Aim: Metabolic dysfunction-associated steatotic liver disease (MASLD) and liver fibrosis are increasingly prevalent among people living with HIV (PLHIV), particularly as metabolic comorbidities such as prediabetes rise. Yet, liver fibrosis risk in PLHIV with prediabetes remains poorly characterised, particularly in sub-Saharan Africa. Non-invasive tests (NITs), including the Fibrosis-4 (FIB-4) Index, are recommended for first-line fibrosis risk stratification. Most lack validation in sub-Saharan African PLHIV. We aimed to estimate liver fibrosis risk and ten-year cirrhosis risk using blood-based NITs in a Tanzanian cohort of PLHIV with prediabetes.
Methods: We conducted a cross-sectional analysis of baseline data from 1,691 PLHIV with prediabetes enrolled in the Metformin Trial (META) Trial in Tanzania. Fibrosis risk was assessed using FIB-4, Metabolic Dysfunction-Associated Fibrosis 5 (MAF-5), NAFLD Fibrosis Score (NFS), and LiverRisk with validated age-adjusted cut-offs. Ten-year cirrhosis risk was estimated using the Cirrhosis Outcome Risk Estimator (CORE).
Results: Participants had a mean age of 49.4 years (SD 9.4); 75.0% were female and 99.2% were Black. FIB-4 classified 65.0% as low risk and 3.04% as high risk. MAF-5 identified 50.26% as high risk, while NFS classified 7.46% as high risk. Less than 1% were medium- to high-risk by LiverRisk. Using CORE, 5.8% had > 1% predicted 10-year cirrhosis risk. Substantial discrepancies were observed.
Conclusion: Multiple NITs identified measurable fibrosis or cirrhosis risk, yet risk classification varied markedly. These findings highlight both the potential utility and major limitations of existing NITs in African HIV and prediabetes settings and underscore the urgent need for locally validated, context-appropriate fibrosis screening tools.
KW - Cardiometabolic disease KW - liver fibrosis KW - long-term well-being KW - multimorbidity KW - prediabetes DO - 10.20517/mtod.2026.52 UR - https://dx.doi.org/10.20517/mtod.2026.52