Advancing Hematopoietic Stem Cell Transplantation (HSCT) in Africa: A Pathway to Curing Hematological Disorders.

Introduction

Among all the hematological disorders, hemoglobinopathies and hematological malignancies are a serious public health concern in Africa [ 1 , 2 ]. Africa is home to more than 70% of all hemoglobinopathies in the world. In the vast majority of African nations, hemoglobinopathies are a public health concern that at least partially explains the rising rates of newborn death and morbidity. Compared to thalassemias (0.07%), sickle cell diseases (SCD) are more common (10.68%) among these impacted newborns [ 1 ]. In 2018, about 6.6% of all cancer diagnoses reported globally were hematological malignancies. Hematological malignancies account for over 10% of sub‐Saharan Africa's total cancer burden. In comparison to 2018 statistics, WHO projects that the incidence of hematological malignancies in low‐ and middle‐income countries will rise by 48% by 2030 [ 2 ].

Blood transfusions, infusion therapy, and drugs are among the available treatments for hemoglobinopathies [ 3 ]. However, a precise diagnosis, staging, and availability of suitable chemotherapy and palliative care—particularly antimicrobials and blood products—are necessary for the best possible treatment of hematological malignancies [ 2 ]. Due to the lack of palliative care in sub‐Saharan Africa, it may not always be possible to implement stringent regimens created in high‐income nations. Although organizations like the African Palliative Care Association have prioritized and supported palliative care throughout Africa. In many centers, it is not enough to provide effective pain relief for individuals nearing the end of their lives. Over 90% of people in need in Africa still cannot obtain palliative care, primarily due to issues like late disease presentation and lack of suitable facilities for diagnosis and treatment [ 2 ]. However, all this treatment only provides supportive care to those with hematological disorders, showing a need for a restorative therapeutic intervention that can cure hematological disorders completely.

Hematopoietic stem cell transplantation (HSCT) is a known restorative therapy for malignant and nonmalignant disorders of blood and bone marrow and congenital and immune disorders [ 4 ]. It involves the harvest of hematopoietic stem cells (HSCs) from a HLA matched donor or a haploidentical donor, conditioning of the patient, intravenous infusion of the HSCs, and reassembling of the hematopoietic system and consequently the reconstitution of the immune system [ 5 ]. HSCs can be sourced from the bone marrow, umbilical cord blood, and mobilized peripheral blood [ 4 ]. HSCT is clinically applied to restore bone marrow function following intensive cancer treatments and replacing impaired bone marrow with healthy tissue in nonmalignant hematological disorders. It also has therapeutic purposes for various inherited and acquired immune and hematopoietic system abnormalities and in hemoglobinopathies, e.g., sickle cell anemia [ 5 ].

The first successful HSCT was performed by Dr. E. Donnall Thomas, the “father of bone marrow transplantation,” and his colleagues in 1963 [ 6 ]. Significant advances have been made in the quest to bring curative solutions to many hitherto unresolvable human conditions using HSCT in many developed countries with advanced medical care [ 7 ]. However, in many developing countries, stem cell therapy is either nonexistent or still in its infancy, with reasons ranging from the absence of political will to fund HSCT centers to a lack of skilled personnel and a lack of infrastructure [ 7 ]. This study aimed to review the current status of HSCT in Africa as a potential cure for hematological disorders.

Literature Source and Search Methods

Literature was sourced from PubMed, Google Scholar, and African health journals. Also, gray literature was searched to include relevant information. The search utilized keywords such as hematological disorder, treatment, supportive care, HSCT, and Africa. Articles published up to May 2025 were assessed to capture current information.

Hematological Disorder in Africa

In Africa, there are diverse hematological disorders, with the prevalence of sickle cell anemia as number one. In Nigeria, SCD has a mortality rate of 50‐80%, and in Kenya, about 4.5% are born with sickle cell. Uganda has a high rate of 45%, and Gabon, and Cameroon share a rate of 20%–30% [ 8 ]. The disease cases prevail in Africa and affect up to 3% of births and it is stipulated that 6–9 million infants are born with SCD in Africa each year. Moreover, Tanzania ranking fifth in the world after Nigeria, the Democratic Republic of Congo, India, and Angola, reported an SCD burden of 11,000 births annually [ 9 ]. The carrier frequency ranges from 10% to 40% across Equatorial Africa, decreasing to 1%–2% on the North African coast and less than 1% in South Africa [ 10 ]. Also, In tandem with sickle cell disease are other hematological disorders that affect Africans, including multiple myeloma, thalassemias, leukemias, myeloproliferative and myelodysplastic diseases, and non‐Hodgkin and Hodgkin lymphomas [ 2 ].

