Review
Vulnerability to malaria, tuberculosis, and HIV/AIDS infection and disease. Part 1: determinants operating at individual and household level

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Summary

A high burden of malaria, tuberculosis, and HIV infection contributes to national and individual poverty. We have reviewed a broad range of evidence detailing factors at individual, household, and community levels that influence vulnerability to malaria, tuberculosis, and HIV infection and used this evidence to identify strategies that could improve resilience to these diseases. This first part of the review explores the concept of vulnerability to infectious diseases and examines how age, sex, and genetics can influence the biological response to malaria, tuberculosis, and HIV infection. We highlight factors that influence processes such as poverty, livelihoods, gender discrepancies, and knowledge acquisition and provide examples of how approaches to altering these processes may have a simultaneous effect on all three diseases.

Section snippets

Current response to the global burden of malaria, tuberculosis, and HIV disease

In 2001, malaria, tuberculosis, and HIV infection together claimed 5·7 million lives.1 The effect of these diseases, and the inadequate national and international responses, is a major reason why the poor stay poor. Increasing recognition of the link between the burden of these diseases and a lack of economic growth has galvanised global institutions to renew efforts aimed at reducing the impact of these diseases through both health and non-health approaches.2 WHO and the Commission of the

What is “vulnerability”?

Vulnerability is a complex and contested concept, with a variety of definitions arising from different disciplines (panel 2).3, 4, 5, 6 Although vulnerability analyses have been carried out in relation to various settings (eg, disasters, poverty, urban macroeconomic decline, specific health problems such as HIV/AIDS and mental health) some common features emerge (panel 3).7 Vulnerability encompasses the factors that lead to variation in the impact of disease between different communities and

Approaches to vulnerability in infectious diseases

Most discussion on vulnerability in infectious disease has been in the context of the HIV epidemic. Initial approaches to dealing with the HIV/AIDS epidemic focused on “high-risk” groups, such as sex workers, long-distance truck drivers, and soldiers, whose behaviour was constructed as “risky”. This approach places responsibility for change on individuals; it has been criticised because it ignores the social and economic factors that constrain the ability of an individual to change.9, 10, 11, 12

Epidemiology and transmission of malaria, tuberculosis, and HIV infections

Malaria causes more than a million deaths each year worldwide. 90% of the deaths are in sub-Saharan Africa, predominantly in children under 5 years old.1 Malaria is a major cause of poverty and slows economic growth by up to 1·3% per year in endemic countries.17 42 million people are currently estimated to be living with HIV/AIDS. 95% of them are in less developed countries, particularly sub-Saharan Africa.18 In 2002 alone, 5 million people were thought to have become infected with HIV (2

Age

The degree of malaria immunity acquired by individuals living in endemic areas depends on the amount of exposure to infections and genetically determined immunological responses.20 In areas of high stable transmission of malaria, the incidence of clinical malaria peaks between 1 and 5 years of age, then declines rapidly as effective immune responses develop.17, 21 In these areas, 25% of all-cause mortality in children aged 0–4 years has been attributed to malaria.22 Where malaria transmission

Malaria and HIV/AIDS

Despite initial studies suggesting no association between malaria and HIV infection, there is emerging evidence of an important relation, particularly in pregnant women. HIV infection may interfere with pregnancy-specific immunity acquired during first and second pregnancies and increases the chance of parasitaemia and placental malaria.61, 62 The efficacy of intermittent two-dose sulfadoxine/pyrimethamine treatment is decreased in HIV-infected pregnant women, and they may require more frequent

Poverty

Poverty and disease are commonly linked in a downward spiral. Poverty increases vulnerability to malaria, tuberculosis, and HIV infection, and the ill-health and treatment costs associated with the diseases themselves lead to further impoverishment. Although poverty is a complex experience involving a lack of key capital assets (natural, financial, physical, human, and social), it is commonly viewed simplistically in economic terms with low income as a proxy indicator.83, 84 Ideally,

Search strategy and selection criteria

Quantitative, qualitative, and anecdotal evidence, predominantly since 1980 and relevant to less developed countries, was gathered from key informant interviews and hand and web-based literature searches. Web-based academic search engines used were: Bids, Ingenta, ISI Web of Science, Medline/PubMed, and BIDS-Psychinfo. Initial search terms included: “malaria”, “tuberculosis”, “HIV/AIDS”, and “vulnerability”, “malnutrition”, “poverty”, “gender”, “risk or risk factor”, “susceptibility”,

References (174)

  • EL Corbett et al.

    HIV-1/AIDS and the control of other infectious diseases in Africa

    Lancet

    (2002)
  • JL Antunes et al.

    The impact of AIDS, immigration and housing overcrowding on tuberculosis deaths in Sao Paulo, Brazil, 1994–1998

    Soc Sci Med

    (2001)
  • KM De Cock et al.

