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Patients with HIV who had highly active NASH and liver fibrosis were more likely to have cognitive impairment than patients with HIV and no liver disease.

“Regardless of its manifestation and severity, steatotic liver disease (SLD) poses a significant global burden, impacting as much as one-fourth of the world’s population,” Win Min Han, MD, explains. “In addition, some reports have shown a higher prevalence of SLD among people living with HIV. SLD is a multisystemic condition that impacts not only the liver but also other organs. However, there is a lack of information regarding the potential relationship between SLD and cognitive performance among people with HIV.”

For a study published in HIV Medicine, the researchers examined the association of SLD, advanced liver fibrosis, and nonalcoholic steatohepatitis (NASH) with cognitive impairment among patients with HIV. Participants were aged 50 and older and on stable ART. They defined SLD as a controlled attenuated parameter value of 248 decibels per meter or higher. Dr. Han and colleagues used a FibroScan-AST score of 0.67 or higher to define NASH with significant activity and liver fibrosis.

Cognition Worse in Patients With HIV & Liver Disease

The study included 319 people with HIV (63.3% men; median age, 54.4). Almost all participants (98%) had HIV-1 RNA levels equal to or less than 50 copies/mL, and more than half of the study population (60.2%) had cognitive impairment.

Dr. Han and colleagues identified SLD in 38% of participants, metabolic dysfunction-associated liver disease in 34.5%, and advanced liver fibrosis in 10.3%. The median FibroScan-AST score was 0.28 (interquartile range, 0.15–0.55), and 20.7% of participants had a FibroScan-AST score equal to or greater than 0.67, indicating NASH with significant activity and liver fibrosis.

Following adjustment for age, sex, BMI, employment status, education and income level, smoking, alcohol use, diabetes, and hypertension, the mean total Montreal Cognitive Assessment (MoCA) score was lower for people with HIV and NASH with significant activity and liver fibrosis versus those without (Table). When the researchers assessed specific cognitive domains, individuals with NASH with significant activity and liver fibrosis performed worse compared with those without for measures of visuospatial/executive function (P=0.03), abstraction (P=0.04), and orientation (P=0.02).

First Step to Cognitive Care in HIV: Detection

“Our results showed that people living with HIV who had NASH with significant activity and liver fibrosis had higher odds of having cognitive impairment compared with their counterparts without these conditions,” Dr. Han says.

The results “underscore the necessity for increased attention to cognition among people with HIV who are receiving long-term care,” he continues.

“Cognitive impairment, although prevalent among people with HIV, is often overlooked. We encourage HIV specialists and infectious disease doctors to integrate cognitive assessments into routine care for this patient population, especially those with significant activity and liver fibrosis.”

Further, he notes that the incidence of cognitive impairment will continue to increase among aging patients with HIV, as age is one of the most important risk factors for cognitive decline.

“Unfortunately, age is an unmodifiable risk factor, and cognitive performance naturally declines with age,” Dr. Han says. “To mitigate this, efforts should focus on controlling modifiable risk factors and promoting a healthy lifestyle. The first step to cognitive care is detection. Our study provided some key elements for physicians to be attentive to when performing cognitive evaluations in this patient population.”