and steatosis were important in all sites, the highest prevalence was reported in India, Brazil and Mexico. Our findings are corroborated by findings of a more recent meta-analysis reporting a higher prevalence of liver fibrosis and steatosis in PLHIV from Asian and South American countries compared to sub-Saharan African countries [9,13]. These differences could be partly related to the higher prevalence of metabolic disorders observed in India, Brazil and Mexico, identified as important risk factors for liver steatosis and its progression [13].…”

“…In high‐income countries, liver steatosis has increased significantly among PLHIV, and is often secondary to the metabolic syndrome and its components (T2DM, hypertension and dyslipidaemia), and mitochondrial damage leading to insulin resistance and dyslipidaemia [ 8 , 9 ]. Furthermore, some ART drugs, especially some first‐generation ART drugs, could induce lipolysis and mitochondrial dysfunction, leading to steatosis [ 10 ].…”

Liver Steatosis is Prevalent in Lean People With HIV and Associated With Exposure to Antiretroviral Treatment—A Cross-sectional Study

“…The reported prevalence's of liver steatosis and fibrosis in PHIV vary considerably, primarily because of the heterogeneity of the studied populations. A recent systematic review including 24 studies estimated a pooled steatosis prevalence of 38% (95% CI, 31-45) and a pooled fibrosis prevalence of 13% (95% CI, 8-18) in high- and middle-income countries, both with significant heterogeneity [ 27 ].…”

Editorial: Enriching our understanding of MASLD through representation of under‐reported populations

“…3 Data regarding MASLD in people with HIV is sparse, with a notable gap from Sub-Saharan Africa. 4 In the current manuscript, authors from Karolinska University (Sweden), Rakai Health Sciences Program (Uganda) and Johns Hopkins University (USA) aimed to non-invasively determine the prevalence and risk factors of MASLD among black people between 35 and 49 years old, with and without HIV, enrolled in a recent crosssectional survey conducted between May 2016 and May 2018 at the existing Rakai Community Cohort Study (RCCS) in Uganda. 5 After excluding pregnant females and recent alcohol drinkers, MASLD prevalence was 12%, and less than 1% had advanced fibrosis (AF).…”

“…Our current understanding of MASLD, is largely dictated by literature based on Western cohorts 3 . Data regarding MASLD in people with HIV is sparse, with a notable gap from Sub‐Saharan Africa 4 …”