Prevalence, risk factors and liver-related complications of nonalcoholic fatty liver disease in Ethiopian HIV-infected patients: a cross-sectional study in a tertiary care center

doi:10.21203/rs.3.rs-3629862/v1

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Research Article

Prevalence, risk factors and liver-related complications of nonalcoholic fatty liver disease in Ethiopian HIV-infected patients: a cross-sectional study in a tertiary care center

https://doi.org/10.21203/rs.3.rs-3629862/v1

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Background

Ethiopia is one of the countries with high burden of HIV/AIDS. Although the number of fatalities from AIDS-defining illnesses has dramatically decreased, the incidence of non-AIDS defining comorbidities is increasing. Non-alcoholic fatty liver disease (NAFLD), in particular, continues to be one of the main causes of morbidity and mortality in this patient population. Though a few studies have tried to determine the prevalence of metabolic syndrome in Ethiopian patients with HIV infection, the frequency, risk factors, and potential liver-related outcomes of NAFLD among Ethiopian HIV patients have not been adequately studied.

Method

A cross-sectional study aimed at determining the prevalence, associated risk factors, and possible liver-related complications of NAFLD in Ethiopian HIV infected patients was conducted at the HIV clinic of Tikur Anbessa Specialized hospital from April 2020 to December 2020 G.C. A systematic random sampling method was used to recruit participants during their clinic visit. The final analysis included 110 patients, and the data was analyzed using SPSS version 26.0.

Results

The study found a 21.8% prevalence of NAFLD using ultrasound examination. 66.7% of participants with disease duration of more than 10 years had NAFLD; 83.3% of patients with NAFLD had a baseline CD4 count of less than 200; and 58.3% of patients had a BMI of ≥ 25 kg/m2. Liver fibrosis was detected in 5.4% patients using clinical the clinical scores, APRI and FIB-4. The study found significantly association between NAFLD and baseline CD4 count < 200 and BMI ≥ 25kg/m2 in HIV patients.

Conclusions

In comparison to earlier African research, the current study discovered a higher frequency of NAFLD in HIV patients from Ethiopia. Institutions and hospitals should provide better diagnostic techniques for the early diagnosis of steatosis and fibrosis in light of the worldwide rise in the prevalence of NAFLD.

Non-Alcoholic Fatty Liver Disease

Non-Alcoholic Fatty Liver

Non-Alcoholic Steatohepatitis

HIV/AIDS

Nonalcoholic fatty liver disease (NAFLD) refers to a macrovesicular steatosis in ≥ 5% of hepatocytes in the absence of other apparent causes of steatosis in individuals without a significant alcohol consumption. The disease spectrum includes nonalcoholic fatty liver (NAFL) and nonalcoholic Steatohepatitis (NASH). NAFL is characterized by hepatic steatosis without or with mild inflammation; on the other hand the presence of significant inflammation and cellular injury with or without fibrosis characterizes NASH. Liver cirrhosis is the final outcome in this disease spectrum [1].

Prior to the development of antiretroviral therapy, AIDS-defining illnesses were the leading cause of death in HIV patients. The incidence of diseases that define AIDS has decreased dramatically among HIV patients due to advances in anti-retroviral therapy, which has also resulted in a significant increase in the life expectancy of patients with HIV. On the other hand, the incidence and prevalence of non-AIDS defining diseases including cardiovascular and metabolic diseases is increasing in this patient population. In HIV patients, NAFLD has become a clinically relevant comorbidity and NAFLD (steatosis) has been observed to develop in obese and non-obese HIV patients [2].

The global prevalence of NAFLD among the adult population is increasing with an estimated prevalence of 25 to 30% in the general population. Regional and racial differences in prevalence do exist. Data from studies in Africa and sub-Saharan Africa are scarce and suggest a lower prevalence of NAFLD compared to western studies. The prevalence of NAFLD is estimated to be 13·5% for the general population in Africa [3–5]. Despite the globally concerning rise, Ethiopia is believed to be one of the countries with low prevalence of obesity. Although there is no data regarding the population prevalence of NAFLD in Ethiopia, few hospital and institution based studies have tried to assess the prevalence of NAFLD in patients with diabetes. These studies found a higher prevalence of NAFLD ranging between 58.4 and 73% was found [6, 7].

