Metabolic Dysfunction-Associated Steatotic Liver Disease in People Living with HIV: A Scoping Review

Metabolic dysfunction-associated steatotic liver disease (MASLD), previously called non-alcoholic fatty liver disease (NAFLD), has become a leading cause of chronic liver disease in people living with HIV (PLWH), especially in the era of effective antiretroviral therapy (ART). As the life expectancy of PLWH continues to increase, non-AIDS-related comorbidities such as metabolic syndrome, insulin resistance, and cardiovascular disease have become more prevalent, contributing to a rising incidence of MASLD and its progressive form, metabolic dysfunction-associated steatohepatitis (MASH). Studies have shown that the prevalence of MASLD in PLWH ranges from 30% to 50%, with biopsy-based estimates of non-alcoholic steatohepatitis (NASH) approaching 49% and advanced fibrosis up to 23%. This burden is influenced not only by traditional metabolic risk factors but also by HIV-specific mechanisms, including chronic immune activation, lipodystrophy, microbial translocation, and mitochondrial dysfunction associated with ART exposure. Despite its high prevalence and clinical significance, MASLD remains underdiagnosed in PLWH. This scoping review aimed to systematically map the existing literature on MASLD in people living with HIV, including epidemiology, risk factors, diagnostic approaches, fibrosis assessment, and management strategies. Understanding the unique interplay between HIV infection and metabolic liver disease is essential for the early diagnosis and prevention of progression to cirrhosis and hepatocellular carcinoma in this growing patient population.