Viral Hepatitis Treatment in Africa: Integration and Simplified Treatment Criteria - Experiences From Ethiopia
by Dr. Hailemichael Desalegn
In sub-saharan Africa, the level of awareness regarding hepatitis B virus (HBV) infection remains critically low. A significant number of individuals are either unaware of their infection status or hold misconceptions about the nature and treatment of HBV. Current statistics reveal that only 0.2% of these people are receiving treatment, which is inadequate given the scale of the problem. The scenario is further complicated by the prevalence of advanced complications, including decompensated liver disease and hepatocellular carcinoma (HCC), which often go unrecognized until they reach critical stages.
Hepatitis B is a vaccine-preventable disease, and the introduction of a birth dose vaccine as part of routine immunization programs is essential in combating this public health challenge. In Africa, however, only 15 out of the 43 countries have implemented this vital practice, leaving a substantial gap that could otherwise lead to the eradication of the disease in future generations. Alongside vaccination efforts, it is crucial to develop comprehensive programs aimed at identifying and treating individuals who are currently infected or undiagnosed, as they can unknowingly transmit the virus and may present with severe liver disease complications.
In Ethiopia, we initiated the Ethio-Norwegian Hepatology Consortium (EtNoHep) program in 2015, which has since become a cornerstone of our strategy to tackle hepatitis B. The program is centred around the diagnosis, treatment, and ongoing monitoring of HBV patients through a robust research initiative. In its early months, we successfully enrolled 1,300 patients primarily through grassroots efforts, where physicians played a pivotal role in referring diagnosed patients for treatment and support.
The pilot phase of the EtNoHep program yielded striking results. The program also revealed that a mere 1% of patients without cirrhosis died over a five-year follow-up period, in contrast to the 46% mortality rate observed among those with decompensated cirrhosis. This finding underscores the critical importance of early diagnosis and treatment in saving lives. Building on the insights from the pilot program, we expanded our efforts to lower-tier health facilities through different regions in Ethiopia, aiming to identify and treat a larger proportion of the undiagnosed HBV population. Achieving this goal requires a simplified and innovative approach to diagnostics and treatment.
To enhance our outreach, we integrated active screening programs with existing healthcare services, which proved to be an effective strategy. By utilizing resources from HIV and tuberculosis (TB) clinics, an integrated care will be able to share trained staff, counsel patients, and manage patient data more efficiently. We employed the same diagnostic platforms used for HBV viral load testing as those for TB programs, which improved the turn-around time significantly. The integration also fostered adherence to treatment counselling protocols and facilitated medication refills.
Challenges: One of the foremost issues is the lack of funding for hepatitis B initiatives, as the disease receives limited international attention. This constraint hinders major funding opportunities for governmental and non-governmental stakeholders.
Additionally, there remains a widespread lack of awareness regarding HBV status among the population, which slows participation in treatment programs that rely heavily on passive case finding.
Another significant barrier is the restricted access to HBV viral load testing, which is frequently limited to specialized research institutes and private laboratories, resulting in lengthy turnaround times that can extend to several months.
High lost-to-follow-up rates are notable among patients categorized as ineligible for treatment.
Key Lessons Learned
To effectively increase the uptake of HBV treatment, it is essential to focus on health education, community engagement, and the implementation of proactive screening campaigns.
Integrating hepatitis treatment with TB/HIV care and services for non-communicable diseases (NCDs) within “chronic care clinics” has shown promise in reducing stigma while enhancing service efficiency through the collective provision of services such as adherence counselling, side-effect monitoring, and patient tracking.
Facilitating quick access to laboratory results has emerged as a vital strategy for improving patient retention in care. The adoption of diagnostic tools like the Xpert® HBV viral load kit has significantly diminished turnaround times for laboratory results, thereby enhancing patient retention and treatment adherence.
The economic analysis of HBV and hepatitis C virus (HCV) treatments in Ethiopia has highlighted that the high expense associated with advanced laboratory tests constitutes a major driver of overall treatment costs. Therefore, implementing innovative diagnostic approaches or simplified criteria that reduce the dependency on extensive laboratory testing is critical for lowering treatment costs nationwide. As we move forward, we must continue our collective efforts to ensure hepatitis B no longer poses a significant threat to the health and well-being of our communities.
In light of the insufficient funding support for hepatitis B virus (HBV) initiatives and the recent U.S. decision to withdraw from the WHO and other international organizations, Africa must create an innovative funding mechanism to assist its citizens. Health should be prioritized, emphasizing awareness, screening, advanced diagnostic methods, simplified treatment protocols, and support for local drug manufacturers. Achieving this will require collaboration among the African CDC, the African Union, WHO AFRO, scientific societies, COLDA, national hepatology associations, HEPSANET, and civil society organizations in Africa, all working together towards a shared objective.
