Does HIV Affect the Liver? Risks, Coinfections, and Protective Strategies

Living with human immunodeficiency virus (HIV) means you have to take an extra amount of effort taking care of your body. Your liver plays a crucial part in this process. It’s only natural that you have questions like, “does HIV affect the liver” and other concerns related to the liver. And, it’s not wrong considering how much you are managing your condition right now. The good news is that with the correct knowledge and understanding you can put some control over some aspects of your health.

Your liver works hard every day, and HIV can sometimes make that job more challenging through inflammation. The medications that help keep you healthy, along with other infections you might encounter, can also impact your liver. But here's what's encouraging. You have the real power to protect your liver health. With regular check-ups, working closely with your healthcare team to choose the safest medications for you, and making choices that support your overall wellness, most people with HIV maintain healthy livers throughout their lives.

Those routine tests your doctor recommends aren't just numbers on a page. They're your early warning system, catching any changes before they become serious problems. When issues are spotted early, there are effective ways to address them and keep you feeling your best. You're not just managing a condition. You're actively building a healthier future for yourself.

Key Takeaways

• HIV can affect the liver directly through infection and inflammation

• HIV can indirectly affect the liver through coinfections like hepatitis B and C and other medications

• Approximately one-third of HIV patients in the United States (US) are coinfected with hepatitis B or C, increasing the risk for liver cirrhosis and cancer

• Modern antiretroviral therapies (ARTs) are safer, but older drugs like efavirenz may cause hepatoxicity, which requires liver function monitoring

• Protecting liver health involves adhering to ART

• Liver health with HIV must mean getting vaccinated against hepatitis A and B

• Lifestyle modifications like limiting alcohol intake, maintaining a healthy weight, and regular screenings are also part of protecting your liver health

Does HIV Affect the Liver?

Yes, HIV can affect the liver in multiple ways. Research shows that 30-65% of people with HIV develop some form of liver issues at some point, particularly non-alcoholic fatty liver disease (NAFLD).

The virus can directly damage liver cells, while HIV medications and infections like hepatitis B or C further increase liver disease risk.

How Does HIV Directly Damage the Liver?

HIV harms the liver by attacking immune cells inside liver tissue, creating ongoing inflammation that damages liver cells over time. The virus targets CD4+ T cells and other immune cells in the liver, leading to constant immune system activation that hurts liver function.

What is DILS?

DILS stands for diffuse infiltrative lymphocytosis syndrome. It happens when HIV causes the white blood cells to build up in organs like the liver. This buildup creates inflammation and can make the liver swell and work poorly. This condition affects about 3–7.8% of people with AIDS. It usually occurs when CD4+ counts become moderately low.

What happens in DILS?

• It causes liver swelling and pain

• It could raise liver enzyme levels

• It often comes with swollen lymph nodes and dry eyes

• With effective HIV treatment, it could get better

Are There Long-Term Effects Even with ART?

Yes, even with successful HIV treatment, some degree of liver damage may still continue because there is ongoing low-level inflammation. Research states that people with HIV often have higher inflammatory markers than those without. And this is true even when viral loads could not be detected.

What are these long-term effects?

• Ongoing inflammation can lead to liver scarring

• The risk still remains high for fatty liver disease

• Regular monitoring can help catch issues early

• Starting HIV treatment early may help improve long-term liver protection

Can HIV Cause Fatty Liver Disease or Fibrosis?

Yes, HIV greatly increases the risk of fatty liver disease. Like mentioned earlier, people with HIV are at risk for fat buildup in the liver, such as NAFLD. The virus disrupts normal fat processing and increases insulin resistance, creating conditions that promote fat accumulation in the liver.

What Percentage Are Affected?

Among people with HIV, the percentage of people affected with fatty liver disease (FLD) or fibrosis are the following:

• 35-65% will develop NAFLD at some point

• 17-41% will develop significant fibrosis

• 10% will demonstrate some degree of liver stiffness due to coinfection

Also, liver-related deaths among patients with HIV are 10x higher when compared to the general population.

How to Prevent Fatty Liver in HIV Patients?

Prevention focuses on keeping metabolism healthy and reducing liver stress. Key approaches include:

• Maintaining a healthy weight through good nutrition

• Regular exercise to improve how the body uses insulin

• Limiting alcohol to reduce liver stress

• Managing diabetes and high cholesterol effectively

• Taking HIV medications consistently to control the virus

• Regular monitoring of liver function tests

What Role Do Antiretroviral Medications Play in Liver Health?

HIV medications have a complex relationship with liver health. They provide essential virus control while potentially causing liver side effects. Modern HIV medications are generally safer for the liver. But there are some drugs that carry higher risks of liver toxicity. This is especially true for people with existing liver problems.

Which Meds Have Highest Hepatotoxicity?

Certain HIV medications pose greater risks for liver damage, especially when combined with other risk factors:

• Nevirapine–higher risk of severe liver reactions; approximately 4.9% of patients treated with this drug had symptomatic liver events.

