This analytical cross-sectional study included PLWH receiving follow-up care at the infectious diseases outpatient clinic of Hospital das Clínicas, Federal University of Pernambuco (HC/UFPE), a regional referral center in northeastern Brazil.

Potential participants were identified through an active search of the outpatient clinic database. Individuals aged 60-years or older who met the predefined eligibility criteria were contacted by telephone and invited to participate in the study. Those who agreed to participate attended a dedicated study visit, during which eligibility was confirmed and clinical, laboratory, and imaging assessments were performed. Individuals with active Hepatitis B (HBV) or Hepatitis C (HCV) coinfection, notable frailty (defined as inability to walk) or alcohol consumption ≥ 50 g/day (350 g/week) for women and ≥ 60 g/day (420 g/week) for men were excluded to avoid enrolling individuals with Alcohol-related Liver Disease (ALD).10 Individuals with decompensated Heart Failure (HF), previously treated viral hepatitis (HBV or HCV), liver malignancy (primary or metastatic), or schistosomiasis with moderate or severe periportal fibrosis were excluded from the analysis of fibrosis assessed by point Shear-Wave Elastography (pSWE).

Data collection was performed based on structured interviews and through consultation of medical records. Furthermore, standardized instruments were used to record sociodemographic information, lifestyle habits, geriatric evaluation, anthropometric data, clinical history, current and past use of antiretroviral drugs and laboratory tests. Lipodystrophy was defined based on self-reported previous diagnosis, self-reported body fat redistribution suggestive of lipodystrophy (including fat accumulation in the posterior cervical region and abdomen and fat loss in the face, gluteal region, or limbs), or documentation of lipodystrophy in the medical records. Alcohol consumption was assessed through a structured face-to-face interview. Participants were asked about the type of alcoholic beverage, drinking frequency, and the average amount consumed per week. Weekly alcohol intake was converted into grams of ethanol using the standard drink definition of 14 g of ethanol (one serving of spirits, one can of beer, or one glass of wine).

The data referenced in this study were collected and managed with the assistance of Research Electronic Data Capture (REDCap) electronic data capture tools hosted by UFPE. Clinical and laboratory data were obtained from medical records and the Brazilian national HIV information systems for laboratory monitoring (SISCEL) and antiretroviral drug dispensation (SICLOM).

The cardiometabolic criteria considered in this study were based on the 2009 harmonized International Diabetes Federation (IDF) definition of metabolic syndrome, which defines metabolic syndrome as the presence of at least three of the following components: increased waist circumference (> 90 cm in men and > 80 cm in women, according to cutoffs for Latin American populations), elevated fasting glucose (≥ 100 mg/dL), previous diagnosis of type 2 diabetes or glucose-lowering treatment, elevated blood pressure (systolic ≥ 130 mmHg and/or diastolic ≥ 85 mmHg, or antihypertensive treatment), elevated triglycerides (≥ 150 mg/dL or lipid-lowering treatment), and reduced HDL cholesterol (≤ 40 mg/dL in men and ≤ 50 mg/dL in women).11

Ultrasound evaluation was performed by two medical researchers who have extensive experience and training in abdominal imaging. The classification of hepatic steatosis was performed based on traditional ultrasound criteria, considering the increase in hepatic echogenicity in comparison with the right renal cortex, the posterior attenuation of the ultrasound beam and the difficulty of visualizing the intrahepatic vessels and diaphragm. Steatosis was classified as mild, moderate or severe in accordance with these parameters.

To evaluate liver fibrosis, elastography was performed using the pSWE technique, with the goal of evaluating the Liver Stiffness Measure (LSM). In this context, a 3.5 MHz convex transducer was used, alongside SIEMENS ACUSON-2000 equipment. A total of 10 valid measurements were obtained in the right hepatic lobe, and the median Shear Wave propagation Velocity (SWVmed) was recorded. Exams with a variability index (IQR/median) of <15% and a success rate greater than 80% were considered as criteria for adequate technical quality of the exam.12 The LSM values were interpreted according to the criteria associated with the METAVIR system, in which context the cut-off points for shear wave velocity were as follows: F0‒F1 (velocity < 1.34 m/s), F2 (≥ 1.34 m/s), F3 (≥ 1.55 m/s) and F4 (≥ 1.80 m/s). Significant fibrosis was defined as a fibrosis stage of F2 or higher.13

Statistical analysis was conducted with the assistance of STATA/SE version 12.0 and Microsoft Excel 365 software. All tests were performed at a significance level of 5% (p ≤ 0.05), and only valid answers were considered, whereas missing or ignored data were excluded. The results are presented in the form of tables, which include absolute and relative frequencies for categorical variables, alongside measures of central tendency and dispersion for numerical variables.