Statistics show that β‐thalassemia carriers (all variants) account for approximately 3% of the global population [ 11 ]. Africa, the Mediterranean basin, the Middle East, the Indian subcontinent, Southeast Asia, Melanesia, and the Pacific islands are among the most affected areas. The prevalence ranges between 10% and 20% in sub‐Saharan Africa [ 12 ]. According to the World Health Organization (WHO,) leukemia accounts for 6.8% of cancer cases and 24,501 deaths in Africa [ 13 ].

HSCT in Improving Therapeutic Outcomes of Hematological Disorder in Africa

The effect of HSCT in improving hematological disorders has been impressive globally, though faced with challenges. The response rates of allogeneic HSCT were greater than 95% in Australia, Brazil, Canada, Europe, Japan, South Korea, Malaysia, New Zealand, Taiwan, and the USA. The response rate for autologous HSCT in Europe was greater than 90% and it can be estimated to be between 80% and 90% for Australia, Brazil, Canada, Europe, Japan, South Korea, Malaysia, New Zealand, Taiwan, and the USA [ 14 ]. The success of HSCT globally is due to health infrastructure, ongoing research, and proper funding; while in Africa, though there has been a reported success rate, there are still significant factor drawing it back. HSCTs in the African/Eastern Mediterranean region represent only 3% of the total transplant activity reported globally. The transplant rate, defined as the number of HSCT per 10 million inhabitants, is 67.7, the lowest in the world. HSCT is not developed in Africa because of the limited resources available, other health issues for the populations, and limited interest by policymakers [ 15 ].

Furthermore, only seven out of the 54 African countries currently perform HSCT, contributing to the low transplant rate. The countries performing HSCT are South Africa, Nigeria, Egypt, Morocco, Algeria, Tunisia and Tanzania. The process began in South Africa in 1976 and the growth of HSCT in Africa has been identified as being hampered by a number of factors, including the cost and availability of specific medications, a lack of skilled workers, a lack of government commitment and funding, and a lack of necessary facilities and infrastructure [ 16 ]. The few number of countries in Africa performing HSCT compared to the burden of hematological disorder revealed a need for Africa to shoulder the responsibility and change the narrative towards a curative approach to reduce the morbidity and mortality rate of hematological disorder faced by the African populace.

Current Status of HSCT in Africa

HSCT in Nigeria

Aside from the many cases of unreported aplastic anemia and other bone marrow disorders, Nigeria has a large population of homozygous SCD individuals, with a percentage of 1‐3% [ 17 ] The first HSCT in Nigeria was performed in 2011 at a government hospital by Bazuaye et al. [ 18 ] for a 7‐year‐old boy having SCD. It was done utilizing a completely matched sibling donor Human Leukocyte Antigen (HLA) (6/6). However, it faced several challenges, including an ineffective power supply that required the use of generators and inverter batteries, subpar supportive care (particularly blood products), and insufficient diagnostic facilities (especially for fungal and viral studies), in the management of this index patient [ 18 ]. The heartfelt success of HSCT resulted in the creation of stem cell transplantation centers across the country by the Nigerian government. Additionally, the Bone Marrow Registry of Nigeria (BMRN) was initiated in 2012, a bold step taken by a leukemia survivor and his team to increase global recovery statistics for Africans with blood disorders [ 19 ].

In the year 2017, an aggregate of three HSCTs was carried out in a government facility for sickle cell patients with matched sibling donors in Nigeria. The collaboration between the government and Celltek Healthcare Medical Center in Benin from 2017 to July 2019 increased HSCT to an aggregate of seven successful HSCTs performed with completely matched sibling donors (Table 1 ). However, this aggregate decreased owing to the lack of HLA‐matched donors for many patients with SCD [ 21 , 22 ]. This led to Celltek Healthcare Medical Center embracing the use of haploidentical donors, which have proven successful in some centers in Western countries [ 23 , 24 ]. Nonetheless, the two patients who had transplants using a haploidentical donor lacked substantial HSCT‐associated diseases. The newer method provides the chance for many more patients to get transplants at the very initial stage before the onset of complications of the disease [ 19 ]. Furthermore, between 2017 and 2022, Nigeria performed 22 HSCTs, with the University of Benin Teaching Hospital (UBTH) accounting for 3 (13.6%) and Celltek Healthcare Medical Center performing 19 (86.4%) through a public–private collaboration [ 25 ]. In 2023, Nigeria reported only three allogeneic HSCTs and one autologous HSCT among patient having their first transplant (Figure 1 ) [ 26 ].

