Alcohol-Associated Liver Disease Stigma Hinders Diagnosis and Care, With Wei Zhang, MD

New research highlights the disproportionate impact of etiology-specific stigma on patients with liver disease, demonstrating heightened rates, delays in diagnosis, and barriers to care among patients with alcohol-associated liver disease (ALD) compared to those with non-alcohol-related liver disease.1

Wei Zhang, MD, a transplant hepatologist and assistant professor of medicine at Massachusetts General Hospital and Harvard Medical School, presented the findings at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025. The results emphasize the need for patient-informed strategies to reduce stigma, support earlier diagnosis and intervention, and improve clinical outcomes for ALD patients.

The stigma surrounding alcohol use disorder impacts patients at all levels of their lives, including psychosocial and healthcare. As a result, alcohol-associated liver disease can complicate conversations with healthcare providers and family members, interfere with illness recognition and insight, timely help-seeking, treatment adherence, and recovery.2

“Stigma is one of the main reasons patients with alcohol-associated liver disease don’t receive timely or equitable care. When patients feel judged or blamed for their illness, they are less likely to come to care early, disclose their alcohol use honestly, or stay engaged in follow-ups,” Zhang said in an interview with HCPLive. “From a provider perspective, stigma can lead to skepticism about patient motivation and raise questions about whether patients ‘deserve’ care. This bias also lowers the threshold for denying patients with ALD access to liver transplant, while other liver disease etiologies are often considered blameless.”

Zhang and colleagues measured stigma using 3 categories: internalized, anticipated, and experienced. The Liver Disease Stigma Scale (LDSS), a 28-item validated instrument, quantified each category. Internalized stigma includes self-identified negative stereotypes and blame, anticipated stigma refers to expectations of judgment or discrimination, and experienced stigma captures real-world instances of judgment, blame, or differential treatment. These factors were assessed in family and healthcare settings.

The study included 221 adults with liver disease, including 133 with ALD and 88 with non-ALD etiologies. Patients with ALD were more likely to be male and to have lower educational attainment (P <.01).

Across all LDSS subscales, investigators discovered significantly greater reported levels of stigma in patients with ALD, including experienced (mean,1.75; standard deviation [SD], 0.90 vs 1.23; SD, 0.46; P <.001), anticipated (1.57; SD, 0.77 vs 1.24; SD, 0.50; P <.001), and internalized (2.34; SD, 1.12 vs 1.54; SD, 0.84; P <.001). Between domains, differences were also observed in both family and healthcare settings. Family-related experienced stigma was higher in patients with ALD (1.79; SD, 1.07) compared with those with non-ALD (1.19; SD, 0.37), as was healthcare-related experienced stigma (1.71; SD, 0.93 vs 1.27; SD, 0.62).

Investigators found heightened negative attitude towards liver disease (2.11; SD,0.87 vs 1.44; SD, 0.59; P <.001) and liver disease treatment (1.38; SD, 0.54 vs 1.21; SD,0.39; P = .008) in patients with ALD, underscoring stigma’s influence on perceptions of care, engagement, and healthcare outcomes.

“From a provider perspective, education is key to reduce bias and recognizing ALD as a treatable disease, and it's important for providers to feel comfortable prescribing appropriate medications. Providers should also use patient-centered language to make patients feel heard and engaged,” said Zhang. “At the system level, we can implement more objective selection processes for interventions and liver transplant to reduce personal bias. Integrated hepatology-addiction clinics can also provide the comprehensive care these patients need.”

Editor’s note: Zhang reports no relevant disclosures.

References

1. Zhang W, Hsu K, Wu E, et al. Greater liver disease–related stigma among patients with alcohol-associated liver disease compared with non–alcohol-related liver disease. Abstract presented at: American Association for the Study of Liver Diseases The Liver Meeting 2025; 2025; Washington, DC.

2. Schomerus G, Leonhard A, Manthey J, et al. The stigma of alcohol-related liver disease and its impact on healthcare. J Hepatol. 2022;77(2). doi:10.1016/j.jhep.2022.04.026