Comparison of the Aspartate Aminotransferase to Platelet Ratio Index (APRI) and HBV DNA level–Based Approaches for Antiviral Treatment Initiation in Chronic Hepatitis B

Abstract

Objectives : To compare eligibility for antiviral treatment initiation in chronic hepatitis B (CHB) patients using an Aspartate Aminotransferase to Platelet Ratio Index (APRI) cutoff > 0.5 versus a reference strategy based on hepatitis B virus (HBV) DNA level ≥ 2,000 IU/mL combined with elevated alanine aminotransferase (ALT), and to evaluate the strategic performance and cost implications of an APRI-based approach in settings with limited access to HBV DNA level testing.
Methods : A retrospective observational study was conducted among treatment-naïve CHB patients with complete laboratory data who received care at Khon Kaen Hospital between 2017 and 2025. Patients were classified as eligible for treatment according to APRI > 0.5 and the reference criteria. Concordance between strategies was assessed using 2×2 contingency tables, and sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overtreatment proportion were calculated. The diagnostic performance of APRI was evaluated using receiver operating characteristic (ROC) analysis. Total costs of three treatment-selection strategies—APRI-based, reference-based, and a stepwise approach—were compared.
Results : A total of 2,834 patients met the inclusion criteria. The APRI > 0.5 strategy classified a higher proportion of patients as eligible for treatment than the reference strategy (50.1% vs. 27.8%), with a discordance rate of 36.6%. The sensitivity, specificity, PPV, and NPV of APRI were 74.4%, 59.2%, 41.3%, and 85.7%, respectively. The proportion of overtreatment was 58.7%, and the area under the ROC curve was 0.714. The APRI-based strategy resulted in substantially lower total costs compared with the reference strategy, while the stepwise approach partially reduced costs but yielded a similar level of overtreatment.

Conclusions : An APRI cutoff > 0.5 represents a pragmatic and effective strategy to expand access to antiviral therapy for CHB patients in resource-limited settings. Although associated with a moderate degree of overtreatment, this strategy provides high sensitivity and reduces the overall economic burden on the healthcare system.