Human immunodeficiency virus and liver disease: A comprehensive update

Abstract

Among persons living with human immunodeficiency virus (HIV) infection, liver disease remains a major cause of morbidity and mortality. While the etiologies are varied and often overlapping in the individual patient, the underlying mechanisms, including oxidative stress, direct activation of stellate cells, HIV interaction with hepatocytes, and bacterial translocation with systemic immune activation, seem to be unifying characteristics. Early and fully suppressive HIV antiretroviral therapy is a mainstay of management either before or concurrent with treatment of etiologic cofactors, including hepatitis C virus, hepatitis B virus, and nonalcoholic fatty liver disease/nonalcoholic steatohepatitis. Significant barriers to care that still exist include liver disease recognition, appropriate linkage to care, ongoing substance abuse, and psychiatric comorbidities in the HIV-infected population. Emerging issues in these patients include acute and chronic hepatitis E, underreported hepatitis D, and a rising incidence of hepatocellular carcinoma. (Hepatology Communications 2017;1:987-1001).

Figure 1

Changing epidemiology of liver disease etiologies in patients with HIV. Abbreviations: DILI, drug‐induced liver injury; IDU, intravenous drug users. (From Soriano et al., AIDS Rev 2013;15:25‐31. Reprinted with permission from Permanyer Publications.)

Figure 2

Factors in liver disease pathogenesis in HCV/HIV coinfection. HIV infection leads to impaired immune response against HCV, increased HCV replication, hepatic inflammation and apoptosis, increased microbial translocation from the gastrointestinal tract, and increased fibrosis. (From Chen et al., Nat Rev Gastroenterol Hepatol 2014;11:362‐371.)

Figure 3

Lifetime risk of HIV diagnosis. (A) By age and sex, United States. (From Hess et al., Ann Epidemiol 2017:27:238‐243. Reprinted with permission.) (B) By race/ethnicity. (Source: Centers for Disease Control and Prevention. 2016 Conference on Retroviruses and Opportunistic Infections. https://www.cdc.gov/nchhstp/newsroom/2016/croi‐2016.html.)