Syndemic drivers of cirrhosis in sub-Saharan Africa: narrative review

sub-Saharan Africa (SSA) bears the highest global burden of cirrhosis mortality, largely shaped by the convergence of persistent viral hepatitis, rising metabolic dysfunction-associated steatotic liver disease (MASLD), alcohol-related liver disease, and structural health inequities. We conceptualise cirrhosis in SSA as a syndemic, in which interacting viral, metabolic, and alcohol-related risks are shaped by poverty, urbanisation, weak regulation, and constrained healthcare access. Marked subregional heterogeneity persists, with hepatitis B predominating in Western SSA, rising MASLD and alcohol-related disease in Southern SSA, and mixed profiles in Central and Eastern SSA. Fragmented surveillance, reliance on diagnostic tools with limited validation in African populations, and siloed programmes may delay detection and contribute to disease progression. In this Review, we synthesise current evidence and introduce a syndemic framework to guide integrated prevention, early detection, and management. Addressing cirrhosis in SSA will require context-sensitive, equity-focused strategies that integrate viral hepatitis control, metabolic risk reduction, alcohol harm reduction, and strengthened health systems. Funding This work received no specific funding.