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Hepatocellular carcinoma in people living with HIV
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Conclusions and Future Directions.
The risk of chronic liver disease and HCC is higher in PLWH. HIV-induced immune suppression has historically been considered the main factor leading to this epidemiological trend. However, emerging evidence in the post-cART era indicates that HCC developing in the context of HIV infection—even when well controlled—may exhibit distinct immunological and biological characteristics. Furthermore, all therapeutic clinical trials in HCC have inevitably excluded PLWH based on the presence of HIV antibodies, resulting in a lack of high-quality clinical data to guide treatment strategies for PLWH affected by HCC; while recent real-world studies suggest that available oncological treatments can be safely administered to PLWH established on cART. These considerations highlight the need to include PLWH with well-controlled HIV in interventional clinical trials and emphasize the importance of a multidisciplinary approach to optimize both HIV and oncological outcomes.
MASLD
cART increases the risk of metabolic dysfunction and insulin resistance through different pathways, with older ART regimens and protease inhibitors being associated with lipodystrophy and mitochondrial damage and modern cART being associated with weight gain and insulin resistance [51]. Thus, metabolic comorbidities commonly observed in patients with MASLD could represent both an adverse event of cART and a limiting factor in the choice of antiviral therapy, requiring a personalized approach based on virological and metabolic factors and specific metabolic adverse events of ARV therapy. Particularly, the duration of cART appears to be a major determinant of the risk of developing steatotic liver disease and metabolic comorbidities [52, 53].
For all these reasons, all PLWH should be screened for liver steatosis by abdominal ultrasound and for cardiometabolic risk factors. In those with ultrasound evidence of steatosis, non-invasive staging of the severity of liver disease should follow algorithms proposed by current guidelines [9].
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