Combating Stigma and Misinformation in the Fight Against Hepatitis?
by Dr. Mercy Nyakowa
Every thirty seconds, someone in the world dies from a viral hepatitis-related illness. This number accounts for the one million three hundred thousand people who died in 2022. What is truly lamentable about these deaths is that they could have been prevented, either through vaccination or treatment with antiviral medication. Hepatitis, though referred to as a silent killer, doesn’t have to be fatal. A key component in the fight against viral hepatitis is information. Misinformation on the other hand can be a deadly impediment to good health.
Misinformation and stigma often go hand in hand. Societal attitudes and misconceptions about a disease can be deeply ingrained and affect how people are treated or seek treatment. Stigma often stems from a lack of accurate information. For instance, one pervasive myth in one of the communities is that hepatitis B is a result of witchcraft. This belief is not only incorrect but also dangerous, as it fosters unnecessary fear and avoidance of those living with these illnesses.
Pre-existing prejudices can act as an accelerant to misinformation, jeopardizing health outcomes. In Kenya, “From the general public’s perspective, hepatitis C is linked to drug users. As a result, patients infected with hep C are associated with chronic substance use disorders that live in an endless cycle of relapsing.” As a result, many patients may choose to not seek care for fear of being further stigmatized or judged.
We have seen the dangers of misinformation, where after testing positive for hepatitis B, some individuals were led to believe it was caused by witchcraft. This misconception can be particularly dangerous as it delays medical intervention, leading to worsening health outcomes. A report by Citizen Digital highlights the alarming rise of hepatitis B cases in Baringo, shedding light on the myths surrounding the disease and the urgent need for accurate health education.
Delaying care is particularly concerning given that both hepatitis B and C can be managed effectively with proper medical intervention. Hepatitis B can be controlled with antiviral medications, and hepatitis C can be cured with antiviral treatment. However, the stigma and misinformation surrounding these diseases often discourage people from accessing these life-saving medications.
Moreover, stigma can lead to social isolation and mental health issues. "Sisi tumekua tunajua hii ugonjwa ni urogi na inasemekana hio urogi unabebwa na kucha like mtu akikukuta unakula, anakuwekea kwa chakula. Sasa nimekua nikishangaa nilitembelea mkutano gani au sherehe gani,’’ ("We believe this disease is caused by witchcraft, and it is said that it can even be carried in fingernails. The idea is that someone can secretly place it in your food while you are eating. This has left me wondering—at which event or gathering did I unknowingly contract this illness?") says Kiprop. The shame and isolation associated with stigma can worsen mental health issues, making it harder for individuals to seek help and adhere to treatment.
This is a vicious cycle that not only affects the individual but also poses a broader public health risk, as untreated individuals may unknowingly spread the virus. Addressing the stigma and misinformation surrounding hepatitis B and C requires a multifaceted approach.
There is no single recipe for countering the stigma and misinformation. However, one thing is for certain: education is a critical component of this effort. Healthcare professionals, community leaders, and public health organizations must work together to disseminate accurate information about the transmission, prevention, and treatment of hepatitis B and C. This includes debunking myths, such as the idea that these diseases are primarily a concern for drug users or as a result of witchcraft in some communities.
Stigma and misinformation are major barriers to eliminating hepatitis B and C globally. Misconceptions about transmission, cultural attitudes, and the stigma around these diseases delay diagnosis and treatment. To break down these barriers, we must engage communities, leverage digital platforms to spread awareness. A multi-level approach is key to overcoming these challenges and achieving a world free of hepatitis B and C.
Viral Hepatitis in Uganda: Preventing Mother-to-Child Transmission Eliminating Hepatitis B?
by Prof. Ponsiano Ocama
Hepatitis B virus (HBV) remains a major global health challenge, affecting over 290 million people worldwide. Africa and Asia bear the highest burden, yet many African countries lack the infrastructure needed for effective prevention and management. Additionally, HBV receives minimal donor funding, and while some governments allocate national resources, these remain largely insufficient. As a result, liver-related complications, including liver cancer, cirrhosis, and liver failure, contribute to significant mortality across the continent.
HBV is preventable through vaccination and lifestyle modifications. In Uganda, the pentavalent vaccine was incorporated into the Expanded Program for Immunization (EPI) in 2002. A national sero-survey in 2004 reported an overall HBV prevalence of 10%, with regional disparities—Northern Uganda had rates between 18% and 25%, while Southern Uganda reported about 4%. A follow-up survey in 2016 indicated a national prevalence of 4.1%, but the North-South gradient persisted, with rates of 4.6% and 0.8% respectively.