    Preventive therapy for tuberculosis in HIV-infected persons: international recommendations, research, and practice

    Lancet

    (1995)
  • SE Clarke et al.

    Do untreated bednets protect against malaria?

    Trans R Soc Trop Med Hyg

    (2001)
  • TA Ghebreyesus et al.

    Household risk factors for malaria among children in the Ethiopian highlands

    Trans R Soc Trop Med Hyg

    (2000)
  • F Barnhoorn et al.

    In search of factors responsible for noncompliance among tuberculosis patients in Wardha District, India

    Soc Sci Med

    (1992)
  • A Khan et al.

    Tuberculosis in Pakistan: socio-cultural constraints and opportunities in treatment

    Soc Sci Med

    (2000)
  • E Johansson et al.

    Gender and tuberculosis control: perspectives on health seeking behaviour among men and women in Vietnam

    Health Policy

    (2000)
  • H Sawert et al.

    Costs and benefits of improving tuberculosis control: the case of Thailand

    Soc Sci Med

    (1997)

  • Report on infectious diseases: scaling up the response to infectious diseases

    (2002)

  • Macroeconomics and health: investing in health for economic development

    (2001)
  • MB Anderson et al.

    Rising from the ashes: development strategies in times of disaster

    (1998)
  • J Lewis

    Development in disaster prone places: studies in vulnerability

    (1999)
  • T Barnett et al.

    The Jaipur paradigm: a conceptual framework for understanding social susceptibility and vulnerability to HIV

    S Afr Med J

    (2000)
  • P Blaikie et al.

    At risk: natural hazards, people's vulnerability, and disasters

    (1994)
  • B Obrist et al.

    Risk and vulnerability: some conceptual considerations. Input paper IP4: health and well-being

    NCCR Integrated Training Course

    (Sept 9–20, 2002)
  • JR Oppong

    A vulnerability interpretation of the geography of HIV/AIDS in Ghana, 1986–1995

    Prof Geogr

    (1998)
  • AJ McMichael

    The health of persons, populations, and planets: epidemiology comes full circle

    Epidemiology

    (1995)
  • K Carovana

    More than mothers and whores: redefining the AIDS prevention needs of women

    Int J Health Serv

    (1991)
  • C Patten

    With champagne and roses: women at risk from/in AIDS discourse

    (1993)
  • K De Koning et al.

    The concept of ‘high risk groups’ in research for sex work

  • Women, gender and HIV/AIDS in east and southwest Asia: what is vulnerability to HIV?

    (2002)
  • J Twigg et al.

    Understanding vulnerability: an introduction

  • G Bankoff

    Rendering the world unsafe: ‘vulnerability’ as western discourse

    Disasters

    (2001)
  • J Sachs et al.

    The economic and social burden of malaria

    Nature

    (2002)

  • AIDS epidemic update

    (2002)
  • PT Sharp et al.

    Malaria and growth stunting in young children of the highlands of Papua New Guinea

    P N G Med J

    (1980)
  • RW Snow et al.

    Estimating mortality, morbidity and disability due to malaria among Africa's non-pregnant population

    Bull World Health Organ

    (1999)
  • I Kleinschmidt et al.

    Patterns in age-specific malaria incidence in a population exposed to low levels of malaria transmission intensity

    Trop Med Int Health

    (2001)
  • A Kochi

    The global tuberculosis situation and the new control strategy of the World Health Organization

    Bull World Health Organ

    (2001)
  • A van Rie et al.

    Childhood tuberculosis in an urban population in South Africa: burden and risk factor

    Arch Dis Child

    (1999)
  • AB Curtis et al.

    Extensive transmission of Mycobacterium tuberculosis from a child

    N Engl J Med

    (1999)
  • CF Gilks et al.

    Sexual health and health care: care and support for people with HIV/AIDS in resource poor settings: occasional paper

    (1998)
  • T Beattie et al.

    HIV-1 and AIDS: what are protective immune responses?

    J HIV Ther

    (2002)
  • CM Hogan et al.

    Host determinants in HIV infection and disease: part 1, cellular and humoral immune responses

    Ann Intern Med

    (2001)
  • C Vlassoff et al.

    Gender-related differences in the impact of tropical diseases on women: what do we know?

    J Biosoc Sci

    (1994)
  • M Uplekar et al.

    Gender and tuberculosis control: towards a strategy for research and action. 2000

  • CB Holmes et al.

    A review of sex differences in the epidemiology of tuberculosis

    Int J Tuberc Lung Dis

    (1998)
  • A Thorson et al.

    Gender inequalities in tuberculosis: aspects of infection, notification rates, and compliance

    Curr Opin Pulm Med

    (2001)
  • MW Borgdorff et al.

    Gender and tuberculosis: a comparison of prevalence surveys with notification data to explore sex differences in case detection

    Int J Tuberc Lung Dis

    (2000)

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