Based on available studies, the prevalence of NAFLD in HIV patients ranges between 13 and 73%. NAFLD is the most important cause of liver-related mortality in HIV patients [2]. Generally the increasing prevalence of NAFLD parallels the increasing prevalence of obesity and metabolic syndrome and NAFLD patients often have one or more components of metabolic syndrome [8, 9]. Other than these risk factors, direct effect of viral infection and treatment-related factors such as persistent immune activation from the HIV infection and metabolic alterations from ART drugs are believed to predispose these patients to NAFLD [2, 10].

Multiple studies have tried to assess predictors of NAFLD in HIV patients and male sex, increased BMI, increased waist circumference, elevated serum alanine levels, diabetes, dyslipidemia, high CD4 count, and exposure to nucleoside reverse transcriptase inhibitors were found to be potential independent risk factors [2, 11–13].

Although the gold standard for the diagnosis and staging of NAFLD is liver biopsy, because of its invasive nature and potential procedure related complications other non-invasive methods are often used to make a clinical diagnosis. Different biomarkers have been tried to aid clinical diagnosis of NAFLD and cytokeratin-18 (CK-18) is one widely studied biomarker with fair sensitivity and specificity. Despite extensive evaluation, to date none of the studied biomarkers were found to be clinically applicable. Clinical scorings and predictive models have also been also proposed for clinical evaluation and diagnosis of NAFLD, but all have shown low sensitivity and specificity. Magnetic resonance (MR) spectroscopy and transient Elastography (TE) are commonly used and better validated tools for diagnosis of steatosis and fibrosis by measuring fat attenuation and liver stiffness [14–16].

Fibrosis, liver-related complication of NAFLD which may finally end up in cirrhosis and chronic liver disease can be clinically assessed by Fibrosis-4 index (FIB-4) and Aspartate transaminase (AST) to platelet ratio index (APRI) scores. Although it is originally used for HCV/HIV co-infection, FIB-4 score is validated for NAFLD patients with good positive and negative predictive values, especially for advanced fibrosis stages. APRI score is also compared with FIB-4 and/or FIB-5 scores in different studies and found to have a good sensitivity in detecting significant fibrosis and has an excellent negative predictive value as well [17–19].

The current study used the Hamaguchi score from abdominal ultrasound performed by a skilled radiologist to evaluate the prevalence of NAFLD in HIV patients. Although few studies have attempted to access the prevalence of metabolic syndrome in Ethiopian HIV patients, this study was conducted with the aim of evaluating the prevalence, risk factors, and complication of NAFLD in this population and as far as we are literature review goes, this is the first study of its kind on the topic.

We conducted a single-center; hospital-based, cross-sectional study on the prevalence, associated factors, and possible liver-related complications of NAFLD in Ethiopian HIV infected patients at Tikur Anbessa Specialized hospital from April 2020 to December 2020 G.C. The study took place at the HIV clinic of Tikur Anbessa Specialized Hospital (TASH), a tertiary referral center which is the main teaching hospital for Addis Ababa University. The hospital provides various clinical services for patients in Addis Ababa and those refereed from the different corners of the country. Even though the free ARV service began in January 2005 and the free ARV Programme at public hospitals began in March 2005, only 426,000 patients are now receiving ARVs [20]. Over 3000 patients are being treated at the HIV clinic at Tikur Anbessa Specialized Hospital, the majority of these patients are female and under 50 years of age.

Study participants

Inclusion criteria

Age >/=18 years
All patients with HIV infection (both on ART and ART naïve) and who can provide consent

Exclusion criteria

Those with known liver disease of other etiologies, like drug induced liver injury and metabolic liver disease
Those with HBV and HCV infection
Those with previous or ongoing significant alcohol consumption (as defined by > 21 standard drinks per week on average for men and > 14 standard drinks on average in woman)
Patients who cannot provide informed written consent
Those with incomplete medical record

Since there was no previous study done in Ethiopia, the prevalence of NAFLD in patients

with HIV was assumed to be 50% and a sample size of 201 was calculated using a single population proportion formula. A systematic random sampling method was used to recruit participants during their HIV clinic visit at TASH. Written consent was obtained from all the study participants. From the total 201 patients identified during the study period and 91 were excluded, 21 patients suspected HBV and HCV infection, 12 had significant alcohol consumption, 32 were unwilling to provide consent and 26 had incomplete medical record. A total of 110 HIV/AIDS patients were included in the final analysis.

