Elevated AST-to-platelet ratio index is associated with increased all-cause mortality among HIV-infected adults in Zambia

Liver Int. 2015 Jul;35(7):1886-92. doi: 10.1111/liv.12780. Epub 2015 Jan 22.


Background & aims: We investigated the association between significant liver fibrosis, determined by AST-to-platelet ratio index (APRI), and all-cause mortality among HIV-infected patients prescribed antiretroviral therapy (ART) in Zambia.

Methods: Among HIV-infected adults who initiated ART, we categorized baseline APRI scores according to established thresholds for significant hepatic fibrosis (APRI ≥1.5) and cirrhosis (APRI ≥2.0). Using multivariable logistic regression we identified risk factors for elevated APRI including demographic characteristics, body mass index (BMI), HIV clinical and immunological status, and tuberculosis. In the subset tested for hepatitis B surface antigen (HBsAg), we investigated the association of hepatitis B virus co-infection with APRI score. Using Kaplan-Meier analysis and Cox proportional hazards regression we determined the association of elevated APRI with death during ART.

Results: Among 20 308 adults in the analysis cohort, 1027 (5.1%) had significant liver fibrosis at ART initiation including 616 (3.0%) with cirrhosis. Risk factors for significant fibrosis or cirrhosis included male sex, BMI <18, WHO clinical stage 3 or 4, CD4(+) count <200 cells/mm(3) , and tuberculosis. Among the 237 (1.2%) who were tested, HBsAg-positive patients had four times the odds (adjusted odds ratio, 4.15; 95% CI, 1.71-10.04) of significant fibrosis compared HBsAg-negatives. Both significant fibrosis (adjusted hazard ratio 1.41, 95% CI, 1.21-1.64) and cirrhosis (adjusted hazard ratio 1.57, 95% CI, 1.31-1.89) were associated with increased all-cause mortality.

Conclusion: Liver fibrosis may be a risk factor for mortality during ART among HIV-infected individuals in Africa. APRI is an inexpensive and potentially useful test for liver fibrosis in resource-constrained settings.

Keywords: AST-to-platelet ratio index; Africa; FIB-4; HIV/AIDS; hepatitis B virus; liver disease.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Age Factors
  • Anti-HIV Agents / adverse effects*
  • Aspartate Aminotransferases / blood*
  • Biomarkers / blood
  • Cause of Death
  • Chemical and Drug Induced Liver Injury / blood*
  • Chemical and Drug Induced Liver Injury / diagnosis
  • Chemical and Drug Induced Liver Injury / etiology
  • Chemical and Drug Induced Liver Injury / mortality*
  • Clinical Enzyme Tests*
  • Female
  • HIV Infections / blood
  • HIV Infections / diagnosis
  • HIV Infections / drug therapy*
  • HIV Infections / mortality
  • Humans
  • Kaplan-Meier Estimate
  • Liver Cirrhosis / blood*
  • Liver Cirrhosis / chemically induced
  • Liver Cirrhosis / diagnosis
  • Liver Cirrhosis / mortality*
  • Logistic Models
  • Male
  • Multivariate Analysis
  • Odds Ratio
  • Platelet Count*
  • Predictive Value of Tests
  • Prevalence
  • Proportional Hazards Models
  • Risk Assessment
  • Risk Factors
  • Time Factors
  • Treatment Outcome
  • Zambia / epidemiology


  • Anti-HIV Agents
  • Biomarkers
  • Aspartate Aminotransferases