Mother-to-child transmission (MTCT) significantly contributes to the HBV burden and is a primary cause of chronic hepatitis B. However, this transmission route is largely preventable, especially through timely birth-dose vaccination. In 2023, Uganda introduced the HBV birth-dose vaccine, ensuring that all newborns—regardless of maternal HBV or HIV status—receive the vaccine at birth, followed by pentavalent doses at 6, 10, and 14 weeks. This intervention has the potential to drastically reduce MTCT. The addition of hepatitis B immune globulin (HBIG) could further enhance prevention efforts, but its high cost and limited availability pose significant challenges. Nonetheless, birth-dose vaccination alone remains a crucial and effective strategy.
Challenges in Birth-Dose HBV Vaccination in Uganda
Despite the introduction of the birth-dose vaccine, several challenges persist:
Vaccine Shortages: Global supply constraints have led to stockouts in Uganda, leaving some newborns unvaccinated.
Home Deliveries: A significant number of births still occur outside formal health facilities, reducing vaccine access for newborns.
Timing of Vaccination: Even when deliveries occur in healthcare settings, weekend and public holiday births may delay administration beyond the critical 24-hour window.
Proposed Solutions
Targeted Vaccination and Antiviral Therapy: Strengthening antenatal HBV screening would allow healthcare providers to prioritize birth-dose vaccination for babies born to mothers living with HBV. This, combined with antiviral therapy for high-viremia mothers, could significantly reduce transmission.
Community-Based Interventions: Engaging village health teams to identify home deliveries and facilitate postnatal vaccination at health centers could improve vaccine coverage, even if administration falls slightly outside the ideal 24-hour window.
Conclusion
Mother-to-child transmission remains a key driver of HBV persistence in Uganda. However, with comprehensive prevention measures—including universal birth-dose vaccination, targeted maternal screening, and community outreach—Uganda can make significant strides in reducing HBV transmission and protecting future generations.
How Close but Far are we to 2030 Hepatitis Elimination Goals
by Dr. Danjuma Adda
In 2016, the global community at the World Health Assembly, adopted the first ever Global Health Sector Strategy for the elimination of Viral Hepatitis (HIV and STIs ) as a disease of public health importance by 2030. This endorsement was done by over 130 countries Ministries of Health on behalf of their governments and citizens, in Geneva Switzerland. The GHS 2016-2021 was developed to guide the health sector in implementing strategically focused responses to achieve the goals of ending AIDS, viral hepatitis B and C and sexually transmitted infections by 2030.
The strategy outlined a global vision, a global goal, a set of global targets that are outlined with the 2030 Sustainable Development and relevant World Health Assembly Resolutions.
The ambitious targets were:
To reduce by 90% new cases of chronic hepatitis B and C infections (this includes Hep B Birth Dose vaccination and other Prevention of Mother to Child transmission of HBV)
To reduce mortality from hepatitis B and C by 65%
To diagnose 90% of undiagnosed persons with hepatitis B and C
To provide treatment to 80% of eligible persons diagnosed with Hepatitis B and C.
To ensure 100% blood donations are safe (screened in quality assured standards)
About 1.3 million people died of viral hepatitis in 2022, similar to the number of deaths caused by tuberculosis. Every day, more than 3600 people die of viral hepatitis-related liver disease, liver failure and liver cancer.
Viral hepatitis and tuberculosis were the second leading causes of death among communicable diseases in 2022, after COVID-19. At the end of 2019, the major achievement of the global targets was reduction in incidence as the estimated number of people newly infected by viral hepatitis declined from 2.5 million in 2019 to 2.2 million in 2022. Of the 2.2 million new infections, 1.2 million were hepatitis B and nearly 1.0 million hepatitis C. Data from across the world based on the WHO regions varied, however the region with slow pace and high burden of infections is Africa, my mother land.
How much progress in Africa:
The data for Africa is sobering. 63% of HBV infections are in Africa. Only 18% of babies have received the hepatitis B birthdose vaccines, despite the high burden. Only 2% (WHO 4.2%) people with HBV and 10% HCV have been diagnosed while 0.1% and 12% HBV and HCV diagnosed individuals have received treatment across Africa.
Dying from viral hepatitis in Africa is becoming a bigger threat than dying from HIV/AIDS, malaria or tuberculosis. Yet, a new analysis shows that the disease remains neglected in many parts of the continent.
