Metabolic dysfunction-associated steatotic liver disease in people living with HIV: mechanisms, diagnosis, and management.

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common chronic liver disease worldwide and is increasingly recognized as a major contributor to liver-related and cardiometabolic morbidity. In people living with HIV (PLWH), the burden of MASLD is disproportionately high and continues to rise in the era of effective antiretroviral therapy (ART). The recent redefinition of MASLD underscores a paradigm shift toward metabolic dysfunction as a central driver of disease pathogenesis, a concept that is particularly relevant in the context of HIV infection. In PLWH, MASLD may represent a distinct immunometabolic condition in which conventional metabolic risk factors interact with chronic immune activation, persistent inflammation, ART exposure, and gut-liver axis dysfunction. These factors may contribute to steatosis and fibrosis and complicate conventional obesity-based screening and risk stratification. This narrative review summarizes the disease burden, immunometabolic mechanisms, diagnosis, and management of MASLD in PLWH and identifies priorities for research and clinical care. Management requires integrated assessment of metabolic dysfunction, persistent inflammation, cumulative ART exposure, and cardiovascular risk rather than reliance on obesity-based screening alone.