Chronic hepatitis B infection in sub-Saharan Africa: A grave challenge and a great hope

In sub-Saharan Africa, chronic infection with the hepatitis B virus (HBV) is a profoundly important public health issue characterised by high prevalence, frequent co-infection with HIV, and sub-optimally applied ascertainment and management strategies. Prevalence of hepatitis B surface antigen (HBsAg) in the general population varies geographically, with the highest rates (>8%) measured in West Africa.1 Among people living with HIV, between 6% and 25% are co-infected with HBV, and co-infection accelerates fibrosis and increases the risk of liver-related mortality and development of hepatocellular carcinoma (HCC) compared to HIV-negative controls.2 In part, as a consequence of reduced HIV-related mortality, both HCC and cirrhosis are increasing in sub-Saharan Africa.3 The proportion of deaths due to cirrhosis increased by 31% between 1990 and 2010.3 Lemoine et al. argue that if HCC and cirrhosis were grouped together, chronic viral hepatitis would rank within the top 10 causes of global mortality, above malaria and TB.4 However, accurate epidemiological data on liver-related mortality in sub-Saharan Africa are lacking, and verbal autopsy remains the predominant method of ascertaining the cause of death, which is highly likely to underestimate the true burden of disease.5