Data collection and analysis procedure

Patients were recruited in to the study during their routine clinic visit using systematic random sampling. After explaining the purpose of the study, written informed consent was obtained from all study participants and a structured questionnaire was used to evaluate study participants. Data were collected through both patient interviews and a review of patient’s medical records. A thorough history was taken and pertinent physical examination (including vital signs, BMI, waist circumference, and a search for stigmata of liver disease) was done by trained physician and a nurse. The patient’s previous medical record and laboratory investigations were reviewed. All patients had abdominal ultrasound done by a trained radiologist. APRI and FIB-4 scores were used to evaluate for possible liver fibrosis in the study participants..

Operational definitions

NAFLD

NAFLD will be diagnosed when liver steatosis is identified on ultrasound examination done by radiologists who is blinded to the patient’s clinical information. Hamaguchi score, which has hepatorenal echo contrast, bright liver, deep attenuation, and vessel blurring as its components ,was used for the diagnosis of fatty liver and NAFLD will be diagnosed when the score is >/= 2 [21].

Advanced fibrosis (equivalent to F3-F4 fibrosis on Metavir): was diagnosed when the APRI score is ≥ 1.0, and/or FIB-4 score is ≥ 2.67 [22, 23].

Abdominal obesity

was diagnosed when waist circumference as measured at the top of the iliac crest is ≥ 102 cm in men and ≥ 88 cm women [24].

APRI and FIB-4 calculated using the following formulas:

APRI = [(AST / ULN AST) x 100] / Platelets (109/L)]

FIB-4 = Age (years)×AST (U/L)/[PLT(109/L)×ALT1/2 (U/L)]

Data Analysis

The acquired data was verified, cleaned up, and then given a final analysis. The statistical data were entered using Microsoft Excel, and IBM SPSS Statistics software package version 26.0 was used for analysis. Frequency data was used to generate descriptive statistics. The terms used to express continuous variables were means, standard deviations, and range. The multicollinearity was evaluated using the variance inflation factor (VIF), and none was collinear. To evaluate the relationship between each independent variable and the treatment outcome, univariable logistic regression and multivariable binary logistic regression models were used. P-values under 0.05 were taken into consideration when assessing statistical significance.

Ethics approval and informed consent

The ethical clearance of the present study was obtained from the institutional review board of Addis Ababa University, College of Health Sciences. We fully explained the purpose and protocol of the study to all participants included in the study and written informed consent was obtained from each participant. The data collected was recorded and anonymously examined. All acquired information was kept in strict confidence and exclusively applied to the desired goal.

Sociodemographic characteristics of study participants

The mean [± SD] age of the participants was 45.94 ± [11.18] with minimum and maximum ages of 18 and 71 respectively. 74.5% of the participants were female. 94.5% of the study participants were from Addis Ababa followed by Oromia region (4.5%). Only fourth of the participants were married and 80.9% were Orthodox Christian. The average number of household was 3.56 ± [2.26]. Nearly half of the participants were unemployed and the mean monthly income was 2044.29 ± [1756.44] Ethiopian birr.

The Sociodemographic data are shown in Table 1 below.

Table 1

Socio-demographic characteristics of study Participants at Tikur Anbessa Specialized hospital from April 2020 to December 2020 G.C
Characteristics N = 110		Number (n)	Percentage (%)
Sex	Male	28	25.5
Sex	Female	82	74.5
Age [Mean ± SD]	45.94 ± 11.18
Age Category	18–40	25	22.7
	40–65	79	71.8
	≥ 65	6	5.5
Residence	Addis Ababa	104	94.5
	Oromia	5	4.5
	Sidama	1	0.9
Marital Status	Single	21	19.1
	Married	28	25.5
	Widowed	31	28.2
	Divorced	30	27.3
Religion	Orthodox	89	80.9
	Protestant	13	11.8
	Muslim	8	7.3
Occupation	Unemployed	51	46.4
	Private	36	32.7
	Governmental	19	17.3
	Student	4	3.6
Number of Households [Mean ± SD]	3.56 ± 2.26
Monthly Income [Mean ± SD]	2044.29 ± 1756.44
Monthly Income Category	< 1500	49	44.5
	1500–3000	24	21.8
	3000–5000	25	22.7
	≥ 5000	12	10.9

