Near-universal antenatal screening revealed a persistent hepatitis B burden
Antenatal care in Sierra Leone is now reaching almost every woman who enters the system, and the scale of that coverage matters. In a cross-sectional review of facility registers from 21 health facilities across Western Area Urban, Bombali, Bo, and Kenema, HIV and syphilis screening each reached 99.6% among 10,003 women at their first antenatal visit. Screening for hepatitis B was lower at 92.9%, and 92.4% of women received testing for all three infections. Those figures show that integrated antenatal testing is not a theoretical aspiration in these clinics; it is already functioning at a national scale across primary, secondary, and tertiary facilities.
The burden revealed by the test results is harder to absorb than the coverage numbers. HIV positivity was 4.9%, syphilis positivity was 1.3%, and hepatitis B positivity reached 4.0%. A hepatitis B positivity rate of this magnitude signals a large reservoir of maternal infection, with direct implications for vertical transmission during pregnancy, delivery, and the neonatal period. In practical terms, every missed diagnosis leaves a mother and infant exposed to a preventable chain of transmission that begins before birth and can persist for years.
What the facility registers show about real-world elimination efforts
The analysis covered women who attended their first antenatal care visit between November 2024 and October 2025. By drawing from health-facility registers rather than a single urban center or a narrowly selected referral population, the study gives a broader picture of what routine care is achieving in ordinary clinical practice. The district mix—Western Area Urban, Bombali, Bo, and Kenema—was designed to reflect Sierra Leone’s four regions, and the facility mix included 12 primary, five secondary, and four tertiary sites. That design is important because elimination strategies often fail when they are measured only in the strongest settings. Here, the data capture service delivery across the levels where women actually present for care.
The near-complete screening for HIV and syphilis suggests that integrated ANC testing has been embedded into routine workflows. Hepatitis B screening lagged slightly behind, though 92.9% is still a substantial achievement at national scale. Even so, the gap between 99.6% and 92.9% represents more than a statistical difference. It reflects the point at which a prevention program begins to lose mothers to incomplete testing, and incomplete testing is enough to interrupt the cascade from diagnosis to treatment and newborn protection.
Antenatal screening only has value if it triggers action. HIV and syphilis testing can connect women to established treatment pathways, but hepatitis B requires a more complete maternal and neonatal response, including treatment when indicated, safe delivery practices, and infant immunisation. Without that chain, diagnosis becomes documentation rather than prevention.
Hepatitis B positivity creates a prevention gap that screening alone cannot close
The hepatitis B positivity rate stands out because it exposes a service gap that is larger than the screening gap. High testing coverage means more infected women are being identified, but the abstract makes clear that no intervention package is currently in place to address the burden that screening reveals. That leaves clinical teams with an uncomfortable asymmetry: the system can find infection, but it cannot yet consistently prevent transmission after detection.
From a pathophysiological perspective, maternal hepatitis B matters because viral exposure can occur during the intrapartum period and, without timely infant prophylaxis, infection can become chronic early in life. The public health consequence is not confined to a single pregnancy. It extends into a lifelong risk of chronic liver disease, cirrhosis, and hepatocellular carcinoma in the next generation. High maternal positivity therefore functions as both an obstetric issue and a future hepatology burden.
The same logic applies to HIV and syphilis, though the control tools are more established. Antiretroviral treatment and syphilis treatment are familiar components of antenatal prevention programs, and their success depends on early identification. Near-universal screening gives those interventions a chance to work. The challenge is that hepatitis B has not yet been matched with the same level of operational follow-through in this setting.
Scaling testing is feasible; closing the treatment gap is the harder task
This study makes one point unmistakable: triple testing in antenatal care is feasible in Sierra Leone, even across a mixed facility network and across regions. The country does not appear to be struggling with the basic concept of integrating screening into ANC. It is already doing that at high volume. The barrier now lies in what happens after a positive test, especially for hepatitis B.
The findings support urgent scale-up of testing, but the prevention pathway cannot stop there. A maternal programme that includes treatment where appropriate, safer delivery planning, and immunisation for exposed infants will be necessary if the screening data are to translate into fewer infections. Without that package, the health system risks generating a large list of diagnosed women without reducing transmission in a meaningful way.
The registry-based design also leaves some questions unanswered. Secondary data can quantify coverage and positivity, but it cannot by itself show whether women who tested positive received treatment, whether infants were immunised on time, or whether transmission actually fell. Those are the next questions that matter clinically. For now, the registers show that Sierra Leone has reached an important threshold in antenatal screening, while the response needed to convert detection into elimination remains incomplete.