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Female Sex is Protective Against MASLD With Clinically Significant Fibrosis in a Large Cross-sectional Cohort of

Kara Wegermann1, Ayako Suzuki2, Elisa Sarmiento3

  • 1Division of Gastroenterology, Department of Medicine, Duke University Health System, Durham, NC, USA.

Open Forum Infectious Diseases
|November 13, 2025
PubMed
Abstract

Insights

Metabolic dysfunction-associated steatotic liver disease with significant fibrosis is less common in women living with HIV. Men with diabetes, hyperlipidemia, and larger waist circumference need MASLD screening.

Area of Science:

  • Hepatology
  • Infectious Disease (HIV/AIDS)
  • Metabolic Syndrome

Background:

  • Metabolic dysfunction-associated steatotic liver disease (MASLD) with clinically significant fibrosis (CSF) affects men more than women.
  • Limited data exist on MASLD prevalence and severity in people with HIV (PWH).
  • This study investigates MASLD-CSF in PWH stratified by sex and menopausal status.

Purpose of the Study:

  • To determine the prevalence and severity of MASLD-CSF in people with HIV (PWH).
  • To analyze differences in MASLD-CSF based on sex assigned at birth and menopausal status.
  • To identify risk factors for MASLD-CSF in PWH.

Main Methods:

  • Cross-sectional analysis of the HIV NASH CRN cohort.
  • Inclusion criteria: suppressed HIV-1 RNA, self-reported sex and menopause status, transient elastography (TE).
  • MASLD defined by controlled attenuation parameter (CAP ≥ 263 dB/m) and ≥1 cardiometabolic risk factor; CSF defined by TE Liver Stiffness Measurement (≥ 8 kPa).

Main Results:

  • 964 PWH included: 709 men (73.5%) and 255 women (26.5%).
  • Lower prevalence of MASLD-CSF in women (5.5%) compared to men (10.6%) (P = .02).
  • Diabetes (OR 3.26), hyperlipidemia (OR 1.97), and high waist circumference (OR 4.59) increased MASLD-CSF odds; female sex was protective (OR 0.43).

Conclusions:

  • Female sex is protective against MASLD-CSF in people with HIV.
  • Men with diabetes, hyperlipidemia, and high waist circumference should be screened for MASLD.
  • Further research is needed, particularly including more women, especially younger women, with HIV.
Keywords:
estrogenhepatic fibrosismenopausetestosteronewomen’s health

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