Steatotic liver disease (SLD) is a progressive yet largely silent condition that is estimated to affect more than a third of adults worldwide. This public health threat is also the fastest-rising cause of liver-related deaths. However, among special high-risk groups, people living with HIV represent a clinically important population. The condition develops earlier and progresses faster due to chronic immune activation, visceral adiposity, and the long-term metabolic effects of antiretroviral therapy (1).
UNITE and The Public Health Liver Group at Barcelona Institute for Global Health (ISGlobal) are joining forces to highlight the need to address steatotic liver disease (SLD) and HIV together. The intersection of these conditions represents a growing, overlooked public health gap where political leadership and evidence-based guidance are urgently needed. By bringing together political commitment and scientific expertise, we aim to:
- Make liver health a routine, measurable part of HIV care across clinical services and community programs.
- Embed early liver screening, prevention, and patient education within national HIV and NCD guidelines and policies, ensuring that liver disease is consistently assessed and that action follows.
- Include people living with HIV in metabolic dysfunction-associated steatohepatitis (MASH) research and clinical trials, with intentional efforts to close gender gaps, prioritising women who may face a higher risk of advanced liver disease.
- Promote integrated, cross-disciplinary care, linking HIV, metabolic health, and liver health under one shared vision of whole-person, preventative care.
- Drive sustained investment in diagnostics, treatment innovation, and prevention research, so that vulnerable populations can benefit equitably from emerging solutions.
Steatotic liver disease (SLD) is a progressive, often silent condition, driven by a combination of physical inactivity, unhealthy diet, alcohol, and other factors that damage the liver, including chronic inflammation. SLD can lead to liver fibrosis (scarring), cirrhosis, and ultimately cancer if left undiagnosed (2).
“Globally, liver steatosis is estimated to affect more than 1 in 3 adults, including people living with HIV. It is now the fastest rising cause of liver-related deaths (3).”
While SLD is widespread, certain groups are disproportionately affected. For example, this includes people with metabolic risk factors, like obesity and type 2 diabetes; people living with HIV, given virus- and some treatment-related factors, and socially marginalised groups, given the associations with food insecurity and unhealthy diets (2,3).
Despite a high and growing burden, the disease remains largely hidden. Screening for SLD is rare, even in health systems with a tradition for timely diagnosis and long-term care of chronic conditions.
People living with HIV face a substantial risk of developing steatotic liver disease earlier and it progressing faster due to several factors, including chronic immune activation; overlapping risk profiles like ageing, diabetes, and dyslipidemia (unhealthy levels of one or more kinds of lipid [fat] in blood); and the long-term metabolic effects of some antiretroviral drugs (1,3).
Countries like Spain, known for finding, diagnosing, and retaining people living with HIV in care, likely have both the infrastructure to detect liver disease early and a care-retained population (people who remain linked to and actively engaged in long-term care). Yet liver screening, apart from for viral hepatitis, remains uncommon in HIV care pathways.
Because advanced liver disease requires expensive monitoring, hospitalisation and in severe cases, transplantation, this gap contributes to avoidable clinical and economic costs. For instance, in the United States alone, the estimated costs of neither diagnosing nor treating metabolic dysfunction-associated steatotic liver disease exceed $520 billion(4).
Meanwhile, detection relies on low-cost, non-invasive tests and could result in fibrosis reversal (4).
The cost of inaction is clear: delayed diagnosis leads to preventable morbidity, increased long-term healthcare spending, and a reduced quality of life.
“People living with HIV face a substantial risk of developing steatotic liver disease earlier and it progressing faster due to several factors, including chronic immune activation, overlapping risk profiles like early ageing, diabetes, dyslipidemia, and the long-termmetabolic effectsof some antiretroviral drugs.”
Members of Parliament can support the recognition of steatotic liver disease in existing HIV and non-communicable disease strategies, especially those targeting cardiometabolic conditions and cancer (5).
MPs can also champion policies that make routine screening easier and more equitable by integrating care pathways, embedding non-invasive fibrosis tests and metabolic risk assessments within HIV services – especially where engagement and continuity of care are already strong – and tackling stigma and structural barriers to care (5,6,7).
References
- Perakakis N, Harb H, Hale BG, et al. Mechanisms and Clinical Relevance of the Bidirectional Relationship of Viral Infections With Metabolic Diseases. Lancet. Diabetes & Endocrinology. 2023;11(9):675-693. doi:10.1016/S2213-8587(23)00154-7.
- Israelsen M, Francque S, Tsochatzis EA, et al. Steatotic liver disease. Lancet. 2024;404(10464):1761-1778.
- Arenas-Pinto A, Abrescia N, Abdel-Hameed EA. Metabolic dysfunction-associated steatotic liver disease and liver fibrosis in people with HIV. AIDS. 2025;39(12):1822-1824.
- Wallace C, Gamkrelidze I, Estes C, et al. Modeling the health and economic impact of pharmacologic therapies for MASLD in the United States. J Hepatol. 2025;83(1):21-30.
- Lazarus JV, Mark HE, Villota-Rivas M; NAFLD policy review collaborators. The global NAFLD policy review and preparedness index: Are countries ready to address this silent public health challenge? J Hepatol. 2022;76(4):771-780.
- Pericàs JM, Arora AK, Riebensahm C, et al. Steatotic liver disease and HIV: an agenda for 2030. Lancet HIV. 2024;11(8):e561-e566.
- Lazarus JV, Ivancovsky Wajcman D, Pannain S, et al. The People-First Liver Charter. Nat Med 31, 2109–2116 (2025). https://doi.org/10.1038/s41591-025-03759-8
Author: Trenton White
Trenton White is a Postdoctoral Fellow in the Public Health Liver Group at ISGlobal, where he supports research to improve systems of care for metabolic and liver diseases as well as HIV.
Previously, he worked for the World Bank to improve country systems to finance health services and protect individual and public payers from financial risk. He also previously worked for the U.S. Agency for International Development, where he advised on health systems interventions for bilateral development programs in HIV, tuberculosis, malaria, and maternal and child health.
Trenton White holds an MPH in Health Policy from the George Washington University in Washington, DC, USA.