To verify the associations among the categorical variables, Pearson's Chi-Square test or, where appropriate, Fisher's exact test was applied. The normality of the quantitative variables was assessed by performing the Shapiro-Wilk test. For comparisons between two independent groups, Student's t-test was used when the data were normally distributed, and the Mann-Whitney test was used when the data were nonnormally distributed. In comparisons involving more than two groups, an Analysis of Variance (ANOVA) was conducted for normally distributed data, and the Kruskal-Wallis test was used in other cases.

In the bivariate analysis, variables with a p-value ≤ 0.20 were considered for inclusion in the multivariable model. Multivariable analysis was performed using Poisson regression with robust variance, and all selected variables were entered simultaneously into the model. The final selection of variables was based on the strength of the bivariate association, biological plausibility, previous literature, and the authors' clinical judgment, while considering the sample size to reduce the risk of model overfitting. Missing data were assessed for all variables included in the analyses. As the proportion of missing data was low across all variables, complete-case analysis was performed, and no imputation procedures were applied.

The present study was approved by the Research Ethics Committee of HC/UFPE under protocol numbers 5,958169 and CAAE 74,119,223.1.0000.8807. All participants signed a free and Informed Consent Form (ICF) before their inclusion in the study.

The final study sample consisted of 92 older PLWH, who were evaluated from January to July 2024. All patients in the final sample underwent ultrasound and p-SWE to assess hepatic steatosis and fibrosis (Fig. 1).

Fig. 1.

Flow diagram of the study population. PLWH, People Living With HIV; HBV, Hepatitis B Virus; HCV, Hepatitis C Virus; p-SWE, point Shear-Wave Elastography; MASLD, Metabolic Dysfunction-Associated Steatotic Liver Disease.

Table 1 presents the demographic, clinical, laboratory, and ultrasonographic characteristics of the 92 older PLWH according to the presence and severity of hepatic steatosis. Table 2 presents the HIV-related characteristics of the 92 older PLWH according to the presence and severity of hepatic steatosis.

According to the Lipschitz BMI classification for older adults, 20 participants (21.7%) were classified as underweight (BMI < 22 kg/m2), 38 (41.3%) had normal weight (BMI 22–27 kg/m2), and 34 (37.0%) were classified as overweight (BMI > 27 kg/m2). Regarding age distribution, 73 participants (79.3%) were aged 60–69 years, 18 (19.6%) were aged 70–79 years, and 1 (1.1%) was aged ≥ 80-years.

Most participants were functionally independent, with 97.8% being independent in Activities of Daily Living (ADLs). Regarding frailty status, 72.8% were classified as robust, 17.4% as pre-frail, and 9.8% as frail according to the FRAIL scale. Regarding antiretroviral treatment, 53.3% of the participants were receiving a regimen containing lamivudine (3TC) and DTG; 16.3% were receiving Darunavir with Ritonavir (DRV/r) plus DTG; 12% were receiving 3TC, Tenofovir (TDF) and DTG; 8.7% were receiving 3TC and DRV/r; 4.3% were receiving 3TC, TDF, and DRV/r. The remaining participants received various regimens that included Zidovudine (AZT), Nevirapine (NVP) or Efavirenz (EFV) in combination with 3TC, DTG, TDF or DRV/r.

Hepatic steatosis was identified in 53.3% of participants (n = 49). In the overall sample, steatosis was classified as mild in 23 participants (25.0%) and moderate-to-severe in 26 (28.3%) (moderate, n = 18; severe, n = 8).