• Efavirenz–may cause elevated liver enzymes, but it is established as a cause of acute liver injury

• Protease inhibitors–can worsen metabolic problems and fatty liver development

• Older medications–drugs like tipranavir carry FDA warnings for liver damage

How Often Should Enzymes Be Monitored?

Liver enzyme monitoring schedules depend on medications and individual risk factors:

• First 6 months–monthly liver tests for high-risk medications

• Stable patients–every 3-6 months for routine monitoring

• High-risk individuals–more frequent monitoring based on hepatitis infection or existing liver disease

• If symptoms develop–immediate testing for symptoms like fatigue, nausea, or yellowing

How Does Hepatitis C/B Coinfection Affect Liver Disease in HIV?

Hepatitis B or C infection dramatically speeds up liver disease in people with HIV. Coinfection affects 2% of HIV-positive people in the United States and increases the risk of cirrhosis, liver failure, and liver cancer by 3-5 times compared to HIV alone.

How Coinfection Changes Treatment Priority?

When hepatitis infection is present, liver health becomes the main treatment focus because liver disease progresses much faster:

• Hepatitis C–new medicines can cure hepatitis C in over 95% of cases

• Hepatitis B–requires medicines that treat both HIV and hepatitis B simultaneously

• Treatment timing–hepatitis treatment often takes priority over optimizing HIV medicines

• Monitoring intensity–more frequent liver function tests and imaging studies needed

Which DAAs Are Safe Alongside ART?

Most hepatitis C medicines work safely with HIV medications, but drug interactions require careful management:

• Sofosbuvir-based treatments–generally safe with most HIV medications

• Glecaprevir/pibrentasvir–effective but requires dose changes with some HIV medicines

• Drug interaction checking–essential before starting any hepatitis C treatment

• Specialist consultation–infectious disease or liver expertise recommended for people with both infections

How Is Liver Damage Monitored and Treated in People with HIV?

Liver health monitoring involves regular blood tests, imaging studies, and clinical checks to detect early signs of damage. Standard monitoring includes liver enzyme tests, hepatitis screening, and assessment for signs of liver problems.

What Labs/Images Are Standard in the U.S.?

Complete liver monitoring follows established guidelines from major medical facilities:

• Blood tests

• Liver enzyme tests may be done every 3-6 months

• Bilirubin and alkaline phosphatase (ALP)

• Hepatitis B and C screening when HIV is first diagnosed

• Cholesterol panel to check for metabolic health

• Imaging tests

• FibroScan–measures liver stiffness

• Ultrasound to screen for fatty liver

• Computed tomography (CT) or magnetic resonance imaging (MRI) for advanced disease assessment

Regular screening tests help detect changes before symptoms develop or before it turns serious.

Lifestyle Tips Specific to HIV-Positive Groups

People with HIV can greatly improve liver health through targeted lifestyle changes:

• Nutrition focus:--mediterranean-style diet rich in healthy fats and antioxidants

• Exercise routine–150 minutes of moderate activity weekly to improve insulin function

• Alcohol limits–complete avoidance recommended, especially with hepatitis infection

• Supplement caution–avoid herbal supplements that may interfere with HIV medications

• Vaccination–hepatitis A and B vaccines for additional liver protection

When Should Someone with HIV See a Liver Specialist?

People with HIV should see a liver specialist when liver enzymes exceed normal limits, symptoms of liver disease develop, or hepatitis infection is diagnosed. Early specialist consultation helps prevent progression to advanced liver disease and optimizes treatment strategies.

What Symptoms Indicate Urgent Referral?

Certain symptoms require immediate liver specialist consultation due to potential serious liver complications:

• Jaundice–yellowish discoloration of the skin or eyes, which may suggest severe liver problem

• Ascites–buildup of fluid in the belly

• Encephalopathy–altered mental state; patient may appear confused or show cognitive changes from toxin buildup due to liver failure

• Persistently elevated liver enzymes–levels often consistently 2-3 times normal

• Signs of portal hypertension–there will be enlarged spleen or swollen blood vessels in the esophagus

Transplant Eligibility for HIV Patients in the United States

Liver transplantation has become a viable option for HIV-positive patients meeting specific criteria:

• Undetectable HIV viral load–sustained virus control for at least 6 months

• CD4+ count requirements–generally above 100-200 cells/μL depending on center

• No active infections–stable HIV disease without recent complications

• MELD score consideration–priority based on liver disease severity

• Post-transplant outcomes–similar survival rates to HIV-negative recipients at experienced centers

Quick Summary Box

• HIV directly attacks liver immune cells causing chronic inflammation and potential liver damage

• Up to 30-40% of people with HIV develop fatty liver disease, much higher than the general population

• Hepatitis B or C infection increases liver disease risk by 3-5 times and affects 2-15% of HIV-positive individuals

• Modern HIV medications like integrase inhibitors have lower liver toxicity than older drug classes

• Regular monitoring with liver function tests every 3-6 months helps detect problems early

• Lifestyle changes including weight loss and exercise can reverse fatty liver disease in many cases

• Liver transplantation is now a viable option for HIV-positive patients meeting specific criteria

Frequently Asked Questions

Can undetectable HIV viral load protect my liver?

