Background:  Non-alcoholic fatty liver disease and steatohepatitis (NASH) are increasingly described conditions in the general population, but there are currently no data regarding these conditions in HIV-infected persons without co-infection with hepatitis C virus (HCV).

Methods:  Clinic patients from a military HIV clinic with low rates of HCV were prospectively enrolled to examine the prevalence and predictors of steatosis and abnormal liver function tests among HIV patients. A questionnaire regarding medication use and social/behavioral habits was performed, along with a body mass index assessment, liver function tests, and liver ultrasound. Those with abnormal liver function tests had a full laboratory panel to include iron studies, ceruloplasmin, autoimmunity panel, α-1 antitrypsin, and serum alcohol level to ascertain the etiology of the abnormality. A liver biopsy was performed for those with steatosis or liver disease of unclear etiology. Statistical analyses included Fisher’s exact and rank sum testing; multivariate models utilized backward stepwise logistic regression.

Results:  Of 200 patients, 60 (30%) had abnormal liver function tests, most of which were grade 1 (1.25 to 2.5 x normal). The mean age of  patients was 39 years (range, 20 to 68) with a mean CD4 count of 541 (18 to 1448 cells/mm³); 74% had received HAART. Of those with elevated liver function tests, 7 (12%) were HbsAg⁺, 2 (3%) HCV seropositive, and 1 (2%) had probable hemochromatosis. In the multivariate model, past HAART use (OR 5.6, p = 0.002), alcohol use (OR 1.1, p = 0.01), and increased body mass index (OR 1.1, p = 0.03) were predictive of abnormal liver function tests. Ultrasonography indicated that of 148, 44 (30%) had steatosis, and of those 44, 41 (93%) met the criteria for non-alcoholic fatty liver disease. Based on liver biopsy findings, ultrasonography had a sensitivity of 83%, specificity of 90%, and positive predictive value of 94% for detecting steatosis. Biopsy, revealed that 25% of patients had fibrosis. Only 22% of those with steatosis had abnormal liver function tests, but 90% had hepatomegaly. Predictors of steatosis in the multivariate model included body mass index (OR 1.92 per 5-unit increase, p = 0.01) with a trend toward stavudine (d4T) use (OR 1.7, p = 0.13). Body mass index and waist circumference were correlated (r = 0.73, p <0.05).

Conclusions:  Non-alcoholic hepatic steatosis is common (~30%) among HIV-infected patients. Hepatomegaly, but not abnormal liver function tests, was predictive of non-alcoholic fatty liver disease. Liver function tests were not a useful screening test for steatosis. Risk factors for non-alcoholic fatty liver disease among HIV patients include increased body mass index, waist circumference, and perhaps d4T use.