Subtype-Specific Mortality and Cardiovascular Burden in HIV Patients with Steatotic Liver Disease: A Korean National Cohort Study.

BACKGROUND/AIMS: Steatotic liver disease (SLD) is an emerging comorbidity among people living with human immunodeficiency virus (PLWH), but its subtype-specific burden remains unclear. We aimed to evaluate the prevalence of SLD and its associations with mortality, cardiovascular diseases, and liver cirrhosis (LC). METHODS: This retrospective cohort study included 4,597 Korean PLWH using data from the National Health Insurance Service (2013-2022). SLD was defined using the fatty liver index (≥30) and categorized into metabolic dysfunction-associated SLD (MASLD), alcohol-associated liver disease (ALD), and metabolic dysfunction-associated ALD (MetALD). Outcomes were all-cause mortality, cardiovascular diseases, and LC, analyzed using multivariable Cox proportional hazards and Fine-Gray competing risk models. RESULTS: The prevalence of SLD was 45.7%, predominantly MASLD (86.5%), followed by Met-ALD (9.7%) and ALD (3.8%). SLD prevalence in PLWH was not higher than that in matched controls. Over a median 6-year follow-up, SLD was associated with increased mortality (adjusted hazard ratio, 1.53; 95% confidence interval [CI], 1.03 to 2.29). ALD was linked to higher stroke risk (adjusted subdistribution hazard ratio [aSHR], 3.10; 95% CI, 1.04 to 9.20), and MetALD to higher LC risk (aSHR, 5.72; 95% CI, 1.48 to 22.10). CONCLUSIONS: As SLD is significantly associated with mortality in PLWH, integrated management focusing on liver health, metabolic dysfunction, and alcohol use is essential to reduce adverse outcomes.