NASH in HIV: An All-Too-Common Comorbidity

In the United States, 25% of the general adult population have nonalcoholic fatty liver disease (NAFLD), and of those, about 25% have nonalcoholic steatohepatitis (NASH). In individuals with HIV, this number rises significantly; up to 55% may have NAFLD, 67% may have NASH, and 4% may have cirrhosis.

“[NAFLD/NASH] is becoming one of the greatest comorbidities in people living with HIV,” said Giada Sebastiani, MD, who is an associate professor in the Department of Medicine at McGill University Health Centre Research Institute in Montreal, Canada.

Dr Sebastiani presented an interactive case-based workshop on hepatitis, “NASH in HIV,” yesterday at the Conference on Retroviruses and Opportunistic Infections (CROI) 2019.

She started her presentation with a case report of a 51-year-old patient who was referred to her clinic with an abnormal alanine transaminase (ALT) level. She walked the audience through the patient’s medical history, presentation, and laboratory test results. This led into a more in-depth discussion of the definition of NAFLD, the epidemiology of NAFLD/NASH in people living with HIV, diagnosis and staging of disease, and management of disease.

The progression of liver disease among individuals with HIV is more complex than in the general population, Dr Sebastiani said. Among individuals with HIV, metabolic comorbidities are more frequent, including central obesity, hypertension, dyslipidemia, and diabetes.

Also, there are at least 2 risk factors unique to HIV: HIV has a pro-apoptotic effect on hepatocytes and the prolonged exposure to ART treatment. This results in significantly high rates of chronic elevation of liver transaminases.

“NAFLD is much more frequently attributable as a cause of elevation of transaminases in people living with HIV,” Sebastiani said.

Fibrosis can develop as disease progresses. Therefore, it is important to evaluate for fibrosis because liver fibrosis is the single most important predictor of mortality, according to Sebastiani.

Dr Sebastiani also talked about how medication may play a role in liver function. For instance, she said that the STERAL trial showed that when ART therapy was switched from efavirenz to raltegravir, steatosis significantly reduced after 48 weeks from the switch (15% vs 47%).

Moreover, current American Association for the Study of Liver Diseases and European Association for the Study of the Liver guidelines recommend 800 units per day of vitamin E as the first-line pharmacologic treatment for NASH. Based on this, Dr Sebastiani and colleagues conducted a pilot study about whether vitamin E works in the setting of HIV as well. Findings showed that after only 6 months on vitamin E, the proportion of patients with elevated transaminases declined from 76% to 14%.

“We also need to advocate for inclusion of HIV-positive patients in clinical trials of new NASH and fibrotic molecules,” Sebastiani said.

—Melinda Stevens

Reference:

Sebastiani G. NASH in HIV. Talk presented at: Conference on Retroviruses and Opportunistic Infections; March 4-7, 2019; Seattle, WA. http://www.croiconference.org/sessions/nash-hiv.  Accessed March 5, 2019.