Clinical and treatment-related characteristics of study participants

The mean [± SD] duration of HIV/AIDS was 10.67 [± 4.64] and about two-third of the study participants were on treatment follow-up for more than 10 years. The mean baseline CD4 count per microliter of blood was 196.89 [± 166.49]. At the time of initial diagnosis 60.9% (67) of the participants had a CD4 count of less than 200 and only 6.4% (7) patients had a CD4 count ≥ 500. The mean recent CD4 count was 525.56 [± 250.90]. Viral load was undetectable in 107 (97.3%) patients.

All of the study participants were receiving antiretroviral therapy (ART). The majority (86.4%) of study participants were taking first line ART regimens, TDF + 3-TC + DTG was the most commonly used regimen. Only 13.6% (15) patients were on second line ART drugs and none of them were on third line regimens. Other than ART, Cotrimoxazole and Isoniazid were the most commonly prescribed drugs, each in 37 (33.6%) participants. Anti-hypertensive drugs were used in 7 (6.4%) and oral hypoglycemic agents in 4 (3.6%) participants. Two patients were taking anti-tuberculous treatment.

The mean [± SD] BMI among the participants was 24.03 ± [4.60]. 25.5% (28) were overweight and 12.7% (14) were obese. Only third of the study participants had a normal waist circumference. Among patients who had above the normal range waist circumference, 67 were female and 5 male.

The diagnosis of NAFLD was made by ultrasound method in 24 (21.8%) study participants. NAFLD was detected in 16 (66.7%) participants who had disease duration for more than 10 years. Twenty (83.3%) patients who were diagnosed with NAFLD had a baseline CD4 count of < 200 and 14 patients had a BMI ≥ 25kg/m².

Liver fibrosis was diagnosed in six patients using clinical scores, APRI and FIB-4. APRI detected fibrosis in 5/6 cases and FIB-4 in 2/6 of the cases. The mean [± SD] APRI score was 0.32 [± 0.32]. The mean [± SD] FIB-4 score was 1.02 [± 0.55].

The clinical characteristics-related data are shown in Tables 2 and 3.

Table 2

Clinical and treatment characteristics of study Participants at Tikur Anbessa Specialized hospital from April 2020 to December 2020 G.C
Characteristics N = 110		Number (n)	Percentage (%)
Duration of HIV/AIDS in years [Mean ± SD]	10.67 ± 4.64
Distribution of Duration of HIV/AIDS	< 1year	2	1.8
	1 to 5 years	16	14.5
	5 to 10 years	23	20.9
	≥ 10 years	69	62.7
Baseline CD4 Count [Mean ± SD]	196.89 ± 166.49
Distribution of baseline CD4 count	< 200	67	60.9
	200 to 500	36	32.7
	≥ 500	7	6.4
Recent CD4 Count [Mean ± SD]	525.56 ± 250.90
Distribution of recent CD4 count	< 200	10	9.1
	200 to 500	45	40.9
	≥ 500	55	50
Viral Load	Detectable level	107	97.3
Viral Load	Undetectable level	3	2.7
ART Drugs	First line	95	86.4
ART Drugs	Second line	15	13.6
Medications	Cotrimoxazole	37	33.6
	Isoniazide	37	33.6
	Anti-Hypertensive medications	7	6.4
	Oral Hypoglyacemic agents	4	3.6
	Statin	1	0.9
	Anti-tuberculous	2	1.8
BMI [Mean ± SD]	24.03 ± 4.60
Distribution of BMI	< 18.5	16	14.5
	18.5 to 24.9	52	47.3
	25 to 29.9	28	25.5
	≥ 30	14	12.7
Waist Circumference	Normal	38	34.5
	≥ 88 for female	67	61
	≥ 102 for male	5	4.5
Laboratory Parameters [Mean ± SD]	AST	26.73 ± 13.15
	ALT	25.22 ± 20.67
	Platelet	275.72 ± 79.92
	Fasting Blood Sugar	110.60 ± 45.62
	Total Cholestrol	197.54 ± 43.26
	LDL	126 ± 50.34
	HDL	54.61 ± 20.88
	Triglayceride	164.27 ± 127.37
APRI Score [Mean ± SD]	0.32 ± 0.32
FIB-4 Score [Mean ± SD]	1.02 ± 0.55
Fibrosis by clinical scoring	APRI ≥ 1	5	4.5
Fibrosis by clinical scoring	FIB-4 ≥ 2.67	2	1.8
Diagnosis of NAFLD by Ultrasound	Yes	24	21.8
Diagnosis of NAFLD by Ultrasound	No	86	78.2