In Africa, chronic viral hepatitis affects over 70 million Africans (60 million with hepatitis B and 10 million with hepatitis C).
Major barriers to elimination in Africa:
Poor political will and commitment from national governments leading to poor investments in health care services
Low visibility and awareness of viral hepatitis
Poor adoption of public health approach in hepatitis care
Access to viral hepatitis treatment has not yet shifted to a public health approach. Countries have adopted WHO guidelines, but implementation lags behind and the availability of affordable and simplified regimens is limited, especially in primary health care.
Hepatitis B infection is preventable, treatable and hepatitis C virus infection (HCV) is now curable. Yet, despite the availability of diagnostic tools and effective treatment, over 90% of people living with hepatitis B and C in Africa lack much needed care. The result is at least 200 000 deaths a year in Africa, often among the continent’s most youthful and productive population.
Fewer than 1 in 10 people in Africa have access to testing and treatment, so the disease often progresses to advanced liver disease with its associated catastrophic financial burden as well as emotional distress and stigmatization.
To improve access to hepatitis care in Africa, we must adopt the public health approach of simplification and decentralization of care, leaving no populations, including children and adolescents in the cascade of care.
We must simplify our medical and scientific language and ensure patients are properly educated and informed in the most simple and non-stigmatizing way possible each time they visit the clinic.
We must end stigma against affected populations and engage patients as equal partners in the healthcare eco-system in co-creating person centred care.
We must expand testing and linkage to care to secondary and primary levels and community settings, identifying populations at risk of developing liver cancer and linking them to care as early as possible.
We must all put on the garment of advocacy, as clinicians, researchers or patients to increase the visibility of viral hepatitis in Africa.
We must all invest in advocacy, and awareness activities to generate demand for services.
With adequate commitment from everyone, including the healthcare community, improved financial investments and resources and strong political commitment, this disease can be eliminated by 2030 in Africa and the rest of the world.
2024 in Review: SOLDA’s Growth, Global Impact, and a Promising Future for Liver Health in Africa.
by Prof. Mark Sonderup
The end of another year is at hand and 2024 is drawing to a close. SOLDA is no longer an infant, it is now a toddler well beyond delivery, has crawled and just taken its first walking steps. All the administrative hurdles of ensuring that SOLDA as an organization representing the whole of Africa in liver disease in the areas of teaching, training, fostering research, and collaboration is about to adopt its formal founding documents. This will create the foundation on which the organization will grow further and create sustainability through ensuring formalized and good governance. We are grateful to the leadership of SOLDA for having gone through this process and the work done to date. The work of Prof. Manal Elsayed and Prof. Wendy Spearman appropriately received a significant acclamation this year with both Prof. Elsayed and Prof. Spearman being acknowledged by the European Association for the Study of Liver Disease at their June meeting in Milan, Italy. SOLDA has established numerous collaborative relationships with peer societies around the world including the AASLD, EASL, APASL and ALEH and several other sister societies.
SOLDA recently had the opportunity to be acknowledged as a partner at the Liver Meeting held at the 75th AASLD meeting in November 2024 in San Diego, USA. At this meeting SOLDA was recognized amongst many other societies as a key partner within the global liver community.
In mentioning the Liver Meeting, it is important to note that at the meeting a number of very important research was presented. Of major importance to Africa, it is very promising to see that key work in trying to find a functional cure for hepatitis B continues unabated. Professor Ed Gane and colleagues presented the 48-week data on a combination of Tobevibart, a HBV entry inhibitor and Elebsiran, a siRNA, with or without Pegylated Interferon in chronic hepatitis B virus infection. Key findings in the study were that surface antigen loss was significant and occurred in almost 38 - 45% of those, with or without Pegylated Interferon, but a singular factor was that baseline surface antigen quantification had to be <1000 IU/ml to achieve those kind of outcomes. In terms of other work looking at functional cure, the trend is much the same. Functional cure is becoming increasingly achievable with therapies being evaluated, but surface antigen quantification below 1000 remains a key inflection point. Importantly, in the vast majority of these studies, Africans are not being included in these studies, so it will remain difficult for us to translate this data into our own population unless we are included in this research. Cutting edge work being evaluated to achieve hepatitis B functional cure is gene editing. This research is in its early stages, but some remarkable advancements are already being made. There is no doubt the future for functional cure for hepatitis B remains very promising. The real issue is always going to be accessibility of these therapies in the future should they become approved and available to the populations with the greatest burden of HBV such as sub-Saharan Africa. In the meantime, it remains crucial for Africans to be included in this work. Groundbreaking work was presented by Professor Newsome and colleagues in terms of the 72-week data in patients with metabolic associated steatohepatitis (MASH). The data included 800 patients with paired biopsies, on weekly Semaglutide 2.4mg. The data demonstrated an almost 40% improvement in fibrosis by one stage or more as well as significant improvements in steatohepatitis. Weight loss continues. This data represents landmark work in demonstrating that the GLP-RA agonist has therapeutic benefits in terms of those with MASH-related fibrosis. All patients in this study were less than or equal to F3 fibrosis. Further data will determine if those with F4 fibrosis will benefit. This paper represents a landmark study in patients with MASH. Other new data presented at the meeting illustrated the advances in managing cholestatic liver diseases.
