Risk of Hepatocellular Carcinoma or Hepatic Decompensation Associated With Steatotic Liver Disease in People With and Without HIV

Background: Steatotic liver disease (SLD) is highly prevalent in people with HIV (PWH), but factors influencing progression to hepatocellular carcinoma (HCC) and hepatic decompensation (HD) remain unclear. It is unknown if the risk of these outcomes associated with SLD differs by HIV status. Methods: Patients from the Veterans Aging Cohort Study-HIV (includes matched people without HIV [PWoH]) who underwent an ultrasound, computed tomography, or magnetic resonance imaging between 2001-2017 were included. Patients with diagnosed cirrhosis or chronic viral hepatitis were excluded. SLD was defined by a natural language processing algorithm; primary outcome of composite of HCC or HD was defined using International Classification of Diseases 9/10 codes and national cancer registry. Follow-up began on imaging study date and continued until incident HCC/HD, death, or 31 December 2024. Adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) of HCC/HD associated with SLD and HIV status were calculated. Results: Among 19 546 patients (mean age: 54 years; 96.6% male; 28.6% PWH), 13 617 (69.7%) had SLD identified by natural language processing. Rates of HCC/HD were lowest in PWoH and no SLD (18.0/10 000 person-years) and highest among PWH and SLD (46.8/10 000 person-years). When compared to PWoH without SLD, risk of HCC/HD was increased among PWH with SLD (aHR: 2.71; 95% CI: 2.10-3.49) and PWH without SLD (aHR: 1.62; 95% CI: 1.14-2.29), although no interaction between HIV and SLD was observed (P = .25). Conclusions: Among people without cirrhosis or chronic viral hepatitis, radiographic findings of SLD were associated with increased rates of HCC/HD, with the highest rate among PWH and SLD, independent of cardiometabolic factors, alcohol, and tobacco.