In support of HSCT in Nigeria, the Sickle Cell Foundation of Nigeria (SCFN), in collaboration with Lagos University Teaching Hospital (LUTH), commissioned the bone marrow transplant center in February 2022, supporting the commencement of full‐scale bone marrow transplantation in LUTH by June 2023 [ 27 ]. Also, on 20th August 2022, a new hematological disease ward was commissioned in Aminu Kano Teaching Hospital in Kano State with an indication of commencement of bone marrow transplantation as the second teaching hospital to commence the program in the country [ 28 ]. Moreover, the partnership of LUTH and SCFN resulted in the creation of a post‐transplant clinic in 2019, making Nigeria the first country in sub‐Saharan Africa to provide post‐transplant care to patients who had traveled abroad for transplants, thereby developing clinical expertise in post‐transplant care in anticipation of a locally tailored and cost‐effective bone marrow transplant program in Nigeria. Additionally, the initiative created the first stem cell processing laboratory in West Africa with a high‐level multidisciplinary team, comprising various healthcare professionals, who were involved in this LUTH/SCFN bone marrow transplant program [ 29 ]. LUTH has successfully performed its first bone marrow transplant, marking a significant milestone in Nigerian healthcare and giving hope to SCD patients. This marks a significant advancement in the nation's medical system and highlights the expanding ability of regional healthcare facilities to offer cutting‐edge treatments for complicated illnesses like SCD [ 30 ].

HSCT in Egypt

In Egypt, thalassemias and SCD are the most common inherited recessive disorders associated with consanguineous marriage. The first HSCT was performed in 1989, and the program started on a narrow scale. However, the program expanded with the initiation of the program at Nasser Institute in 1997, and as of 2008, there are ten known HSCT centers in Egypt (five Cairo centers, two military centers, one Alexandria center, one Upper Egypt center, and one Tanta center), performing both autologous and allogeneic transplants. Grafts used were sourced from bone marrow and mobilized peripheral blood. To resolve the issue of a lack of donors, haplo‐identical transplants began in 2015 [ 20 ]. Moreover, Egypt recorded an aggregate of 4256 patients who had undergone HSCT between 1997 and 2017 (Table 1 ) [ 31 ].

HSCT in Morocco

In Morocco, HSCT was first implemented in 2004, with three academic hospitals and three private clinics currently carrying out bone marrow transplants. However, autologous HSCT started in 2004 and allogeneic HSCT debuted in 2010. Five centers carry out peripheral stem cell collection, four laboratories offer HLA antigen‐typing services, two laboratories have liquid nitrogen and regulated freezing, and two smaller centers offer stem cell processing. Moreover, two clinics have the potential to provide extracorporeal phototherapy, and the Marrakech Center offers the possibility of chimerism examination. Between 2004 and 2017, Morocco saw 45 cases of allogeneic HSCT and 615 cases of autologous HSCT (Table 1 ) [ 16 ].

HSCT in Tunisia

In Tunisia, HSCT started in 1998, and before the commencement of the program in 1996, the National Bone Marrow Transplant Center signed a convention with the National Social Insurance to support transplant patients. The financing mechanism was based on patient classification in diagnosis related groups (DRGs). As a result of this, about 80% of the population was covered by health insurance. However, at the only HSCT center in Tunisia, the National Center for Stem Cell Transplantation, about 40–50 allogeneic HSCTs and 60‐70 autologous HSCTs were reported to be performed annually. Between 1998 and 2017, Tunisia recorded 962 autologous HSCTs and 789 allogeneic HSCTs (Table 1 ). The predominant indications of allogeneic HSCT were leukemia and aplastic anemia, while the major indications of autologous HSCT were multiple myeloma and lymphomas [ 16 , 32 , 33 ]. Moreover in 2023 only, Tunisia reported conducting 28 allogeneic HSCT and 41 autologous HSCT among patient having their first transplant (Figure 1 ) [ 26 ].

