Metabolic dysfunction-associated steatotic liver disease in people living with HIV: a framework for integrated screening and care.

Metabolic dysfunction-associated steatotic liver disease (MASLD) has emerged as a major cause of liver-related and cardiometabolic morbidity and mortality among people living with HIV, driven by ageing, obesity, type 2 diabetes, and long-term antiretroviral therapy. Approximately 20-41% of people living with HIV have MASLD, and significant liver fibrosis affects 12-20% of all people living with HIV, suggesting a fibrosis burden that exceeds that of the general population. HIV-specific mechanisms, including chronic immune activation, altered adipose distribution, and historical exposure to older antiretroviral agents, contribute to a more severe metabolic liver phenotype. Sex, gender, and social determinants of health-including menopause, food insecurity, and material deprivation-further influence fibrosis risk and access to care. International guidelines now recommend routine fibrosis screening in at-risk people living with HIV with the use of non-invasive tools such as transient elastography and serum biomarkers. Lifestyle interventions, optimisation of metabolic comorbidities, and emerging therapies including glucagon-like peptide-1 receptor agonists are reshaping management. Inclusion of people living with HIV in MASLD therapeutic trials remains a major, unmet research priority.