Table 3

Distribution of NAFLD among study variables of study Participants at Tikur Anbessa Specialized hospital from April 2020 to December 2020 G.C
Characteristics N = 110		Diagnosis of NAFLD
		Yes		No
		Number (n)	Percentage (%)	Number (n)	Percentage(%)
Duration of HIV	< 1 year	0	0	2	1.8
	1 to 5 years	4	3.6	12	10.9
	5 to 10 years	4	3.6	19	17.3
	≥ 10 years	16	14.5	53	48.2
Baseline CD4	< 200	20	18.2	47	42.7
	200 to 500	3	2.7	33	30
	≥ 500	1	0.9	6	5.5
Current CD4	< 200	1	0.9	9	8.2
	200 to 500	10	9	35	31.8
	≥ 500	13	11.8	45	38.2
ART Regimen	First line	23	20.9	72	65.5
ART Regimen	Second line	1	0.9	14	12.7
BMI	< 18.5	1	0.9	15	13.6
	18.5 to 24.9	9	8.2	43	39
	25 to 29.9	8	7.3	20	18.2
	≥ 30	6	5.5	8	7.3
APRI Score	< 1	20	18.2	85	77.3
APRI Score	≥ 1	4	3.6	1	0.9
FIB-4 Score	< 2.67	23	20.9	85	77.3
FIB-4 Score	≥ 2.67	1	0.9	1	0.9

Multivariate analysis of factors associated with NAFLD in HIV/AIDS Patients

A logistic regression analysis of factors associated with NAFLD in HIV/AIDS patients was done, and the odds ratio and a 95% confidence interval were used to determine the magnitude of the association between the independent variables and detection of NAFLD. None of the independent variables were collinear when multicollinearity was assessed using the Variance of Inflation Factor (VIF). Three variables were found to be significantly associated with detection of NAFLD on the initial univariate binary logistic regression analysis with a p-value of </= 0.2. These include female sex (crude odd ratio (COR) 2.116, 95% Confidence Interval (CI): 0.801–5.586), baseline CD4 count < 200 (COR 4.149, 95% CI: 1.308–13.161), and overweight (BMI ≥ 25kg/m²) (COR 2.900, 95% CI: 1.146–7.338).

At a p-value < /= 0.05, the final multivariate regression model revealed that only 2 factors had a statistically significant association with NAFLD in HIV patients. These include baseline CD4 count < 200 and overweight (BMI ≥ 25kg/m²). When compared to patients with baseline CD4 above 200, NAFLD was detected 3.5-fold greater in patients who had a baseline CD4 count < 200 (adjusted odds ratio (AOR 3.540), 95% confidence interval (CI): 1.075–11.661, p = 0.038). NAFLD was detected 3.6-fold greater in overweight (BMI ≥ 25kg/m²) patients (AOR 3.609, 95% CI: 1.285–10.136, p = 0.015).

Multivariate analyses of factors associated with NAFLD in HIV/AIDS patients are shown in Table 4 below.