HSCT in Tanzania

In response to the elevated incidence and mortality rate of hemoglobinopathies, including SCD, the Tanzanian government established a sickle cell clinic at Muhimbili National Hospital in Dar‐es‐Salaam in the 1980s and exempted SCD patients from user payment in public hospitals [ 7 ]. In 2004, Muhimbili University of Health and Allied Sciences dedicated a research program to improving health services, advocacy, and training. Furthermore, sickle cell health services were also strengthened in other health facilities. The Ministry of Health, in collaboration with the Sickle cell program, developed a standard of care suitable at various levels of health care, later incorporated into the National Strategy for noncommunicable disease (NCD)—which conformed with the World Health Organization's strategy for NCD in Africa. These standards of care were provided into a booklet (containing crucial information such as patient clinical and laboratory info) to be kept by the patient or relative. As a result of a partnership between the Tanzanian Ministry of Health and Italy, four tertiary hospitals were identified with the potential of providing HSCT services. These included three public hospitals: Muhimbili National Hospital, Dar‐es‐Salaam, Benjamin Mkapa Hospital, Dodoma, Bugando Medical Center, Mwanza, and one private Hospital; Aga Khan Hospital, Dar‐es‐Salaam [ 34 ]. Owing to strategic planning and a collaborative partnership, Tanzania was able to perform a total of 11 transplants between November 2021 to March 2022, representing the dawn of HSCT in East Africa [ 35 ].

HSCT in South Africa

The South African Bone Marrow Registry (SABMR), founded in 1992, is Africa's only bone marrow registry with World Marrow Donor Association qualifying status. Moreover, the National Stem Cell Transplantation Society (SASCeTS) maintains the transplant activity registry. Over 400 unrelated grafts have been provided through this registry. It has been reported that South Africa annually performs 250 allogeneic and 175 autologous HSCTs (Table 1 ) [ 16 , 36 ]. However, in Red Cross War Memorial Children's Hospital and Groote Schuur Hospital, between 2018 and 2023, 254 individuals received 275 HSCTs, with 88% having their first transplant. Of these procedures, 125 (46%) were allogeneic and 145 (54%) were autologous HSCTs indicating higher transplantation uptake in South Africa [ 37 ]. Although, the country reported 128 allogeneic and 258 autologous HSCTs in 2023 only among patient having their first transplant across the whole HSCT centers (Figure 1 ) [ 26 ].

Since the onset of HSCT in South Africa the country has been pooling much strength and capacity to increase the curative potential for patient with hematological disorder. As of 2017, SABMR had recruited over 73,000 registered donors, intending to ease a much more equitable approach to HSCT treatment options and patients receiving services from the SABMR both domestically and abroad, with additional access to a database of more than 32 million worldwide donors, thanks to their partnership with the World Marrow Donor Association (WMDA). To fully address the complicated needs of the nation's genetically diverse population, the SABMR organized an effort to recruit additional local donors. An independent non‐profit organization called The Sunflower Fund was established as a donor recruitment center and registry in 2018. It has been actively involved in educating the public about the need for South African donors and helping patients obtain funding. Additionally, they established partnerships with global bone marrow and stem cell registries, including those of other African nations such as Ghana, to recruit donors [ 36 ].

The two biggest transplantation facilities in South Africa, Groote Schuur Hospital, a public hospital, and Pretoria East Netcare Hospital, a privately owned facility, both adopted haplo‐identical HSCT in 2014 [ 38 ]. Du‐Toit et al. [ 38 ] research indicates that unaltered haploidentical HSCT is a feasible choice, particularly for acute leukemia and myelodysplastic syndrome patients, and supports the safety and feasibility of haploidentical HSCT. The creation of haploidentical HSCT is in line with the requirement that all patients in South Africa, regardless of socioeconomic background, have equal and inexpensive access to stem cell transplantation. Haploidentical HSCT has been effectively used at clinics for patients without access to completely matched siblings since 2014. Haploidentical transplantation has shown promising results and could be a good option if there are no fully matched, eligible donors available. Additionally, concerning the Stem Cell Registry Alliance (SCRA), the Sunflower Fund hopes to raise awareness and educate the public while also recruiting 100,000 African American donors by 2030 to support HSCT in Africa [ 38 ].

