Each year, on 1 December, World AIDS Day reminds us of the importance of equity in HIV care and the ongoing need to address the full spectrum of health challenges faced by people living with HIV (PLHIV). As we strive toward the ambitious global targets for HIV prevention and treatment, it's time to expand the conversation to include comorbidities like liver diseases, which disproportionately affect this population.
In this special interview, Trenton M. White, a leading researcher in HIV and liver health at the Barcelona Institute for Global Health (ISGlobal) Public Health Liver Group, discusses the under-recognised issue of liver diseases in PLHIV and explores the interconnectedness among three of his studies published in Springer Nature journals and The Lancet. From championing the inclusion of a long-term well-being metric in HIV targets to tackling research gaps and advancing digital health innovations, White offers insights into creating more equitable and people-centred health systems that seek to improve the liver health and health-related quality of life of PLHIV.
1. Can you tell us about your journey into research? What inspired you to focus on the intersection of HIV care and liver health?
My journey into research has been shaped by a desire to address health inequities and improve care for those living with chronic illnesses from a systemic perspective. My focus on HIV care stems from its intersection of science, social justice, and health systems.
HIV is not just a medical issue—it’s deeply connected to societal factors like stigma, access to care, and structural inequities. Not only do PLHIV face chronic health challenges as they age, such as high rates of heart and kidney diseases, as well as some cancers, there has been an alarming and silent rise in liver conditions, like metabolic dysfunction-associated steatotic liver disease (MASLD), which need immediate attention.
2. In the paper “Beyond viral suppression of HIV – the new quality of life frontier”, which was published by your research group leader Jeffrey V Lazarus, there was a call for a ‘fourth 90’ target in HIV care, emphasising quality of life. Why is this focus on comorbidities, including liver health, so critical for PLHIV?
The ‘fourth 90’ comes from the UNAIDS 90-90-90 targets for 2020 and reframed the conversation around HIV care to focus not just on survival but on living well. 90-90-90 refers to national targets that 90% of all PLHIV are diagnosed, 90% of those receive treatment, and a further 90% of those reach viral suppression–which has since been updated by UNAIDS to 95% by 2030. Viral suppression leads to a longer lifespan, but a fourth 90 focuses on the quality of that lifespan.
We now advocate for a long-term well-being metric: in doing so, we acknowledge a person’s health-related quality of life, the impacts of stigma and discrimination on well-being, and multimorbidity as one ages. For PLHIV, comorbidities like steatotic liver disease aren’t just side issues; they can significantly undermine quality of life and lead to long-term complications if left unaddressed. Liver health, in particular, is a bellwether for broader systemic health challenges that many people with HIV face, from metabolic disorders to inequities in healthcare access.
“For PLHIV, comorbidities like steatotic liver disease aren’t just side issues; they can significantly undermine quality of life and lead to long-term complications if left unaddressed.”
By prioritising the management of these conditions alongside viral suppression, we can ensure a more holistic approach to care. Integrating patient-reported outcome measures (PROMs) and experience measures (PREMs) into routine HIV care can capture the physical, emotional, and social dimensions of health that extend beyond viral suppression, as described in our recent article, “Co-Creation of Patient-Centered Metrics for Long-Term Well-Being Involving People with HIV and HIV Care Providers.” This focus is about honouring the full humanity of PLHIV—not just treating the virus.
3. Interestingly, you authored a paper titled “Recommendations for the equitable integration of digital health interventions across steps of the HIV Care Cascade” which touches on “quality of life” as well. How could DHIs address gaps in liver disease management for PLHIV, considering aspects like patient-reported outcomes?
Digital health interventions hold incredible potential to bridge gaps in liver disease management for PLHIV. By enabling regular monitoring, these tools can provide real-time insights into liver health and empower patients to take an active role in their care.
Patient-reported outcomes collected via digital tools can shed light on symptoms or challenges that might otherwise go unnoticed in current care. Moreover, digital tools can break down barriers to access by providing remote care options, especially for those in underserved communities. Equitably implemented with proper privacy controls, they can be a powerful equaliser, ensuring that no one’s liver health—and by extension, their quality of life—is left behind.
4. Shifting the focus just slightly–in a separate paper on “Steatotic liver disease and HIV: an agenda for 2030”, you mentioned PLHIV have been historically excluded from clinical trials and large cohort studies of steatotic liver disease. What are the most urgent data gaps in research, and how can they be addressed to advance liver health for PLHIV?
The exclusion of PLHIV from steatotic liver disease research has left us with critical blindspots. We don’t fully understand how HIV itself—and its treatment—interacts with metabolic processes to increase the risk of liver disease. This knowledge gap limits our ability to develop targeted prevention and management strategies. The most urgent needs are longitudinal studies that include PLHIV to clarify the natural history of steatotic liver disease in this population, including the influence of social determinants like stigma, housing instability, and economic inequity.
5. Finally, what role can policymakers, healthcare providers, and researchers play in promoting the integration of liver health into HIV care?
Policymakers should prioritise liver health as an essential component of HIV care by allocating resources and funding for integrated chronic care services. They should also support policies that address social and commercial determinants of health, recognising that these factors profoundly influence outcomes. Healthcare providers can champion a holistic approach, routinely screening for risk factors of liver disease and other comorbidities. Researchers have a responsibility to fill knowledge gaps and ensure that their work reflects the lived realities of PLHIV, especially those in marginalised communities. Together, these stakeholders can create person-centred health systems that not only extend life but promote well-being in ageing.
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Indeed. A re- focus on improving the real health and wellbeing for a long term basis is the need of the hour. Unfortunately, no Government system around the world is truly concerned about it.