The “Lupus Paradox” in Sub-Saharan Africa: a scoping review of diagnostic delays, systemic barriers, and clinical outcomes in SLE

Abstract

Abstract Introduction Systemic Lupus Erythematosus (SLE) in Sub-Saharan Africa (SSA) presents a unique clinical and epidemiological paradox. Individuals of African descent tend to have disproportionately aggressive phenotypes of the disease, despite being in an environment with health systems extremely under-equipped to identify, diagnose, or manage this condition. Method This scoping review generates evidence from 13 studies ranging from systematic reviews, cross-sectional cohort studies, qualitative analyses, and descriptive studies conducted in countries in SSA such as Nigeria, Ghana, South Africa, and other low- and middle-income countries, and it is aimed at mapping the structural, socio-cultural, and clinical perspectives of this paradox. Result A delay in diagnosing SLE appears to be the most consistent and important finding. In South African paediatric cohorts, the mean time of diagnosis is 23.6 weeks. In adult populations in Nigeria, diagnostic delay was reported in 80% of patients. Male patients face a composite delay due to a common clinical assumption that SLE is a disease of females. Key socio-cultural factors include misdiagnosis as TB, HIV, or malaria, and resort to traditional healing methods. Structural constraints include a severe shortage of rheumatologists and limited access to diagnostic testing. Corticosteroids remained the key form of treatment, with their use recorded in 99% of patients, reflecting the “Glucocorticoid Trap”. The cumulative mortality rate across studies in SSA is about 10.3%, with primary causes of death being renal diseases, infections, and CNS involvement. Conclusion This scoping review suggests targeted, resource-stratified interventions: incorporating SLE screening into the current TB/HIV screening frameworks, expanding task-shifting models via tele-rheumatology programmes and digital health tools, strengthening the local diagnostic capacity, and advocating for inclusion of hydrochloroquine and immunosuppressants in the national essential medicines lists. To close the lupus equity gap in SSA, both structural commitment and clinical innovative approaches are needed.