www.nature.com/scientificreports OPEN Similar prevalence of hepatic steatosis among patients with chronic hepatitis C with and without HIV coinfection M. Fernandez-Fuertes1,2, J. Macías1,2 ✉ , A. Corma-Gómez1, P. Rincón1, N. Merchante1, J. Gómez-Mateos1, J. A. Pineda1,2 & L. M. Real1,2 Hepatic steatosis (HS) is frequently observed in HIV-infected patients. It is not known whether HIV infection is an independent risk factor for HS development. We aimed to analyze whether HIV coinfection was associated with a higher frequency of HS in patients with chronic hepatitis C. This was a retrospective cross-sectional study. 574 subjects with chronic hepatitis C virus (HCV) infection were included, 246 (43%) of them coinfected with HIV. All of them underwent transient elastography with controlled attenuation parameter (CAP) measurement. HS was defned as CAP ≥ 248 dB/m. 147 individuals (45%) showed HS in the HCV-monoinfected group and 100 (40.7%) in the HIV/HCV- coinfected group (p = 0.318). HS was associated with body mass index (BMI) [<25 Kg/m2 vs. ≥25 Kg/ m2, 67 (23.5%) vs. 171 (62.9%); p = 0.001], with plasma HDL-cholesterol [<50 mg/dL vs. ≥50 mg/dL, 122 (48.6%) vs. 95 (37.5%), p = 0.012], with plasma triglycerides [<150 mg/dL vs. ≥150 mg/dL, 168 (40.2%) vs. 65 (52.4%); p = 0.016] and with plasma total cholesterol [<200 mg/dL vs. ≥200 mg/dL, 181 (41%) vs. 53 (52.5%); p = 0.035]. In the multivariate analysis, HS was associated with BMI [adjusted OR (AOR) = 1.264 (1.194–1.339); p = 0.001], age [AOR = 1.029 (1.001–1.058); p = 0.047] and HCV genotype 3 infection [AOR = 1.901 (1.081–2.594); p = 0.026]. HIV coinfection was not associated with HS [AOR = 1.166 (0.719–1.892); p = 0.534]. In conclusion, HIV coinfection is not related with an increased frequency of HS in HCV-infected patients. Te main causes of hepatic steatosis (HS) are metabolic factors1, alcohol use2 and HCV infection, particularly HCV genotype 33,4. Non-alcoholic fatty liver disease (NAFLD), HS in the absence of other causes than metabolic factors, is recognized as one of the most common liver diseases worldwide with an estimated prevalence of 25% among the general population in Western countries5,6. NAFLD has a spectrum of liver disease ranging from sim- ple fatty liver to nonalcoholic steatohepatitis (NASH), fbrosis and cirrhosis7–10. In HIV-uninfected patients, the prevalence and risk factors of NAFLD and its complications have been eval- uated, specifcally in industrialized countries6,8,11–13. In HIV infection, studies carried out in unselected patients with or without HCV coinfection have reported a prevalence of HS, determined by the controlled attenuation parameter (CAP), of approximately 40%14–17. Tis rate nearly doubles that found of the general population in similar areas5 and it is closer to the NAFLD prevalence observed in obesity and type 2 diabetes mellitus8. Despite this diference between HIV-infected patients and the general population, there are very few direct comparisons of HS frequency between individuals with and without HIV infection. Indeed, a study comparing men who have sex with men (MSM) with and without HIV infection found a lower prevalence of HS in HIV-infected MSM than in MSM without HIV infection18. On the contrary, two case-control studies conducted in small samples found higher frequencies of HS in HIV-infected individuals than in controls19,20. Because of this, the actual impact of HIV infection on the risk of HS still remains unknown. Among HIV-infected patients with chronic hepatitis C, the frequency of HS estimated by liver biopsy showed a wide range from 23% to 72%21. In a metanalysis of HCV-infected patients who underwent liver biopsy, the rates of HS were similar in HIV/HCV-coinfected and HCV-monoinfected subjects21. However, patients undergoing 1Unit of Infectious Diseases and Microbiology, Hospital Universitario Virgen de Valme, Sevilla, 41014, Spain. 