Table 4

Multivariate analysis of factors associated with NAFLD in HIV/AIDS Patients of study Participants at Tikur Anbessa Specialized hospital from April 2020 to December 2020 G.C
Variables	NAFLD		COR (95% CI)	P value	AOR (95% CI)	P value
Variables	Yes	No	COR (95% CI)	P value	AOR (95% CI)	P value
Sex
Male	9	19	1	1
Female	15	67	2.116 (0.801–5.586)	0.130	2.522 (0.828–7.680)	0.104
Baseline CD4
< 200	20	47	4.149 (1.308–13.161)	0.016	3.540 (1.075–11.661)	0.038
≥ 200	4	39	1	1
Overweight (BMI ≥ 25kg/m2)
No	10	58	1	1
Yes	14	28	2.900 (1.146–7.338)	0.025	3.609 (1.285–10.136)	0.015

The current study found a 21.8% (24) prevalence of NAFLD among HIV patients without hepatitis B or C coinfection by ultrasound examination using Hamaguchi criteria. Although the prevalence of NAFLD in HIV patients ranges between 13 and 73%, the finding in this study is lower than the prevalence found in non-African countries (31% in study from California, 40% from Spain, and 35% from metanalysis of 10 USA studies) and higher than a study done in Nigeria, which found a 13% prevalence of NAFLD in adult HIV patients [2, 11–13, 25, 26].

In this study, the mean [± SD] age of the participants was 45.94 ± [11.18], which is comparable with other studies. Our study constitutes a larger number of female particpants (74.5%) as compared to previous studies. Metanalysis of ten studies from USA showed > 90% male participants and in the Nigerian study female accounted for 58.4%. In this study 62.5% of the NAFLD cases were detected in female participants. This showes a higher prevalence of NAFLD in female participants in our setting as compared to other studies. The possible justification could be the difference in study population, study setting, and most importantly women constitute the majority of HIV patients on treatment follow up in our setting [12, 13, 25, 26].

Increased BMI and waist circumferences have been shown to be associated with metabolic syndrome and increased risk of NAFLD. In this study, the mean [± SD] BMI among the participants was 24.03 ± [4.60] and 38.5% had above normal BMI. Two-third of the study participants had an increased waist circumference. This finding is comparable with other studies [11, 12].

The mean [± SD] duration of HIV/AIDS was 10.67 [± 4.64] years and at the time of initial diagnosis 60.9% of the participants had a CD4 count of less than 200 and only 6.4% (7) patients had a CD4 count ≥ 500. The mean recent CD4 count was 525.56 [± 250.90]. Viral load was undetectable in 107 (97.3%) patients. The majority (86.4%) of study participants were taking first line ART regimen and nucleoside reverse transcriptase inhibitors were used in all cases. TDF + 3-TC + DTG was the most commonly used regimen. Although many studies did not show association between viral load and duration of illness and treatment, some found association with CD4 count and exposure to nucleoside reverse transcriptase inhibitors. Our study also found a significant association between low CD4 count and NAFLD, but not with drug exposure and duration of illness [11–13].

In this study, the laboratory parameters (shown in Table 2) were with the laboratory normal range in most cases and significant elevation of serum alanine levels were not detected.

The diagnosis of NAFLD was made by ultrasound examination in 21.8% study participants. NAFLD was detected in 66.7% participants who had disease duration for more than 10 years and 83.3% patients who were diagnosed with NAFLD had a baseline CD4 count of < 200 and 58.3% patients had a BMI ≥ 25kg/m².

Although the study found 21.8% prevalence of NAFLD among the study participants, liver fibrosis was diagnosed in 5.4% patients using clinical scores, APRI and FIB-4. APRI detected fibrosis in 5/6 cases and FIB-4 in 2/6 of the cases. This finding is lower than other studies in whom assessment of fibrosis was done by TE or histopathology method [11–13, 27].

The study found a baseline CD4 count < 200 and BMI ≥ 25kg/m² to be significantly association with NAFLD in HIV patients at p-value < /= 0.05. When compared to patients with baseline CD4 above 200, NAFLD was detected 3.5-fold greater in patients who had a baseline CD4 count < 200 (adjusted odds ratio (AOR 3.540), 95% confidence interval (CI): 1.075–11.661, p = 0.038). NAFLD was detected 3.6-fold greater in overweight (BMI ≥ 25kg/m²) patients (AOR 3.609, 95% CI: 1.285–10.136, p = 0.015). This finding is in line with the results of other studies. Most studies showed a significant association between NAFLD and BMI, metabolic syndrome, diabetes, hypertension, dyslipidemia, male sex, exposure to nucleoside reverse transcriptase inhibitors, and elevated serum alanine level [11–13, 26, 27]. As it has been shown by metanalysis of ten studies from USA, our study also did not find significant association with viral load level, duration of HIV, and duration of ARV [13].