Among older PLWH with hepatic steatosis, 46 (94%) reported low-risk alcohol consumption and had at least one cardiometabolic risk factor; therefore, these patients met criteria for MASLD.10 Three patients with SLD reported alcohol consumption between 20 and 50 g/day among women or between 30 and 60 g/day among men. These patients were classified as MASLD with increased alcohol intake (MetALD).14

Among participants with hepatic steatosis, two patients were excluded from the analysis of MASLD-associated fibrosis: one due to previously treated HCV infection and the other due to not meeting the technical quality criteria for hepatic elastography. Among the 47 individuals included in this analysis, 89.4% were classified as F0/F1, whereas 5 (10.6%) had significant fibrosis (≥ F2), including 4 with F2 fibrosis and 1 with F4 fibrosis. Regarding the FIB-4 score, among individuals with hepatic steatosis, 7 (14.3%) had FIB-4 values < 1.3, 38 (77.6%) had values between 1.3 and 2.67, and 4 (8.2%) had values > 2.67. None of the participants with values below 1.3 presented significant hepatic fibrosis on elastography.

The presence of hepatic steatosis was significantly associated with several clinical and anthropometric factors: higher body weight, higher BMI values, increased waist circumference, increased calf circumference and the presence of metabolic syndrome. With respect to laboratory parameters, individuals with SLD exhibited higher fasting glucose levels, HbA1c levels, platelet counts and triglyceride levels.

Multivariable Poisson regression analysis was performed to evaluate factors independently associated with the presence of liver steatosis (Table 3). After adjustment, increased waist circumference, higher BMI, and higher HbA1c levels remained significantly associated with liver steatosis.

Among 49 older PLWH with MASLD, 26 (53%) had moderate-to-severe steatosis. Moderate-to-severe hepatic steatosis was significantly associated with various clinical, demographic, anthropometric and laboratory factors (Table 1). Associations were observed between more intense steatosis and higher educational level, higher household income, increased body weight, increased waist circumference, metabolic syndrome, hypertriglyceridemia and higher ALT levels. Regarding HIV-related factors (Table 2), moderate-to-severe hepatic steatosis was associated with higher CD4 nadir and exposure to DTG, while an inverse association was observed with DRV exposure.

Multivariable Poisson regression analysis was performed to evaluate factors independently associated with moderate-to-severe hepatic steatosis (Table 4). After adjustment, lipodystrophy and higher ALT remained independently associated with moderate-to-severe hepatic steatosis.

Since this study included only PLWH, survival bias may have influenced the findings. The sample likely consisted predominantly of long-term HIV survivors with a healthier clinical profile, which may have led to an underestimation of the true frequency of liver steatosis and fibrosis. Individuals with more severe HIV-related disease and metabolic complications may have died at earlier ages and therefore may have been underrepresented in the study population.

In addition, individuals who initiate ART early after diagnosis or who were less exposed to older antiretroviral drugs may experience a lower burden of age-related comorbidities than those exposed to prolonged untreated viremia and older ARV regimens. Among the 92 participants included in this study, only one had acquired HIV before the availability of combination ART, which may reflect the historically higher mortality observed in individuals diagnosed during that period.

Moreover, the absence of comparison groups restricts causal interpretation. Because only older people with HIV were included, it was not possible to disentangle the effects of aging, HIV infection, cumulative antiretroviral exposure, and conventional cardiometabolic risk factors on hepatic steatosis. Studies including younger people with HIV from the same geographic region would be useful to evaluate whether the prevalence and severity of steatosis increase with age under similar socioeconomic, environmental, and healthcare conditions. In parallel, studies with an HIV-negative control group matched for age, sex, and cardiometabolic profile could help estimate the independent contribution of HIV infection and antiretroviral exposure to hepatic steatosis and fibrosis. Multicenter studies with larger samples and appropriately selected comparison groups are therefore needed to confirm these findings and improve their generalizability.

Despite these limitations, an important strength of this study is the inclusion of older PLWH, a population historically underrepresented in studies evaluating MASLD. Notably, a high frequency of hepatic steatosis was observed even in this survivor population, suggesting that the burden of steatosis and fibrosis in the broader population of PLWH may be even greater than that observed in our sample.