According to research presented at the 26th International AIDS Conference (AIDS 2026) in Rio de Janeiro, lean individuals classified as normal weight by body mass index can still develop steatotic liver disease and its complications, with people living with HIV potentially facing an elevated risk. Florence Bascombe, a senior research nurse at University College London, stated that normal body mass index scores do not rule out clinically relevant liver disease among patients managing HIV.
Understanding Steatotic Liver Disease Risks in Lean Patients
Steatotic liver disease, or SLD, represents the updated medical terminology for excess fat accumulation within the liver. This classification encompasses metabolic dysfunction-associated steatotic liver disease, alcohol-related liver disease, and liver disease attributable to both metabolic factors and alcohol. Over time, hepatic steatosis can progress to fibrosis, cirrhosis, and liver cancer. While fatty liver conditions are frequently linked to obesity, general population studies indicate that roughly 10% of people with normal or low body weight develop SLD. Data suggest this figure may climb as high as 25% among individuals living with HIV. Consequently, relying solely on body mass index can underestimate liver disease prevalence in lean populations.
Did you know?
With hepatitis B now preventable via vaccination and hepatitis C curable through direct-acting antiviral therapy, steatotic liver disease accounts for an increasing share of advanced liver diagnoses worldwide, according to findings discussed at AIDS 2026.
Clinical Findings From the London HIV Cohort Study
To investigate fatty liver disease dynamics within HIV care, Bascombe and her research team conducted a cross-sectional analysis using clinical data gathered from a large central London HIV service between 2019 and 2025. Researchers utilized transient elastography, commonly known as FibroScan, to measure both liver stiffness and steatosis via noninvasive ultrasound imaging. Out of 391 participants diagnosed with HIV and fatty liver disease, 57 patients—representing 15% of the cohort—had a body mass index below 25 and were categorized as having lean SLD. Comparative analysis revealed that these lean individuals were typically older, showing a median age of 58 years compared to 54 years for participants with a body mass index of 25 or higher. Despite exhibiting more favorable cardiometabolic profiles and slightly less hepatic fat accumulation, the lean cohort displayed similar markers of liver disease severity, including liver fibrosis scores.
Hepatitis B and Lipodystrophy Associations in Lean SLD
Further analysis of the London cohort uncovered specific clinical factors strongly linked to lean steatotic liver disease. Hepatitis B coinfection appeared more than twice as frequently among lean patients with SLD compared to those dealing with overweight or obesity, registering at 19% versus 8%. Furthermore, lean SLD showed a robust association with a history of lipodystrophy, characterized by abnormal body fat distribution. While 11% of participants with lean SLD experienced lipodystrophy, only 2% of overweight or obese participants reported the condition. Researchers also noted an association between lean SLD and the use of tenofovir alafenamide, a component found in combination pills like Descovy and Biktarvy. These patterns suggest that lean SLD in patients with HIV may stem from distinct pathways—such as adipose dysfunction, altered fat distribution, or mitochondrial mechanisms—rather than simply representing obesity-driven disease at a lower body mass index.
Implications for HIV Clinical Management and Screening
The findings emphasize that current screening protocols relying strictly on body mass index and metabolic factors may fail to identify patients at risk for progressive liver complications. Medical providers are increasingly moving away from reliance on body size alone and toward including body composition measures such as waist circumference, waist-to-height ratio, body roundness index, and body fat percentage. Recognizing these diagnostic gaps also influences therapeutic decisions, particularly regarding the prescription of weight-loss medications like semaglutide, marketed as Wegovy, which was approved last year for treating metabolic dysfunction-associated steatohepatitis.
Pro Tip for Clinical Practice:
Clinicians managing HIV care should consider non-invasive imaging techniques like FibroScan for patients with normal body mass index scores who present with risk factors such as prior lipodystrophy or hepatitis B coinfection.
Frequently Asked Questions
What is steatotic liver disease?
Steatotic liver disease is the updated term for fat accumulation in the liver, which encompasses metabolic dysfunction-associated steatotic liver disease, alcohol-related liver disease and liver disease attributable to both metabolic factors and alcohol. Over time, this fat buildup can lead to fibrosis, cirrhosis, and liver cancer.
Why are lean people at risk for fatty liver disease?
Research indicates that approximately 10% of the general population with normal or low body weight can develop fatty liver disease, a percentage that may rise to 25% among people living with HIV. Factors such as altered fat distribution, lipodystrophy, and viral coinfections can drive liver disease independently of body mass index.
How is liver disease detected without a biopsy?
Doctors frequently use transient elastography, or FibroScan, which is a non-invasive ultrasound imaging method that estimates both steatosis and fibrosis.
Does HIV treatment cause fatty liver disease?
Certain early antiretroviral drugs were linked to lipodystrophy. Recent analyses also associate lean steatotic liver disease with the use of tenofovir alafenamide, highlighting complex metabolic pathways beyond standard obesity.
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