HSCT in Algeria

HSCT commenced in 1998 in a center in Algiers. According to reports of M. Benakli at the African Blood and Marrow Transplantation (AfBMT), a total of 2828 allogeneic and autologous HSCTs have been performed at the center from 1998 to 2018, with graft sources from bone marrow, peripheral blood stem cells, and cord blood. The haploidentical HSCT program started at the center in 2013 to improve HSCT in Algeria (Table 1 ). The principal indications for autologous HSCT were lymphomas (57%) and multiple myeloma (38.5%) and the indications for allogeneic HSCT included acute leukemias, aplastic anemias, and thalassemias. In 2009, a second HSCT center commenced in Oran, and cord blood banks exist in both centers. The cost of HSCT in Algeria is expensive, ranging between US$15,000 and US$20,000. However, the cost is fully funded by either the Ministry of Health or health insurance, as 90% of Algerians have health insurance policies [ 16 ]. However, owing to the advancement of HSCT in Algeria, the country documented 182 allogeneic and 155 autologous HSCTs among patient having their first transplant in year 2023 (Figure 1 ) [ 26 ].

Challenges Limiting HSCTs in Africa

Lack of Donors

There is a significant need for a donor to be available for an allogeneic transplantation. The lack of matched‐related or unrelated donors is the biggest obstacle facing the HSCT facility. Even the relatives of patients often hesitate to undergo matching tests and provide HSC in support of their patient [ 39 ]. Van‐Eyssen et al. [ 40 ] reported that the recent demography of donors as documented by the SABMR does not symbolize the heterogeneity in the ethnicity of patients in the country. Owing to the poor representation of recipient genotypes in both local and international registries, patients who are eligible for allo‐HSCT cannot access a transplant owing to the unavailability of fit donors [ 40 ]. The chance of locating a matched donor is determined by numerous factors, such as the family size, the occurrence of a precise HLA type among the population, and the ethnicity of both the donor and the recipient. The lack of a local donor registry in Egypt, with less than 3% of Egyptian donors listed in the international registries, complicates locating matched donors for patients [ 31 , 41 ].

An additional layer of difficulty to the lack of donors is the high prevalence of HIV. About 13.7% of South Africa's overall population is believed to be infected with HIV [ 42 ]. With the largest antiretroviral roll‐out program in the world, 66.9% of HIV‐positive individuals in South Africa are receiving antiretrovirals. As South Africa works to expand its pool of donors to facilitate greater accessibility to HSCT, clinical hematologists, and clinical oncologists will need to address the concerns and uncertainties surrounding transplantation from an HIV‐positive donor to an HIV‐negative recipient (D + /R–) or from an HIV‐positive donor to a recipient (D + /R + ) [ 42 ].

Healthcare‐Associated Challenges

Adequate care of the patient's pre‐transplantation, during transplantation, and post‐transplantation processes is taken into consideration for the establishment of the HSCT center. Owing to inadequate infrastructure, funding, and diagnostic services, poor infection control strategies, and antimicrobial stewardship, the low‐ and middle‐income countries are faced with greater challenges in running the HSCT centers [ 7 , 18 , 43 ].

HSCT is an intricate medical procedure that calls for highly trained and qualified healthcare professional teams, an adequate and efficient hospital infrastructure system, the collaboration between medical professionals, access to sophisticated laboratory facilities, and pharmacy assistance, which the African healthcare system lacks [ 16 ]. Also, Mekonnen & Farris [ 44 ] reported that the main obstacle to starting an HSCT program in Ethiopia is the dearth of health workers, such as lab technicians, nurses, and pharmacists, and the scarcity of transplant physicians, except for a small number of hematologists.

Infrastructures like power supply, which is unstable in African countries like Nigeria, are required for the smooth and efficient running of HSCT centers; equipment and backups, which are expensive, are affected by inadequate funding of the health care system in Africa [ 6 ]. This challenge reduces the productivity of the procedure [ 45 ].

The price of classic molecular techniques and newer drugs needed to achieve a better transplantation practice is sometimes limiting. However, developing countries are unable to offer “state‐of‐the‐art” treatment strategies, including HSCT, owing to poor funding of the health system [ 31 ]. In Nigeria, there are inadequate funds to purchase and maintain the equipment required for the procedure, to train skilled health care professionals, and to provide other necessary infrastructure, like state‐of‐the‐art hospitals, as well as a stable and uninterrupted power supply. This affects the effective delivery of healthcare services [ 45 ].

Post‐transplant infections caused by multidrug‐resistant organisms can result in a significant post‐transplant mortality rate, especially during the neutropenic phase [ 46 ]. A South African retrospective study detailed a 35% incidence rate of bloodstream infections caused by multidrug‐resistant bacteria among HSCT recipients, with over 9% mortality. This undermines the significant headway made towards HSCT [ 47 ].

