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Metabolic Syndrome's Link to Liver Fibrosis in Patients With HIV


Helping Patients Who Have HIV and Metabolic Syndrome

As it is now recognized that individuals living with HIV are becoming more likely to fall prey to non-AIDS–related maladies as their lifespans increase, the health care community needs to respond accordingly. The causes of obesity in individuals living with HIV, said Dr. Lemoine, include poor diet and lack of exercise—much as they do in the general population. Practitioners who treat individuals living with HIV must be aware of the impact of these factors and help patients create and adhere to strategies to lose weight, get more active, and control their diabetes and hypertension, if those conditions are present.

Alcohol, too, may play a role in the development of liver fibrosis, which physicians and other providers should address. “Excess alcohol consumption is definitely a risk factor for fibrosis, and any discussion about fibrosis must make note of this reversible cause,” Benjamin Young, MD, PhD, senior vice president and chief medical officer of the International Association of Providers of AIDS Care (although not an author of this study), told Contagion®. “Alcohol consumption and dependency should be assessed and addressed, and for those with chronic hepatitis or liver fibrosis, a harm reduction approach should be used to support reduction and cessation.”

According to the National Institute on Drug Abuse, alcohol and drugs are significant problems for individuals living with HIV: one of 3 used drugs or binged on alcohol between 2005 and 2009, and 24% have a problem serious enough that they should be in a substance-abuse treatment program.2

Patients with HIV also need to be screened for hepatitis, traditionally a major driver of liver disease in this population. “Diagnosis, treatment, and—in the case of hepatitis C—cure, of viral hepatitis should be done, and for uninfected individuals, vaccinations to prevent hepatitis A and B should be administered,” Dr. Young said.

What role, if any, does ART play in the development of liver fibrosis? “This has not been clearly demonstrated,” Dr. Lemoine told Contagion®. “Probably [there is] an indirect role…but in our study, the role of ART was not significant.”

A more accurate question might be which drugs used in ART pose the most risk rather than whether ART itself is problematic, as the medical community recognizes that the risks of forgoing ART are greater than the potential risks of administration. “It’s generally appreciated that treating HIV with antiretrovirals reduces the risk of liver fibrosis,” said Dr. Young. “Yet there remains controversy as to whether any particular antiretroviral drug might increase the risk over others.” Older drugs, such as d4T (stavudine) and azidothymidine (AZT), Dr. Lemoine said, seem to be more toxic than newer therapies and might best be avoided. Other studies have shown, for example, that when HIV-infected patients with NAFLD switch from efavirenz to raltegravir, liver steatosis is significantly improved.3

Treatment for NAFLD remains a work in progress. A recent study out of Case Western Reserve University in Cleveland, Ohio, examined whether statins are an appropriate therapy for people living with HIV who have NAFLD, as they have been suggested as a viable NAFLD treatment option for people without HIV.4 Interestingly, the HIV-positive subjects treated with statins experienced an increase in their liver fat scores after 96 weeks compared with the liver fat scores of the HIV-positive placebo takers. Therefore, it would seem that although statins are effective at reducing cardiovascular risks, they cannot be relied upon to treat fatty liver disease—and in fact may be counterproductive.

This study had a few limitations, including its use of a noninvasive method to scan for liver fibrosis and the absence of histological confirmation of this diagnosis with liver biopsies. A small percentage of participants (13%) had invalid transient elastography results that could not be used. The participants were overwhelmingly male, which could have skewed the findings as a previous study found that women living with HIV have significantly lower levels of liver steatosis, or fatty liver, than women without HIV. Also, as this was a cross-sectional study, follow-up is necessary to examine rates of morbidity and mortality in this population. The authors hope the medical community engages in further research to learn more about the exact mechanisms that lead patients with HIV to experience liver fibrosis and how this can be prevented.
Ms. Saloman, MS, is a health writer with more than 20 years of experience working for both consumer- and physician-focused publications. She is a graduate of Brandeis University and the Medill School of Journalism at Northwestern University. She lives in New Jersey with her family.

  1. Lemoine M, Lacombe K, Bastard JP, et al. Metabolic syndrome and obesity are the cornerstones of liver fibrosis in HIV-monoinfected patients. AIDS. 2017;31(14):1955-1964. doi: 10.1097/QAD.0000000000001587.
  2. National Institute on Drug Abuse. Drug and alcohol use - a significant risk factor for HIV. NIH website. Updated April 2015. Accessed on October 14, 2017.
  3. Macias J, Mancebo M, Merino D, et al. Changes in liver steatosis after switching from efavirenz to raltegravir among human immunodeficiency virus-infected patients with nonalcoholic fatty liver disease. Clin Infect Dis, online edition. DOI: 10.1093/cid/cix467.  
  4. El Kamari V, Hileman CO, Mccomsey G. Fatty liver disease in HIV: Predictors and response to statin therapy. Open Forum Infectious Diseases, 2017 Fall; 4(Suppl 1): page S58. DOI: 10.1093/ofid/ofx162.136.

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