Transforming sickle cell haemotherapy in Africa: building safe, antigen-matched, available, and sustainable transfusion pathways.

Sickle cell disease (SCD) is a major haematological and health-system challenge in Africa, where a substantial global burden occurs alongside persistent limitations in access to safe and comprehensive transfusion services. Blood transfusion remains essential for selected acute complications, perioperative support, stroke prevention, and chronic transfusion programmes. However, effective SCD haemotherapy is constrained not only by blood shortages but also by transfusion-transmitted infections, red-cell alloimmunisation, limited antigen matching, complex immunohaematological phenotypes, iron overload, fragmented transfusion histories, and inadequate haemovigilance. This narrative review examines these interconnected challenges across the haemotherapeutic continuum and proposes practical pathways for safer, more available, and sustainable transfusion care. Evidence from published literature, transfusion guidance, SCD recommendations, and African blood-service studies was synthesised across donor recruitment, blood collection, infectious-disease screening, component preparation, compatibility testing, antigen profiling, transfusion administration, haemovigilance, and long-term monitoring. The review identifies a critical distinction between blood availability and compatible blood availability and proposes integrated solutions including sustained voluntary donor recruitment, improved inventory management, extended red-cell antigen profiling, risk-based antigen matching, selective molecular genotyping, lifelong transfusion records, antibody registries, rare-donor networks, regional reference laboratories, and strengthened haemovigilance. Rh and Kell matching should form an important foundation for frequently transfused patients, while Duffy, Kidd, MNS, and other clinically significant antigens should be incorporated according to patient risk and local capacity. Iron surveillance, appropriate chelation, patient blood management, and disease-modifying therapies can reduce cumulative transfusion-related morbidity. Africa therefore requires a transition from episodic blood provision to resilient, integrated, lifelong haemotherapeutic systems capable of improving transfusion safety, continuity, equity, and long-term outcomes for people living with SCD.