<scp>UltRaSoUnd</scp> ‐guided <scp>evaLuAtion</scp> of metabolic health in a cohort of midlife women with <scp>HIV</scp> : The <scp>URSULA</scp> study

OBJECTIVES: We aimed to determine the prevalence of metabolic disorders, liver steatosis and metabolic dysfunction-associated steatotic liver disease (MASLD) in a cohort of middle-aged women with HIV (WoWH) and to explore associations between liver steatosis, visceral fat depots and carotid atherosclerosis. We also assessed the contribution of lifestyle, HIV- and antiretroviral therapy (ART)-related factors to liver steatosis and the accuracy of United States National Cholesterol Education Program/Adult Treatment Panel III (NCEP-ATP III) criteria in identifying at-risk patients. METHODS: Between 1 April and 31 July 2025, all ART-experienced WoWH aged ≥40 years received comprehensive metabolic and laboratory assessment, including abdominal and carotid Doppler ultrasound (US). Visceral fat depots were evaluated, and metabolic syndrome (MetS) was defined according to NCEP-ATP III criteria. Demographic, clinical and immunovirological data were collected. Logistic regression analyses identified factors associated with liver steatosis. Spearman correlations assessed associations between steatosis and fat distribution, and receiver operating characteristic (ROC) curves evaluated NCEP-ATP III accuracy in identifying liver steatosis. RESULTS: Among 98 WoWH, 55 (56%) had at least grade I liver steatosis, 24 (25%) had MetS. Overall, MASLD was diagnosed in 41 participants (76%). Slight carotid intima-media thickness (cIMT) increases were observed, and 35 participants (36%) had carotid plaques. MetS was the main risk factor for steatosis (OR 14.14, 95% C.I. 3.23-84.40, p = 0.001), with no HIV- or ART-related associations. Progressive liver steatosis correlated with increasing retroperitoneal (rho = 0.393; p = 0.0001), subcutaneous (rho = 0.277; p = 0.005) and epicardial fat (rho = 0.312; p = 0.002) thickness. Conversely, epicardial fat thickness was not linked to cIMT. NCEP-ATP III criteria showed limited accuracy (AUC = 0.67) in identifying patients at risk for liver steatosis. CONCLUSIONS: In the URSULA cohort, hepatic steatosis-largely driven by MetS-was highly prevalent and associated with abnormal visceral fat depots. US may offer a cost-effective tool for fast metabolic surveillance.