Little to no Awareness, Poor Knowledge, and Acceptance of Hematopoietic Stem Cell Transplantation

A study conducted in 2016 to assess the awareness, knowledge, and acceptance level of HSCT for sickle cell anemia in Nigeria reported a 64.5% awareness and poor knowledge among the participants. However, this was low compared to reports from advanced countries. In addition, the level of acceptance was very low, with a few outrightly refusing the procedure, although most were uncertain [ 48 ]. The report buttresses a similar study that was conducted in 2015 on pediatric sickle cell anemia patients, which reported minimal acceptance of HSCT as a restorative therapy for sickle cell anemia [ 49 ]. The issue of donating tissues like blood, bone marrow, and cord blood is yet to be seen from an altruistic viewpoint in Africa. The poor donation culture is a product of fear, ignorance, and apathy. Even for blood donation, which is a relatively safe and easy procedure, voluntary donations from suitable donors are offered by a very low percentage of the population. Convincing individuals to offer bone marrow donations, except for close relatives, would therefore be a herculean task. In the case of cord blood as a source of HSCs there is palpable ignorance among the populace. It is doubtful if awareness goes beyond those who have heard of or seen cord blood. Another study conducted in 2018 to evaluate the level of awareness of cord blood donation among pregnant women in a tertiary hospital in Lagos also reported restricted awareness among pregnant women, while religious factors and level of education were identified as the causes [ 50 ].

Furthermore, when the South Egypt Cancer Institute (SECI) reported from their everyday work that a major obstacle to HSCT and HSC donation in their facility was the widespread myths and misconceptions surrounding these procedures. These myths and misunderstandings originated from TV dramas, films, and other media that portrayed HSC donation—especially bone marrow donation—as frightening and exaggerated. Furthermore, they dramatically depicted the difficulties and agony following transplantation and donation. These myths and misconceptions were widespread, even among highly educated professionals, as a result of the remarkable influence of mass media on subjects' knowledge, thoughts, and beliefs [ 39 , 51 ]. In addition, a study conducted by Khaled et al. [ 39 ] among final‐year medical and nursing students found that the majority of these students had high levels of myths and misconceptions about the HSCT program during the pretest phase. This amount decreased once the enlightening program on HSCT treatment was conducted. Nonetheless, there is a greater prevalence of HSCT myths and misunderstandings among nursing students, particularly among those who live in rural areas and have low to moderate FAS (Family Affluence Scale). Even after the intervention, these inequalities remained [ 39 ].

Cultural Beliefs

Great hurdles to HSCT include culturally associated variables, including family cohesion, skepticism of the medical system as a whole or in the equal distribution of HSC donations, and religious beliefs, and possibly religious objections to HSC donation [ 52 ]. For instance, Nigeria is a country with over 300 ethnic groups having diverse cultural beliefs, with a population estimated to be over 200 million, and a high birth rate [ 50 , 53 ]. A country with this population and birth rate is expected to have an adequate supply of grafts obtained from cord blood donation; however, umbilical cord blood transplantation is hindered as there are myths surrounding the umbilical cord and the placenta in many Nigerian cultures [ 54 ]. Thus, umbilical cord blood is regarded as sacred and should be buried [ 54 ]. This is a hindrance to the donation and use of cord blood for restorative therapy in Nigeria [ 50 ].

Cost of Accessing Hematopoietic Stem Cell Transplantation

Generally, Eastern Mediterranean countries and Africa were known to perform the least number of HSCTs. Between 2006 and 2014, HSCTs were not carried out in countries with inhabitants of less than 300,000 or countries with less than USD 1260 per capita as their gross national income [ 55 ]. These outcomes were attributed to the higher expenses linked with the technique, restraining the accessibility of this therapeutic choice in developing nations. These caused an increase in related ethical issues concerning distributive justice, surrounding the inadequate opportunity of lower socioeconomic populations in sub‐Saharan Africa to this therapeutic modality [ 56 ].