In terms of hepatitis C, the challenge of global elimination remains. However, advances are being made and Africa has already demonstrated significant leadership with a number of champion countries including Egypt, Rwanda, and Mauritius, amongst others, demonstrating that eliminating hepatitis C is entirely feasible.
We trust 2025 will be good to you and SOLDA wishes you a productive, fruitful, and blessed New Year. SOLDA will continue to grow from strength to strength. Many exciting initiatives are planned for 2025 with our COLDA meeting planned for Accra, Ghana.
Hepatocellular carcinoma in African context : “Prevention is better than cure”
by Prof. Nabil Debzi
Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide and the fourth on our continent. Africa includes six of the 15 countries with the highest HCC incidence globally.
HCC develops at a younger age in Africa than in other parts of the world, with a usually poor prognosis and death. The median overall survival of HCC in sub-Saharan Africa (SSA) is only three months.
The main risk factors for HCC are chronic infection with hepatitis B virus (HBV) or hepatitis C virus (HCV), aflatoxin-contaminated foods, heavy alcohol consumption, obesity, type 2 diabetes, and smoking. Its prevalence and etiology show some differences between North and SSA. HCC incidence in a part of North Africa is twofold higher than in SSA, due to the unusually high prevalence in Egypt of HCV infection, which remains the primary risk factor in this country. Compared with 0.2% in Algeria. In the other parts of North Africa excluding Egypt (Maghreb), the incidence of HCC is lower than in SSA, due to lower levels of viral hepatitis, as well as low consumption of alcohol and aflatoxin exposure.
To date, establishing African guidelines including prevention, surveillance, diagnosis, and treatment for HCC is too ambitious. Barcelona liver cancer classification (BCLC) is the most popular staging system adopted by our colleagues and experts from our regions. According to survey studies, implementation of screening programs is sub-optimal. The utilization of combinations of serum alpha-protein and liver ultrasonography is encountered in only 50% of African countries . The access of diagnosis is also lacking due to a 56% rate of use for computed tomography scans and deployment of magnetic resonance imaging in only 5.2% cases.
Most patients are diagnosed at advanced stages (BCLC B, C and D) due to absence or inefficient screening, therefore access to therapy will be limited . In our context, liver transplantation is available for only 28% of north and southern (NS) and 3% east and west . Availability of local therapy ranged from 94% in NS to 62% in central. Sorafenib is the most commonly used systemic therapy (66%). Only 12.9% reported access to other medications including immune checkpoint inhibitors .
From what we reported previously, HCC management programs must be focused on prevention. All adult patients with chronic liver disease including cirrhosis, chronic HBV and HCV infections, and NASH/ NAFLD with advanced fibrosis (fibrosis stages 3 and 4) are considered at high risk for developing HCC and should be enrolled in a screening and surveillance program. As mentioned in previous newsletter by Dr. Nanelin Alice Guingané ,the burden of chronic hepatitis B is largely attributed to MTCT .To prevent MTCT, WHO recommends administering a birth-dose vaccine, screening pregnant women, and providing antiviral treatment with tenofovir disoproxil fumarate (TDF) for women with a high viral load (≥200,000 IU/ml) or a positive HBV e antigen (HBeAg) test. Vaccination remains the cornerstone of the fight against MTCT of hepatitis B.
The HCV elimination program, particularly in Egypt and Rwanda is driven by political commitment with the decreasing cost of direct-acting antivirals in Egypt from $1,650 for 12 weeks of sofosbuvir plus daclatasvir in early 2015 to $85 for local generics in 2018. The management is simplified, supported by primary care physicians. Aflatoxin has been shown to be important risk factor in the initiation of HCC, particularly in synergism with HBV and HCV infection. The introduction of Alfasafe to check the toxin producing Aflavus will hopefully lead to a substantive decrease in aflatoxin-induced HCC.