No, an undetectable HIV viral load cannot protect your liver. But it does reduce the risk. While virus control decreases HIV-related liver inflammation, people with HIV still face higher risks for fatty liver disease and need regular monitoring. Maintaining an undetectable viral load is crucial for overall liver health.

Are there safe ART drugs for people with liver conditions?

Yes, several HIV medications are considered safer for people with existing liver disease. Integrase inhibitors like dolutegravir and raltegravir have minimal liver toxicity. Tenofovir alafenamide (TAF) is preferred over tenofovir disoproxil fumarate (TDF) for people with liver concerns. Always consult your HIV specialist for personalized medication selection.

Can lifestyle changes reverse HIV-related fatty liver?

Not directly. Lifestyle changes can greatly improve and sometimes reverse fatty liver disease in people with HIV. Weight loss of 7-10% through diet and exercise can reduce liver fat content. Combined with effective HIV treatment, lifestyle changes often lead to measurable improvements in liver function tests and imaging studies.

What's the connection between HIV and liver cancer risk?

HIV increases liver cancer risk, particularly when combined with hepatitis B or C infection. The risk comes from chronic inflammation, faster progression to cirrhosis, and weakened immune surveillance. Regular screening with ultrasound and blood tests is recommended for people with advanced liver scarring or cirrhosis.

 

Related Resources

Does Lupus Affect the Liver? Making the Connection

What is an Echogenic Liver? Understanding Ultrasound Findings

Which Hepatitis is the Worst? Understanding Hepatitis

References

References

Adekunle, R. O., Rodrigues, M., & Durand, C. M. (2025). Evaluating Challenges in Access To Transplantation for Persons with HIV. Current HIV/AIDS Reports, 22(1). https://doi.org/10.1007/s11904-025-00735-2 

Dieterich, D. T., Robinson, P. A., Love, J., & Stern, J. O. (2004). Drug-Induced Liver Injury Associated with the Use of Nonnucleoside Reverse-Transcriptase Inhibitors. Clinical Infectious Diseases, 38(Supplement_2), S80–S89. https://doi.org/10.1086/381450 

Efavirenz. (2012). PubMed; National Institute of Diabetes and Digestive and Kidney Diseases. https://www.ncbi.nlm.nih.gov/books/NBK548521/ 

Ghrenassia, E., Martis, N., Boyer, J., Burel-Vandenbos, F., Mekinian, A., & Coppo, P. (2015). The diffuse infiltrative lymphocytosis syndrome (DILS). A comprehensive review. Journal of Autoimmunity, 59, 19–25. https://doi.org/10.1016/j.jaut.2015.01.010 

Hepatitis B & C. (2019, April 30). HIV.gov. https://www.hiv.gov/hiv-basics/staying-in-hiv-care/other-related-health-issues/hepatitis-b-and-c 

Hui, D. Y. (2003). Effects of HIV protease inhibitor therapy on lipid metabolism. Progress in Lipid Research, 42(2), 81–92. https://doi.org/10.1016/s0163-7827(02)00046-2 

Liver function tests. (n.d.). Aidsmap.com. https://www.aidsmap.com/about-hiv/liver-function-tests 

Mechanisms of Accelerated Liver Fibrosis Progression during HIV Infection. (2016). Journal of Clinical and Translational Hepatology. https://doi.org/10.14218/jcth.2016.00034 

Mohr, R., Schierwagen, R., Schwarze-Zander, C., Boesecke, C., Wasmuth, J.-C., Trebicka, J., & Rockstroh, J. K. (2015). Liver Fibrosis in HIV Patients Receiving a Modern cART. Medicine, 94(50), e2127. https://doi.org/10.1097/md.0000000000002127 

Rosenthal, E. S., Kottilil, S., & Polis, M. A. (2016). Sofosbuvir and ledipasvir for HIV/HCV co-infected patients. Expert Opinion on Pharmacotherapy, 17(5), 743–749. https://doi.org/10.1517/14656566.2016.1157580 

Seth, A., & Sherman, K. E. (2019). Fatty Liver Disease in Persons With HIV Infection. Topics in Antiviral Medicine, 27(2), 75. https://pmc.ncbi.nlm.nih.gov/articles/PMC6550355/ 

Sherman, K. E., & Thomas, D. L. (2022). HIV and Liver Disease: A Comprehensive Update. Topics in Antiviral Medicine, 30(4), 547. https://pmc.ncbi.nlm.nih.gov/articles/PMC9681142/ 

World Health Organization. (2024, April 9). Hepatitis C. World Health Organization; World Health Organization: WHO. https://www.who.int/news-room/fact-sheets/detail/hepatitis-c