OBJECTIVE The association of hepatitis C virus genotype 4 (HCV-4) with hepatic steatosis has not been clarified. We aimed to determine the parameters associated with steatosis among HCV-4 patients and to assess the effect of steatosis on treatment with peginterferon and ribavirin. METHODS In a prospective study; 131 nondiabetic genotype 4 CHC patients were enrolled for analysis, treated with peginterferon-α-2b/ribavirin. Histopathologic, anthropometric, clinical, biochemical features, and insulin resistance (IR) estimated by the homeostasis model assessment index (HOMA-IR). RESULTS Hepatic steatosis was present in 58 patients (44.2%); 62% of them experienced mild steatosis. In univariable analysis, steatosis was associated with HOMA-IR, body mass index, waist circumference, serum triglycerides, cholesterol level, systolic hypertension, and histologic scores for inflammation and fibrosis. Multivariate analysis revealed that body mass index, waist circumference, and HOMA-IR were found to be significantly associated with steatosis. IR but not steatosis was associated with a lower rate of sustained virologic response when adjusted for known factors that predict response (odds ratio: 0.16, 95% CI 0.046-0.59, P=0.005). CONCLUSIONS In HCV-4 patients, the prevalence of steatosis was 44.2%; the majority (62%) has mild steatosis. Steatosis was significantly associated with metabolic factors. IR but not steatosis was independently associated with lower sustained virologic response.