Another challenge to take on, is the epidemic rising of non-communicable diseases in SSA, that includes cardiovascular disease, cancer and metabolic diseases such as diabetes and obesity. So the contribution of MASH as a risk factor for HCC is expected to rise. We also have an excessive alcohol consumption in most African countries, so its role in developing HCC in our regions is probably underestimated. Therefore, efforts to reduce the incidence of HCC should be holistic based on primary prevention targeting HBV and HCV infections, toxin exposure, and metabolic risk factors.
To conclude, therapeutic management of HCC depends on allocated financial resources and the level of development of medicine in general. For the moment, a pragmatic approach adapted and specific to each country based on prevention of risk factor is the most direct route to prevention.
Prevention of Mother-to-Child Transmission of Hepatitis B in Africa
by Dr. Nanelin Alice Guingané
Hepatitis B virus (HBV) infection is a significant global public health issue, with an estimated 254 million people living with HBV. Among them, approximately 65 million women of childbearing age are chronically infected. Although the global rate of new HBV infections has declined, it remains high, especially in the WHO African Region, which accounts for 63% of new infections, translating to around 771,000 new cases annually. Alarmingly, only 18% of newborns in this region receive the critical hepatitis B birth-dose vaccination.
Viral hepatitis is a leading cause of increasing mortality worldwide, with deaths rising from 1.1 million in 2019 to 1.3 million in 2022, of which 83% are due to hepatitis B. The burden of chronic hepatitis B is largely attributed to MTCT, where early infection increases the risk of chronic disease progression to complications like cirrhosis and liver cancer.
Sub-Saharan Africa remains a high-endemic area, with HBV transmission primarily occurring from mother to child. However, data on pregnant women infected with HBV is insufficient. Studies indicate that the prevalence of HBV among pregnant women is approximately 8% in West Africa and 5-7% in Central, Eastern, and Southern Africa.
To prevent MTCT, WHO recommends administering a birth-dose vaccine, screening pregnant women, and providing antiviral treatment with tenofovir disoproxyl fumarate (TDF) for women with a high viral load (≥200,000 IU/ml) or a positive HBV e antigen (HBeAg) test. Yet, in sub-Saharan Africa, less than 1% of pregnant women are screened and treated with TDF when eligible.
Several challenges must be addressed to enhance PMTCT efforts, including:
Raising awareness about the asymptomatic nature of HBV, which remains undetected in 80% of cases.
Improving access to free screening tests to increase global screening rates, which stood at just 4.2% in 2022.
Ensuring early prenatal care to start treatment timely.
Enhancing access to viral load testing or alternatives to identify women for treatment in the third trimester.
Expanding the availability of affordable or free TDF to improve the treatment initiation rate, which was only 0.2% globally in 2022.
Ensuring timely sero-vaccination of newborns within the first 24 hours of life, followed by the full course of the Expanded Programme on Immunization (EPI) doses.
Vaccination remains the cornerstone of the fight against MTCT of hepatitis B. Its effectiveness in preventing vertical transmission has been proven in several African studies, showing over 95% effectiveness against chronic HBsAg carriage and over 80% effectiveness against all HBV infections. Significant global public health successes have been achieved, such as reducing the prevalence of HBV among children under five from 4.7% in 2000 to 1.3% in 2015. However, Africa still reports the highest prevalence of chronic HBV in this age group.
As of 2020, only 14 African countries have introduced universal hepatitis B birth-dose vaccination, and by 2022, five out of 12 focus countries had included the birth dose in their national immunization programs. Despite this, vaccination coverage remains the lowest globally, with only 18% of infants receiving the birth dose within the first 24 hours.
Urgent expansion of access to effective interventions is crucial to save lives and prevent future generations from HBV-related infections, cancer, and deaths. The global health sector strategies for HIV, HBV, and sexually transmitted infections (STIs) for 2022-2030 aim for triple elimination, allowing the fight against HBV to benefit from advances in HIV and STI prevention.
The 2024 WHO recommendations broaden the treatment criteria for pregnant women with HBV, both for PMTCT and their individual health. However, implementing these recommendations in Africa requires addressing the aforementioned challenges. While progress has been made, it remains insufficient. Continued awareness and action are essential, underscoring SOLDA's commitment to communication for behavior change.
Elimination of Viral Hepatitis in Africa:
It’s Time for Action!
by Dr. Gibril Ndow
On July 28th, the World commemorated World Hepatitis Day. This year’s theme, It’s Time For Action, sets emphasis on bridging the “know-do” gap in implementation and scaling up of viral hepatitis interventions.