The high cost of HSCT is one of the factors limiting the acceptance of HSCT in Nigeria. HSCT is no doubt an expensive procedure that requires professional expertise, equipment, and supportive care, including drugs, which are all very expensive. A single bone marrow transplantation has been estimated to cost between $31,500 and $51,900, depending on whether it is autologous or allogenic [ 57 ]. Only a very limited number of Nigerians can afford this, thereby making access to this procedure available only to wealthy individuals

In Egypt, the cost of stem cell transplantation ranges from $11,000 to $17,000 based on the transplantation procedure (autologous, allogeneic, or haploidentical) to be carried out [ 58 ]. Following the follow‐up period after transplantation, the cost further exacerbates the socioeconomic affliction on patients [ 31 ].

Documentation

The African healthcare system suffers from the bane of poor documentation of services provided. In many countries where HSCT has been successfully implemented, a database for HLA is available in the registries. This enables easy genetic matching between donor and recipient. The deliberate testing and documentation of existing and potential donors could aid future transplantation efforts. A major factor in the matching process between patients and possible donors is the degree of HLA concordance on the cell surface. Since many of the transplantations carried out are allogenic, a mismatch in HLA proteins leads to inappropriate recognition by the host's immune system and subsequent graft failure [ 59 ]. With the level of diversity in the African population, finding a suitable match for those in need of HSCT could be highly challenging. According to Mishra et al. [ 60 ], ethnicity is an important factor in finding a suitable donor and plays a great role in increasing the chances of a successful HSCT procedure. A database of HLA patterns among the different ethnic groups in the region will therefore bring an unquantifiable benefit to the HSCT campaign, irrespective of the graft source.

Post‐Transplant Follow‐Up

Follow up care and maintaining stringent hygiene standards at home are crucial during the post‐transplant phase, as they contribute to the success of the transplantation procedure. However, some patients find it difficult to adhere to their appointments and hygienic guidelines, even when the procedure is free. This can be attributed to the lower socioeconomic status of developing African countries compared to developed countries [ 31 ]. This results in a 10% drop‐out rate in Algeria during the follow‐up process [ 61 ]. Others who travel for the procedure will have to return to their home country, where post‐transplant follow‐up resources and expertise are lacking [ 62 ].

Ethical Considerations

When dealing with the bioethical issues related to HSCT, the issue of informed consent is a very central one. Adults with decision‐making capacity have a long‐recognized and legally protected right to make decisions about their bodies and health. Consent is a basic ethical consideration, implying that it is informed and that patients must be given adequate and accurate information. HSCT is a “high‐stakes” medical treatment [ 63 ]; people who are undergoing HSCT should thus be prepared to participate in decisions that involve weighing benefits, harm, long‐term risks, and uncertainty linked to the treatment itself [ 64 ].

Future Direction in Improving HSCT in Africa

Technology Advancement

Future efforts to improve HSCT in Africa should focus on expanding the number of transplant centers, particularly in Central Africa, where no active programs currently exist. Establishing more HSCT centers across the continent will enhance accessibility, reduce patient backlog, and improve outcomes for conditions like hemoglobinopathies. Additionally, future initiatives should prioritize increasing donor availability and addressing resource constraints to strengthen HSCT services and ensure sustainable growth [ 65 ].

The advancement of HSCT in Africa can be significantly enhanced through the integration of artificial intelligence (AI) and machine learning (ML), by improving donor matching and managing complications like GVHD. AI‐driven algorithms can analyze genetic datasets to identify compatible donors more efficiently, even with limited registries, and help early prediction and prevention of transplant‐related complications like GVHD. Although AI doesn't increase the donor pool, it optimizes selection and treatment through predictive modeling and big data analysis.

Also, big data integration with AI systems is capable of analyzing vast amounts of information from transplant registries such as the Centre for International Blood and Marrow Transplantation (CIBMTR) and the European Society for Blood and Marrow Transplantation (EBMT). By refining predictive models and identifying outcome patterns, AI can contribute to better decision‐making in transplantation. However, as AI tools become more sophisticated, concerns about the “deskilling” of physicians and ethical considerations surrounding data privacy must also be carefully managed [ 66 ]. Advancing HSCT in Africa requires a balanced approach that integrates technological innovations with strong regulatory policies and comprehensive physician training. AI‐driven solutions should be designed to support rather than replace clinical expertise, ensuring healthcare professionals can effectively utilize these tools. Strengthening infrastructure, capacity building, and policy frameworks will be key to optimizing AI's role in HSCT, improving patient care, and expanding access to transplantation services across the continent.

