Sustainable development goals for HBV elimination in South Africa: Challenges, progress, and the road ahead

International Sustainable Development Goals set ambitious elimination targets for hepatitis B virus (HBV) infection by 2030. We here set out to review barriers, challenges and opportunities for progress towards these goals, with a particular focus on South Africa. Although many African populations still have a high prevalence of HBV infection (defined as ≥8%), interventions and planning have been hampered by limited data. The majority of HBV infections (>90%) currently remain undiagnosed, and - even when a diagnosis is made - cases are not well stratified to determine prognosis, risk of transmission, and treatment eligibility. Nucleos(t)ide analogues can be successful in suppressing the virus but must generally be taken life-long, and there are concerns around the possible emergence of drug and vaccine resistance. Poor funding, lack of advocacy and education, and the stigma associated with infection represent further barriers. Despite these diverse challenges, we are in an era of opportunity to advance South Africa’s progress towards elimination goals. Widespread deployment of the HBV vaccine in infancy has already markedly reduced paediatric infection, and birth dose vaccinations will further reduce the risk of vertical transmission. South Africa can capitalise on the laboratory and clinical infrastructure that already supports HIV diagnosis and treatment, by expansion of services to include HBV. HBV treatment and diagnostics are now on WHO lists of essential drugs and equipment. In the decade ahead, South Africa can make significant advances, but this will require sustained attention and investment from stakeholders in policy, public health, clinical care, and basic science.