Viral hepatitis remains a major global public health threat in Africa. The World Health Organisation (WHO) 2024 Global Hepatitis Report clearly highlights the urgency of the viral hepatitis problem in Africa. It is estimated that 73 million people in Africa are living with chronic hepatitis B and C infection. Among these, only 4.2% with hepatitis B and 13% with hepatitis C have been diagnosed and 0.2% and 3% of people with hepatitis B and C respectively were receiving treatment as of 2022. A direct impact of this low coverage of and access to diagnostics and treatment is the high mortality from chronic viral hepatitis infections. The WHO estimates that 25% of the total 1.3 million deaths from hepatitis B and C recorded in 2022 were in Africa. This represents 272,000 deaths from hepatitis B and 35,000 from hepatitis C annually.
More concerning than the high burden of disease and death from viral hepatitis is the sustained high transmission of hepatitis B and C in Africa. Despite an effective and cheap vaccine against hepatitis B, two-thirds of all new infections globally occur in Africa, estimated at 771,000 new infections annually. A recent systematic review estimates that in 2022, 172,000 babies born in Africa acquired hepatitis B infection through mother-to-child transmission. The low coverage of both hepatitis B testing and prophylaxis in pregnancy and timely hepatitis B birth dose vaccination in Africans are main drivers of the high rate of mother-to-child transmission. As a result, the region has the highest global prevalence of chronic hepatitis B infection among children aged less than 5 years. Individuals infected with hepatitis B at birth have a higher risk of developing severe liver disease and liver cancer in adulthood. As a result, these sustained hepatitis B infections both increase the number of individuals living with the virus in Africa and the likely deaths from hepatitis B infection.
Similar to hepatitis B, Africa has a high burden of new hepatitis C infections, estimated at 172,000 new infections each year. A WHO survey estimates that 13.5% of these new hepatitis C infections are due to unsafe injecting drug use and 5% from unsafe medical injections. However, poor surveillance systems and limited data on probability of transmission suggests that both the number of new infections and the estimated contribution of transmission routes could be underestimated.
The rationale to action against viral hepatitis is therefore strongest in Africa. SOLDA hosted a World Hepatitis Day webinar to highlight the burden and challenges of viral hepatitis across the 5 regions in Africa, and to share best practice from champion countries like Egypt. A second webinar, led by the African Viral Hepatitis Action Group (AVHAG) and the African Union Scientific, Technical and Research commission (AU-STRC), provided a platform for building partnerships towards hepatitis elimination in Africa. The two webinars brought together community representatives, members of parliament, healthcare workers and technical experts to discuss strategies to increase domestic funding, access to diagnostics and treatment, and enhance policy at national and continental levels to scale up intervention strategies. These webinars build on other efforts like the UN Group of Friends to Eliminate Hepatitis, to advance health diplomacy and national/continental commitments to achieve WHO targets of hepatitis elimination by 2030.
Indeed, there are unique opportunities that African countries can leverage to regain the trajectory needed to achieve hepatitis elimination. The WHO 2024 hepatitis B guidelines offer an opportunity to expand access to treatment in Africa and to decentralise and integrate viral hepatitis care into various levels of the healthcare system. The guidelines substantially simplify and expand eligibility for treatment for adults and adolescents, and eligibility for prophylaxis for pregnant women to prevent mother-to-child transmission. These simplified and expanded criteria can rapidly scale up diagnosis and treatment which are critical to reduce morbidity and mortality and reduce new infections.
Leveraging on the global commitment to triple elimination of HIV, syphilis and hepatitis B; the Global Fund support toward triple elimination; and the GAVI support for lower-income countries to introduce the hepatitis B birth dose, will further reduce new infections in Africa. Validating available data on hepatitis B and C burden will measure progress, identify gaps and guide national strategies; therefore, countries must strengthen measures for improved surveillance. Existing continental partnerships can advance pooled procurement mechanisms, allow countries access to reference pricing for diagnostics and generic drugs, and support South-South collaboration for sharing of experience. Continuing the engagement with law makers at national, continental and global levels can unlock funding, including domestic financing, and influence policies that increase awareness, reduce barriers and promote viral hepatitis elimination.
LIVER DISEASE IS SILENT:
THE CONSEQUENCES OF INACTION
by Prof. Manal Hamdy El-Sayed and Prof. Wendy Spearman
The Society on Liver Disease in Africa (SOLDA), established in 2022, has already created a large community, with more than 1500 members from both scientific and civil society representing 37 African countries across the continent. SOLDA has been developed to support the education, training and research landscape in the field of hepatology in Africa. Africa needs more efforts to create data platforms for liver disease while exploring tailored models for diagnosis, prevention and treatment including expansion in clinical trials. This can only be achieved through large-scale continental and intercontinental collaborations that could be critical in achieving research and intervention goals that can influence the outcome of liver disease in Africa.
