Liver Inflammation Is Common and Linked to Metabolic Derangements in Persons With Treated Human Immunodeficiency Virus (HIV)

Clin Infect Dis. 2023 Feb 8;76(3):e571-e579. doi: 10.1093/cid/ciac708.


Background: We sought to characterize in people with human immunodeficiency virus (PWH) the potential etiologies of elevated alanine aminotransferase (ALT) levels, which are common and often unexplained.

Methods: Participants from the longitudinal observational AIDS Clinical Trials Group HAILO cohort without a history of hepatitis C virus (HCV) or hepatitis B virus (HBV) infection nor reported heavy alcohol use were included. Clinical and demographic characteristics, including medication use, the hepatic steatosis index (HSI), and metabolic syndrome (MetS) were compared between participants with and without ALT elevation.

Results: Six hundred sixty-two participants were included; 444 (67%) had ≥1 and 229 (35%) ≥2 consecutive ALT elevations during a median of 4.0 years of follow-up. HSI and Hispanic or other (non-White or Black) race/ethnicity were consistently associated with higher odds of abnormal ALT (odds ratio [OR] 1.1 for HSI as a continuous variable, OR 1.9-2.8 for Hispanic/other race/ethnicity for ≥1 or ≥2 ALT elevations); older age and current smoking were associated with lower odds of abnormal ALT. Associations with metabolic disease, as well as with incident HBV and HCV infection, were strengthened by restricting outcomes to persistent and higher degrees of ALT elevation.

Conclusions: ALT elevation was common in this cohort of PWH and associated with metabolic disease and hepatic steatosis markers. Nonalcoholic fatty liver disease is likely a common cause of liver inflammation in PWH receiving suppressive antiretrovirals, deserving targeted diagnosis and intervention.

Keywords: HIV; hepatic steatosis; liver inflammation; metabolic disease; nonalcoholic fatty liver disease.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Alanine Transaminase
  • HIV
  • HIV Infections* / complications
  • HIV Infections* / drug therapy
  • Hepatitis B virus
  • Hepatitis B* / complications
  • Hepatitis C* / complications
  • Humans
  • Inflammation / complications
  • Metabolic Diseases* / complications
  • Metabolic Diseases* / epidemiology
  • Non-alcoholic Fatty Liver Disease*


  • Alanine Transaminase