More than 70 million people in Africa are living with chronic viral hepatitis

Hepatitis occurs when different viruses cause inflammation of the liver. Hepatitis A (HAV) and hepatitis E (HEV) viruses are mainly spread through contaminated food or water and typically cause self-limiting infections.

This means that following a short period of illness — ranging from mild to severe and occasionally life-threatening — the affected person usually recovers fully.

In contrast, three other types of hepatitis viruses — hepatitis B (HBV), C (HCV) and D (HDV) — are transmitted mainly through contact with infected bodily fluids such as blood, saliva and semen. This may lead to chronic infection of the liver, meaning the infection persists for at least six months.

Chronic infection may last for life, and carriers, as people with chronic infection are called, remain infectious and can pass the infection to their close contacts without ever knowing they are infected. The younger someone is when becoming infected, the higher the risk of developing a chronic infection.

Mother-to-child transmission

A mother can also pass HBV to her child during childbirth, especially when she has a high concentration of the virus in her blood. More than 90% of babies infected by their mothers will become carriers.

Mother-to-child transmission of HBV is a major contributor to the global burden of chronic HBV infection. Fortunately, HBV infection can be prevented with a safe and effective vaccine. While there is no vaccine for HCV, it can be treated and cured using effective antiviral medications.

Chronic HBV and HCV infections, unless recognised and treated on time, may eventually lead to serious, often fatal conditions such as liver cirrhosis or primary liver cancer.

Of the more than 300 million people worldwide estimated to be living with chronic HBV or HCV infection, more than 70 million are in Africa. Two to three million South Africans have chronic viral hepatitis, with most remaining undiagnosed and untreated.

Studies from our group and others have shown that chronic HBV infection is responsible for more than 60% of primary liver cancer cases in South Africa.

Primary liver cancer is more common in males and tends to develop relatively early in adulthood, cutting lives short. Alarmingly, chronic infection often goes unnoticed until it causes serious complications, by which time treatment options are very limited and usually too late.

Public awareness

It is therefore fitting that 28 July is commemorated annually as World Hepatitis Day to raise public awareness of viral hepatitis. The theme for 2025, Hepatitis: Let’s Break It Down, is aimed at dismantling various obstacles — including financial, social and systemic barriers — that stand in the way of eliminating viral hepatitis as a public health threat by 2030.

South Africa has been making commendable progress towards eliminating viral hepatitis as a public health threat. The country introduced the vaccine against HBV in the Expanded Programme on Immunisation in 1995. This has led to a significant decline in the number of infections among children under the age of five.

Nevertheless, some children continue to be infected because their mothers are not tested for HBV. This can be done using a simple rapid test, and if pregnant women are found to be infected with HBV, antiviral therapy will reduce the risk of transmitting the virus to their children.

Pregnant women

Diagnosing pregnant women with chronic hepatitis is an entry point to medical care — not only for their own health, but also that of their sexual partners and other family members who should also be screened for HBV.

In 2024, South Africa started screening pregnant women for HBV and rolling out a birth dose HBV vaccine for babies born to infected mothers. This is a long-overdue move. It is still too early to evaluate its success, which depends on full commitment from all relevant stakeholders in all provinces.

A simpler alternative that is less prone to implementation issues would be to administer the birth dose HBV vaccine to every baby instead of waiting until they are six weeks old, regardless of the mother’s status.

While eliminating new HBV infections among children is crucial, it is equally important to diagnose those who are already infected.

Diagnosis is the gateway to care. This includes antiviral treatment and regular monitoring to enable early detection of liver cancer should it develop.

The latest World Health Organization guidelines for management of chronic HBV infection have been simplified by abandoning previously complicated algorithms that excluded many people who could benefit from antiviral therapy. It is estimated that currently, fewer than 10% of those who should be getting treatment for chronic viral hepatitis are receiving it.

Economic benefit

Diagnosing and treating more chronically infected individuals requires financial resources. It is highly likely to be cost-effective from an economic standpoint, as severe illness and death affect adults in their productive years.

In addition, it will kill two birds with one stone: to prevent serious illness in the infected person and to prevent new infections. The same applies to HIV: someone who is on treatment and has a low or undetectable viral load is essentially no longer infectious to others.

However, there is an urgent need to identify funding mechanisms, particularly considering the current US administration’s withdrawal of donor aid.

It will be wise for African countries to come together and speak with one voice when entering into any negotiations with pharmaceutical companies that manufacture antivirals for chronic viral hepatitis.

Societal barriers and misinformation

While providing the necessary preventative and treatment methods, we also must break down societal barriers that hinder access to clinical care.

We must also address misinformation. We have heard sad stories from individuals with chronic viral hepatitis during our community engagement initiatives of being ostracised within the community because of miseducation on how the infection is transmitted and its complications.

Some patients with viral hepatitis have been accused of promiscuity, while in certain cases, the development of liver cancer has been blamed on witchcraft. Health educators will need to do more to educate the general public.

It will also be beneficial to have functional support groups of people living with viral hepatitis, while the involvement of prominent individuals can also help to raise awareness about viral hepatitis.

We can learn from public health responses to other viral infections and borrow some of the strategies to address viral hepatitis. Together we can “break it down.” DM

Dr Tongai Maponga is a scientist/researcher and Prof Wolfgang Preiser a chief specialist in the Division of Medical Virology at Stellenbosch University.