2These authors contributed equally: M. Fernandez-Fuertes, J. Macías, J. A. Pineda and L. M. Real. ✉e-mail: juan.macias. [email protected] SCIENTIFIC REPORTS | (2020) 10:6736 | https://doi.org/10.1038/s41598-020-62671-y 1 www.nature.com/scientificreports/ www.nature.com/scientificreports HCV HIV/HCV monoinfection coinfection Characteristics (N = 328) (N = 246) p-value Male sex, n (%) 271 (82.6) 214 (87) 0.152 Age (years)* 52 (48–57) 53 (49–56) 0.695 IDUa, n (%) 205 (66.3) 209 (87.1) 0.001 Alcohol intake ≥50 g/d, 168 (51.2) 60 (24.4) <0.001 n (%) HCV Genotype 3 54 (16.5) 43 (17.5) 0.748 infection, n (%) BMIb (kg/m2)* 25.9 (22.6–28.5) 24 (21.3–27) 0.001 BMIb (kg/m2), n (%) 18–25 141 (44.3) 144 (60.3) 26–30 123 (38.7) 67 (28) 0.004 31–35 41 (12.9) 18 (7.5) >35 11 (3.5) 9 (3.8) Fasting plasma glucosec ≥100 mg/dL, 72 (24.4) 75 (30.5) 0.113 n (%) Plasma triglyceridesd ≥150 mg/ 42 (14.1) 82 (33.5) 0.001 dL, n (%) Plasma total cholesterole 156 165 (145–199) 0.001 (mg/dL)* (137–182) Plasma HDL-cholesterolf 47.5 52.5 (41.5–65.4) 0.003 (mg/dL)* (37.6–59.0) Plasma LDL-cholesterolg 91 (71–115) 76 (61–99) 0.001 (mg/dL)* 9.7 LS (kPa) 7.3 (5.4–13.3) 0.001 * (6.9–16.9) Cirrhosis, n (%) 78 (23.8) 80 (32.5) 0.020 HbsAgh+, n (%) 1 (0.3) 8 (3.3) 0.001 486 (310.5– CD4 cell counts/mm3)I — * 726.0) Plasma HIV-RNA < 50 — 194 (78.9) copies/mL, n (%) ARTj, n (%) — 241 (99.2) Table 1. Characteristics of study populations (N = 574). *Median (Q1-Q3). aAvailable data for 549 patient; bAvailable data for 557 patients; cAvailable data for 541 patients; dAvailable data for 542 patients; eAvailable data for 543 patients; fAvailable data for 504 patients; gAvailable data for 505 patients; hAvailable data for 562 patients; iAvailable data for 245 patients; jAvailable data for 243 patients. Abbreviations: HCV: hepatitis C virus; HIV: human immunodefciency virus; IDU: injecting drug users; BMI: Body mass index; HDL: High-density lipoprotein; LDL: Low-density lipoprotein; LS: Liver Stifness; ART: antiretroviral therapy. a liver biopsy are not representative of the overall population with HCV infection. Tus, information provided by this study on the risk of HS inherent to HIV infection is very limited. Because of this, comparative studies of the HS prevalence conducted in unselected populations of HCV-infected patients with and without HIV coin- fection are required. Non-invasive techniques may allow these studies, as the overall HCV-infected population, irrespective the estimated liver stage or the therapy perspectives, may be included9,10. Tis kind of studies may provide very valuable data on the risk of HS due to HIV infection minimizing the possible confounding efect of the HCV coinfection. Because of these, we aimed to compare the prevalence of HS, evaluated using CAP, in patients with chronic HCV infection, with and without HIV coinfection, in order to appraise the efect of HIV infection on the HS presence in this setting. Results Characteristics of the study population. Five hundred and ninety-eight consecutive patients fulflled the inclusion criteria. A reliable elastography result could not be obtained in 24 (4%) of them. Tus, 574 patients were fnally analyzed. Among them, 328 (57.1%) were HCV-monoinfected patients and 246 (42.9%) were HIV/ HCV-coinfected individuals. Te demographic, anthropometric and laboratory characteristics of these patients are shown in Table 1. BMI and plasma total cholesterol, HDL cholesterol and LDL cholesterol values were lower in HIV/HCV-coinfected than in HCV-monoinfected patients (Table 1). Nearly all of HIV/HCV-coinfected patients were under antiretroviral therapy [241 (99.2%)] with undetectable viral load in 78.9% of the cases (Table 1). Prevalence of HS according to HIV infection status. Median CAP was 241 (209–280) dB/m among HCV-infected patients and 237 (202–273) dB/m among HIV/HCV-coinfected patients, (p = 0.296) (Fig. 1). Te SCIENTIFIC REPORTS | (2020) 10:6736 | https://doi.org/10.1038/s41598-020-62671-y 2 www.nature.com/scientificreports/ www.nature.com/scientificreports 400 p=0.296 350 300 CAP 250 241 (209-280) 237 (202-223.5) 200 150 100 HIV/ s Figure 1. CAP median and interquartile range in both HCV-infected and HIV/HCV-coinfected group of patients. HIV p=1 100% p=0.516 90.9% 88.9% 83.3% 80% p=0.467 73.2% 60% 57.7% 52.2% p=0.247 40% 26.0% 26.4% 20% 0% <25 25-30 30-35 >35 n 29 38 71 35 30 15 10 8 N 141 144 123 67 41 18 11 9 te HCV mono-infected or HIV/HCV co-infect ade of obesity Figure 2. Frequency of steatosis in HCV-infected and HIV/HCV-coinfected populations classifed according to the grade of obesity. frequency of HS (CAP ≥ 248 dB/m) in HCV-monoinfected patients was 147 (44.8%) and in HIV/HCV-coinfected patients was 105 (40.7%) (p = 0.318). Eighty-three (25.3%) individuals without HIV infection showed severe steatosis compared to 51 (20.7%) among those with HIV coinfection (p = 0.2). Tere were no diferences in the prevalence of steatosis between the group with and without HIV coinfection by BMI category (Fig. 2). In an anal- ysis excluding patients with alcohol intake ≥50 g/d, there were no diferences between the two study groups in the median CAP values nor in the prevalence of HS (Supplementary Fig.