Strengths and Limitations of the Study

The smaller number of study participants and the method used to detect steatosis and fibrosis are the main limitations of the current study and makes it difficult to generalize the results of this study for the general population. We recommend conducting a multicenter, prospective study with a larger sample size and a better steatosis and fibrosis detection methods (TE or histopathology).

Ethiopia is one of the countries with high HIV burden. In order to prevent and treat morbidity and mortality from non-AIDS defining diseases in this population, it is crucial to identify comorbidities. The current study found a higher prevalence of NAFLD in Ethiopian HIV patients as compared to other African settings. The prevalence of fibrosis in this study is low as compared to other studies. A baseline CD4 count < 200 and BMI ≥ 25kg/m² were significantly associate with NAFLD in HIV patients. Institutions and hospitals should provide better diagnostic techniques for the early detection of steatosis and fibrosis in light of the global rise of NAFLD in general and the HIV population. Finally, we urge decision-makers to develop plans for early detection of risk factors and NAFLD in at risk population and to implement preventing strategies.

AAU

Addis Ababa University

AIDS

Acquired Immune Deficiency Syndrome

ALP

Alkaline Phosphatase

ALT

Alanine Transaminase

AST

Aspartate Aminotransferase

AOR

Adjusted Odd Ratio

APRI

AST to platelet ratio index

ART

Antiretroviral treatment

ARV

Antiretroviral

BMI

Body Mass Index

CAP

Controlled Attenuation Parameter

cART

combination Antiretroviral Therapy

COR

Crude Odd Ratio

FBS

Fasting Blood Sugar

FIB

4-Fibrosis 4 score

FMOH

Federal Ministry of Health

HAART

Highly active antiretroviral therapy

HIV

Human Immunodeficiency Virus

HDL

High Density Lipoprotein

LDL

Low-Density Lipoprotein

LFT

Liver Function Tests

NAFL

Non-Alcoholic Fatty Liver

NAFLD

Non-Alcoholic Fatty Liver Disease

NASH

Non-Alcoholic Steatohepatitis

PLT

Platelet Count

PLWH

People Living With HIV

TASH

Tikur Anbessa Specialized Hospital

Transient Elastography

WHO

World Health Organization

Acknowledgment

We would like to express our heartfelt gratitude to our advisor, Dr. Wondwossen Amogne, for his thorough counsel and invaluable insight. We also want to thank staff members at Tikur Anbessa Specialized Hospital's gastroenterology department.

Ethics approval and consent to participate

The ethical clearance of the present study was obtained from the institutional review board of Addis Ababa University, College of Health Sciences. Written informed consent for participation was obtained from each participant.

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to the national ART program privacy concern but are available from the corresponding author on reasonable request with permission of Addis Ababa University.

Funding

None.

Authors' contributions

YB and WA conceptualized and designed the research. The study was primarily conducted by YB, who also wrote the original draft of the current manuscript. ZD did the statistical analysis and involved in the final write up process. WA supervised the whole process of the current study.

Conflict of Interest

All authors declare that they have no competing interests.

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Prevalence, risk factors and liver-related complications of nonalcoholic fatty liver disease in Ethiopian HIV-infected patients: a cross-sectional study in a tertiary care center

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Abstract

Background

Method

Results

Conclusions

Introduction

Study Methodology: Design and Setting

Study participants

Inclusion criteria

Exclusion criteria

Data collection and analysis procedure

Operational definitions

APRI and FIB-4 calculated using the following formulas:

Data Analysis

Ethics approval and informed consent

Results

Sociodemographic characteristics of study participants

Clinical and treatment-related characteristics of study participants

Multivariate analysis of factors associated with NAFLD in HIV/AIDS Patients

Discussion

Strengths and Limitations of the Study

Conclusions

Abbreviations

Declarations

References

Additional Declarations

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