Although Africa has a high burden of liver disease, only a small proportion of liver disease patients are receiving diagnosis and treatment. This is despite of advancements in the field of hepatology worldwide and major strides made by the African continent in the field of infectious disease. It also highlights the essential need for intervention and improvement in health-care services for liver diseases in Africa.
The recent WHO Global hepatitis 2024 report was a sobering reflection of where the WHO Africa Region stands in the fight against viral hepatitis.
Despite access to preventative Hepatitis B vaccines, effective nucleoside therapy against Hepatitis B and curative Direct-acting antiviral therapy for Hepatitis C, the WHO Africa region accounts for 63% of new viral hepatitis Infections (66% of Hepatitis B and 51% of Hepatitis C infections).
The prevalence of Hepatitis B in Africa reflects a failure of maternal and child health services to identify HBsAg positive pregnant women, link them to care and initiate prevention of mother-to-child transmission interventions with maternal tenofovir and timeous Hepatitis B birth dose vaccination. Despite Hepatitis B vaccination being a safe and effective cancer-preventing vaccine, only 15 African countries have implemented HB Birth dose vaccine with only 18% having timeous administration. Although Gavi’s recommitment to assisting low-income countries initiate implementation of the Hepatitis B birth dose vaccination will have an impact in the reducing the HBsAg prevalence in under 5-year-olds, this must be sustainable.
Successful elimination programmes will require decentralisation with task-shifting to primary care level and integration into existing infectious disease and non-communicable disease programmes with associated dedicated domestic funding. Challenges to elimination include the cost of diagnostics particularly molecular diagnostics and lack of access to point-of-care diagnostics, affordable and simplified treatment regimens, and out-of-pocket expenditure.
The cost of antiviral therapy varies considerably across Africa with the lowest reported price of a public sector procurement of a generic 30-tablet Tenofovir supply varies between US$ 2.20 in South Africa and US$ 26.70 in the Democratic Republic of Congo. Similarly, for
Hepatitis C, the lowest reported price for the procurement of a 12-week supply of generic Sofosbuvir and Daclatasvir varies between USD$ 60.0 in Nigeria and US$ 491.40 in Cameroon.
We need to learn from the Champion Countries in Africa, Egypt and Rwanda who are leading the charge towards the WHO 2030 viral hepatitis elimination goals.
Egypt through its nationwide screening and treatment campaign (100 Million Healthy Lives) in 2018-19, screened nearly 63 million individuals for anti-Hepatitis C antibodies and were able to treat 4.1 million people living with Hepatitis C. This led to the WHO awarded Egypt gold tier status on the path to HCV elimination on 29 October 2023.
Rwanda is on track to eliminate Hepatitis C by 2024 with 7 million people ≥15 years having been tested for HCV and 60 000 treated, thereby reducing the prevalence of hepatitis C infection to <1% In addition, HBV: 5 million people have been tested for hepatitis B, 7000 are on lifelong nucleoside treatment and 7 million people vaccinated against hepatitis B.
Of note, Egypt’s campaign was supported by US$250 M in financing from the World Bank, as a part of the US$530 M Transforming Egypt’s Health Systems project, emphasising the importance of political will and dedicated funding with the development of national investment cases to achieve the viral hepatitis elimination goals.
Another silent liver disease is Metabolic dysfunction-associated steatotic liver (MASLD) associated with the rising prevalence of obesity and diabetes mellitus across Africa and an estimated prevalence of 13.5%. MASLD encompasses the spectrum of simple steatosis, steatohepatitis (MASH), advanced fibrosis and cirrhosis. MASLD is independently associated with the risk of developing extra-hepatic diseases, including cardiovascular disease, the leading cause of death in people living with MASLD, type 2 diabetes, chronic kidney disease and extra-hepatic malignancies (gastric, colorectal, pancreatic, biliary duct, thyroid, urinary system, breast, skin and female genital cancer), with the risk advancing with the severity of MASLD. This further emphasizes the need to promote a holistic approach to liver health beginning at community and primary care level.
Education of the public and healthcare workers at all levels of care about the silent but preventable and treatable burden of liver diseases associated with viral hepatitis and MASLD is essential to break cycles of infection and prevent the complications of cirrhosis and hepatocellular carcinoma.
SOLDA will communicate with its community through a monthly newsletter, distributed by its board members who represent different regions of Africa. The newsletters will include advances in the field, innovative initiatives on the African continent, educational articles, and information about new collaborations.