An emerging direction in HSCT is its application in treating diseases driven by somatic mutations, such as VEXAS (vacuoles, E1 enzyme, X‐linked, auto‐inflammatory, Somatic syndrome). VEXAS is a recently characterized, life‐threatening auto‐inflammatory disorder caused by somatic mutations in the UBA1 gene. Conventional immunosuppressive therapies often fail, making long‐term management difficult. A recent review of 33 patients reported that allogenic HSCT not only improved clinical outcomes but also completely eradicated the UBA1 mutation in several cases, suggesting curative potential. However, the risks remain considerable, with high rates of graft‐versus‐host disease and infection. As HSCT techniques and supportive care continue to improve, their role in managing complex, acquired genetic diseases like VEXAS is likely to expand, representing a significant future direction in transplantation medicine [ 67 ].

Overcoming Financial, Infrastructure, and Workforce Challenges

The need for HSCT in Africa is expected to continuously increase in the future. However, HSCT is a high‐cost procedure, which poses significant financial challenges to both patients and healthcare systems across the continent. As with the correlation observed between the economic strength of a country and transplant rates, African nations can address the financial barriers to HSCT through a combination of strategic partnerships, resource mobilization, and policy‐driven funding mechanisms. The availability of HSCT is also heavily dependent on the infrastructure and trained medical personnel. To increase the number of HSCT procedures performed, African nations should focus on establishing stronger healthcare systems, improving training for healthcare professionals, and enhancing regional collaboration to disseminate expertise. Collaborative efforts can ensure better technology transfer and uniformity in procedures, which will ultimately lead to an increase in the transplant rate.

Regional Collaborations and Capacity‐Building Initiatives

The future of HSCT in Africa hinges on regional collaboration to overcome challenges such as limited infrastructure, trained personnel, and economic constraints. Addressing policy and economic barriers is essential for developing local transplant programs. Affluent African nations should invest in HSCT to reduce costs and strengthen healthcare systems rather than sending patients abroad. Expanding insurance to cover HSCT and promoting medical tourism can help fund and sustain these services. For poorer countries, economic justification remains a hurdle, but with proper planning and shared expertise, they can eventually establish effective transplant programs [ 68 ]. These efforts should focus on training healthcare professionals and developing specialized centers that can serve as regional hubs, improving access to treatment. Collaboration between universities, research institutes, and health ministries is crucial to creating tailored training programs for local needs. Regional collaborations should also extend to joint clinical trials and funding for clinical research, ensuring equitable access to advancements in HSCT across the continent.

Development of African‐Specific Donor Registries

The development of African‐specific donor registries is crucial for improving access to HSCT across the continent by addressing the difficulty of finding HLA‐matched donors in regions of genetically diverse populations. These registries can enhance donor matching, reduce wait times, and improve transplant success rates. Regional collaboration is key to ensuring broad population inclusion and expanding the donor pool, ultimately leading to better outcomes for patients with rare genetic profiles across Africa.

Conclusion

HSCT in Africa is in its infancy, facing hurdles such as limited infrastructure, scarce donor registries, economic constraints, a poor healthcare system, and a shortage of trained personnel. Nevertheless, progress is being made through investment in local healthcare programs, regional collaboration, the use of artificial intelligence for donor matching and early risk predictions, and the expansion of insurance coverage and medical tourism. With strategic planning and support, HSCT has the potential to become more accessible and effective across Africa, transforming the hematological disorder towards curative purposes.

Author Contributions

Tolulope Joseph Ogunniyi: conceptualization, writing – original draft, writing – review and editing, methodology, formal analysis, data curation. Rodiat Remilekun Abdulkareem: conceptualization, methodology, writing – original draft, writing – review and editing. Adeola Roqeebat Emiola: writing – original draft, conceptualization, writing – review and editing. Toluwase Ruth Bamidele: conceptualization, writing – original draft, methodology, writing – review and editing. Godsave Binlak Wazhi: conceptualization, methodology, writing – review and editing, writing – original draft, formal analysis. Precious Opeyemi Arinde: conceptualization, writing – original draft, writing – review and editing. Sarah Sokolabe Yisa: conceptualization. Oluwatoyin Makanjuola: conceptualization, writing – original draftand writing – review and editing. Kesaobaka Batisani: formal analysis, conceptualization, writing – original draft and writing – review and editing. Ayodele Ilesanmi: conceptualization, writing – original draft, writing – review and editing, supervision.

Ethics Statement

The authors have nothing to report.

Consent

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The lead author Kesaobaka Batisani affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Acknowledgments

The authors declare they have not use AI‐generated work in this manuscript.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

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