Catherine Wendy Spearman

Purpose: Hepatocellular carcinoma (HCC) during pregnancy is rare, with the literature confined to isolated case reports and small series. Women in sub-Saharan Africa (SSA) face disproportionate risk due to chronic hepatitis B virus (HBV) infection acquired perinatally, HCC in noncirrhotic livers at a young age, and fertility rates nearly three times those of Europe. To our knowledge, we report the largest cohort of pregnancy-associated HCC from SSA, drawn from a single South African center, and the first quantitative estimate of regional disparity versus Europe. Methods: Pregnant women with HCC at Groote Schuur Hospital, Cape Town, over 24 years (2001-2025) were identified from a prospectively maintained registry. A model integrating HCC incidence, age-at-diagnosis, fertility rates, and 1-year mortality compared the probability of pregnancy-associated HCC and maternal death in SSA versus Europe. Results: Of the 728 registry patients, 192 (26.4%) were female and 10 (5.2%) were pregnant or within 1 year postpartum. The median age was 32.5 (IQR, 28.5-35.3), 70% had chronic HBV infection, and three had cirrhosis. Seven (70%) died, six within 90 days. Two patients survived beyond 10 years following curative resection. Four pregnancies ended in intrauterine fetal demise and five in live births. The modeled probability of pregnancy-associated HCC was 16 per 100,000 women in SSA versus 0.14 per 100,000 in Europe—a 114-fold difference—with a 187-fold greater risk of maternal death. Conclusion: Pregnancy-associated HCC in SSA is a quantifiable, preventable contributor to maternal mortality—nearly two orders of magnitude greater than in Europe. HBV endemicity, early-onset noncirrhotic HCC, and high fertility rates create a hostile environment for women of reproductive age. HBV-aware liver surveillance in antenatal care, strengthened prevention of mother-to-child transmission programs, and improved maternal mortality data systems are urgently needed.

To address data gaps around metabolic liver disease in Africa, within the Hepatitis B in Africa Collaborative Network (HEPSANET), we evaluated participants with chronic hepatitis B virus infection (CHB) for steatotic liver disease (SLD) using transient elastography with controlled attenuation parameter (CAP). Using multivariable logistic regression, we identified sociodemographic, anthropometric, and clinical associations with SLD (CAP ≥ 248 dB/m), and evaluated whether SLD severity was independently associated with fibrosis. Short‐term impacts of SLD on mortality were also assessed with Cox proportional hazards analysis. We also evaluated the diagnostic performance of B‐mode ultrasound for SLD, with CAP as reference. Across 6 countries and 1601 participants (age range, 12–80 years; 39.5% female; 4% with diabetes; 11% unhealthy alcohol use; median body mass index, 24.4), 421 (26.3%) had SLD; 219 (13.7%) had severe steatosis (CAP ≥ 280 dB/m). Older age, male sex, overweight and obesity, and HIV‐negative status were associated with SLD. After adjusting for age, sex, HIV status, HBV treatment, and country, severe steatosis, but not mild and moderate forms (i.e., 248–279 dB/m), was associated with a 8.4% (95%, 1.9%–14.9%) increased probability of fibrosis. Over limited follow‐up (median 2.69 years) and small number of deaths, SLD was not associated with all‐cause or liver‐related mortality. B‐mode ultrasound had low sensitivity for SLD, overall or when severe, but specificity was 95%. In conclusion, SLD was common in people with CHB in Africa and its severe form was associated with liver fibrosis. These data support screening for metabolic comorbidities as part of HBV care and treatment in Africa.

Significant progress on hepatitis B treatment pathways has been made since the last World Gastroenterology Organisation (WGO) guidelines in 2015. Global elimination targets have been set, prioritizing the prevention of new infections and optimizing screening and linkage to care in resource-limited settings. This has been led by the World Health Organization (WHO), which first published hepatitis B treatment and care guidelines in 2015 and updated its recommendations in 2024. The critical importance of preventing new infections was supported in 2020 by the WHO policy brief guidelines on antiviral prophylaxis for the purpose of preventing mother-to-child transmission of hepatitis B. A commitment by the global community to support maternal and infant health with the goal of triple elimination of HIV, HBV, and syphilis was established with the first WHO country guidance in 2025. Updated regional liver society guidelines [American (AASLD), European (EASL), Latin American (ALEH), and Asia Pacific (APASL)] have supported application of HBV management to regional contexts, with a focus on simplification and expansion of treatment eligibility. However, consensus on a clear roadmap for HBV guidance that may be broadly adopted in global, resource-limited settings remains elusive. The WGO guidelines are unique in their global lens with evidence-based recommendations, and where evidence is limited, expert opinions have been sought from leaders with broader global representation. Cascade-of-care algorithms ensure optimal access to hepatitis care. The opportunity to consider a test-and-treat approach is also discussed when access to the diagnostic assessment tools is unavailable (particularly in high-burden settings). The main purpose of this document is to provide a simple, easy-to-follow framework for global hepatitis B care pathways, particularly in lower-resource settings. Broadening treatment eligibility, using simplified tools, and, where required, delivering care in a decentralized model with limited test results is encouraged. Key statements that address the main issues at hand were prepared based on prevention, testing, treatment, and monitoring. Invited panel members were asked to grade recommendation statements with adjustments made on repeat voting until concordance was reached. Seminal papers for review are referenced, and supportive tool kits for implementation.

Over the last decade it has become clear that obesity and type 2 diabetes are key to the aetiology, pathogenesis and outcomes of metabolic dysfunction-associated steatotic liver disease (MASLD). The considerable current and potential burden of MASLD on patients and healthcare systems is therefore inextricably linked with today's global epidemics of obesity and type 2 diabetes. In this review, we discuss estimates of the global MASLD burden in terms of prevalence, incidence, disability from complications and reduced life expectancy associated with the condition. We also highlight the variability in MASLD prevalence estimates among different populations, with a particular focus on the sub-Saharan Africa and Asia Pacific regions, where population increases and the epidemiological transition (a sustained shift in population mortality and disease patterns from infectious diseases towards non-communicable diseases) are occurring most rapidly. Additionally, we consider the impact of social determinants of health, including socioeconomic conditions, structural inequities, care access, food environments and systemic discrimination. We also identify opportunities to advance equity in MASLD prevention, diagnosis and treatment worldwide.