Liver disease diagnostics and access barriers in African settings: a narrative review

In Africa, chronic liver conditions are discordantly higher due to infectious and parasitic aetiologies, especially viral hepatitis. Early diagnosis is a linchpin for successful management and improved outcomes; however, diagnostic power is extremely limited. Yet, profound gaps compromise every step of the diagnostic continuum. Histopathological evaluation through liver biopsy remains the gold standard for establishing aetiology, grading inflammation and staging fibrosis. Biopsy services in Africa are limited by limited infrastructure, a deficit of qualified professionals, substantial costs, unreliable tissue samples and limited access to advanced pathology techniques such as immunohistochemistry and molecular testing. Non-invasive diagnostic tools such as serum markers, transient elastography and imaging techniques are unequally accessible, poorly updated for African-specific aetiologies and largely inaccessible outside tertiary centres. This review explores the aetiological spectrum of chronic liver disease in Africa and evaluates the availability and performance of both histological and non-invasive diagnostic techniques. This review illustrates gaps affecting screening, staging, initiation of management and he⁠patoc⁠e‍llular carcino‍ma surveillance. Addressing these diagnostic limitations through improved infrastructure, expanded professional training and local validation of non-invasive tools is essential to reducing the burden of liver disease across Africa. In addition, it offers tiered and feasible recommendations while considering the current reality of healthcare in sub-Saharan Africa.