Metabolic Dysfunction‐Associated Steatohepatitis and the Progression of Cognitive Decline in Older Thai People With HIV

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Abstract
Introduction: Metabolic dysfunction‐associated steatohepatitis (MASH) is more common in people with HIV and associated with systemic inflammation and extrahepatic complications, including cognitive impairment. While cross‐sectional studies suggest an association between MASH and worse cognitive outcomes, its impact on longitudinal cognitive trajectories in people with HIV remains unclear. Methods: This prospective study included people with HIV aged≥50 years from HIV‐NAT, Bangkok, Thailand, between 2015 and 2024. MASLD and MASH were identified at baseline using the FibroScan‐AST (FAST) score. Cognitive function was assessed using the Thai‐validated Montreal Cognitive Assessment (MoCA) at baseline and a follow‐up visit. A multivariate linear mixed model was used to determine the difference in changes in MoCA scores between participants with and without baseline MASH. Results: Among 291 participants (60.5% male; median age 54.4 years), 60 (20.6%) met criteria for MASH at baseline. Over a median follow‐up of 5.9 years, baseline MASLD was not associated with cognitive decline, whereas participants with baseline MASH showed a significantly greater cognitive decline between ages 50 and 80 years, after adjusting for age, sex, body mass index, education level, employment status, smoking, alcohol consumption, diabetes, hypertension, duration of HIV acquisition and exposure to efavirenz. Participants with MASH showed a mean MoCA decline of –4.79 (95% CI –7.49 to –2.09), compared with –0.94 (95% CI –2.20 to –0.32) among those without MASH ( p ‐interaction = 0.007). Conclusions: MASH is a significant predictor of steeper cognitive decline in older people with HIV, independent of traditional metabolic and HIV‐related risk factors. These findings suggest that early identification and management of MASH may help mitigate cognitive decline in ageing HIV care.

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