Diverging trends and persistent inequities in cirrhosis burden across sub-Saharan Africa: projections to 2040.

BACKGROUND & AIMS: Liver cirrhosis and chronic liver diseases remain major causes of premature mortality globally, with a disproportionate burden in sub-Saharan Africa (SSA). We aimed to quantify temporal trends and future projections of cirrhosis burden in SSA and assess the potential impact of hepatitis B vaccination scale-up. METHODS: We analysed Global Burden of Disease 2023 data from 1990 to 2023. Age-standardised death rates (ASDRs) and disability-adjusted life years (DALYs) were examined by sex, geography, aetiology, and socio-demographic index (SDI). Bayesian hierarchical models were used to project burden to 2040, including a scenario-based hepatitis B vaccination intervention. RESULTS: In 2023, cirrhosis accounted for 179,329 deaths in SSA, despite a 31% decline in ASDR since 1990. Absolute deaths increased by 72%, and DALYs rose by 68%, reflecting demographic change. Hepatitis B (37%), hepatitis C (29%), and alcohol-related cirrhosis (14%) were the leading causes. Marked geographic and sex disparities persisted, with the highest burden in Central and Western SSA and among males. Low-SDI countries were disproportionately affected, driven by hepatitis B, whereas MASLD contributed more prominently in higher-SDI settings. By 2040, ASDRs for viral and alcohol-related cirrhosis are projected to decline by approximately 6-32% across subregions, while MASLD-related burden remains relatively stable. Under model assumptions, vaccination scale-up was associated with reductions in HBV-related cirrhosis burden. CONCLUSIONS: Despite declining age-standardised rates, the absolute burden of cirrhosis continues to rise across SSA owing to demographic change. Viral hepatitis remains the dominant driver, alcohol-related liver disease continues to contribute substantially, and metabolic liver disease is emerging in higher-SDI settings, highlighting an increasingly layered liver disease burden requiring integrated prevention strategies. IMPACT AND IMPLICATIONS: This study addresses the under-characterised burden of cirrhosis in sub-Saharan Africa by integrating long-term trends with scenario-based projections. The findings reveal a divergence between declining age-standardised rates and rising absolute burden, alongside persistent geographic and socio-demographic inequities. These results are directly relevant to clinicians, researchers, and policymakers prioritising liver disease control in resource-limited settings. They support strategies to sustain viral hepatitis elimination efforts while strengthening preparedness for alcohol-related and emerging metabolic liver disease in higher-SDI settings.