The Brazilian National STD/AIDS Program is recognized worldwide as a successful example of a nationally integrated HIV/AIDS prevention, medical care, and antiretroviral treatment strategy. From 1996, when HAART was introduced and guaranteed free of cost to every Brazilian in need, the number of patients receiving HAART continuously increased in Brazil, reaching around 200,000 patients with top-of-the-line antiretroviral drugs in 2010 
. AIDS incidence subsequently stabilized and mortality declined 
. As a consequence, the wasting syndrome has become a less frequent clinical concern and the nutritional management of patients with AIDS has been largely directed to the lipodystrophy and metabolic alterations associated with HAART 
. This study is one of the first in Brazil to describe the prevalence of nutritional deficiencies in hospitalized patients in the era of HAART. Cross-sectional studies have shown the prevalence of malnutrition in Brazilian outpatients with HIV to be 3–6% 
. Our findings show that malnutrition remains an important public health problem among patients hospitalized with AIDS, affecting 43% of those admitted to the public reference hospital for infectious diseases in Brazil’s third largest city. In fact, our results may underestimate the burden of malnutrition at hospitalization because we did not include patients with more severe disease presentation, such as those with cognitive impairment and immediate intensive care requirement.
Reasons for AIDS-related hospitalization are diverse and may include late diagnosis, non-adherence or poor access to HAART, and clinical failure of treatment. Our results showed that one-third of our patients were first informed of their HIV disease during the current hospitalization and a large proportion of those with known HIV disease at admission had been hospitalized previously. Although a majority of the patients who knew about their HIV infection before hospitalization reported prior use of HAART, most HAART users reported at least one recent interruption in therapy. These results suggest that strategic improvements to Brazil’s national AIDS program need to address early testing and treatment adherence among marginalized populations.
Older age and daily per capita
household income <USD 2.00 were independently associated with malnutrition at hospitalization. We also found that prior or current HAART use was statistically associated with higher CD4 cell count and lower viral load, but neither HAART use nor CD4 cell count was associated with malnutrition. These findings may be due to the fact that this patient population had both inconsistent HAART use and a median CD4 cell count below a level protective against malnutrition. Additionally, we did not find an association between malnutrition and tuberculosis, which was identified in one-third of the patients in our study. Malnutrition in HIV-infected persons is a well-described risk for reactivation and primary progression of tuberculosis, and conversely, tuberculosis itself may result in malnutrition 
. The absence of an association between CD4 cell count, prior or current HAART use, and certain medical conditions (e.g., tuberculosis) with malnutrition suggests that the effect of poverty on nutritional status in HIV may not necessarily be mediated by comorbidities. The mechanisms by which poverty increases the likelihood of malnutrition in HIV and non-HIV populations have been studied in other settings 
. It is critical that future studies elucidate the mechanisms between poverty and malnutrition in Brazil and advance our understanding of how to develop effective interventions.
We found an increased prevalence of malnutrition among patients with chronic diarrhea in the univariate analysis. This association might have achieved statistical significance in the multivariable analysis if we had a larger patient sample. While access to effective antiretroviral therapy remains the foundation of HIV treatment strategies, our results suggest that AIDS-related morbidity may be further reduced by renewed attention to chronic diarrhea as a clinical condition that contributes to malnutrition. HIV-related enteropathy reduces the immunologic capacity of the gastrointestinal tract and results in villous atrophy 
, which leads to diarrhea and malabsorption. This process can be further aggravated by opportunistic enteric pathogens 
This study was not designed to characterize the relationship between malnutrition and the requirement for hospitalization in patients with AIDS, nor was it developed to evaluate the impact of malnutrition on the risk of death. We nonetheless identified a trend toward a higher in-hospital case fatality ratio among patients with malnutrition. This finding is in accordance with current evidence about the importance of good nutrition on survival of patients with HIV 
. Future studies are needed to determine the best nutritional interventions to decrease the burden of deaths in malnourished patients with advanced HIV disease.
Three public hospitals each accounted for approximately one-third of the AIDS hospitalizations in Salvador during 2009–2010: the study hospital (32% of hospitalizations), a state general hospital (33%) and a university hospital (31%) 
. All three provided specialized ambulatory AIDS care during the study period. However, only the study hospital and the state general hospital provided 24-hour open-door emergency services. Because patients may either be referred for hospitalization by providers or they may self-present to hospital, those admitted to the study hospital and to the state general hospital are probably more representative of patients with AIDS requiring inpatient care in Salvador. While the study population is probably similar to those at other open-door public hospitals in Brazil, it may not represent AIDS-related admissions throughout the country, particularly those at private institutions.
This study has other limitations. We relied on patient recall for retrospective ascertainment of clinical data, including the patient’s weight six months prior to hospitalization and the year of first patient knowledge of HIV disease. Some patients may have confused the distinction between an initial notification of HIV infection and a subsequent AIDS diagnosis. Further, given the delay in diagnosis seen in this patient population, this variable probably does not accurately reflect duration of HIV disease. We applied anthropometric measurements to define body fat and muscle mass. Anthropometrics are rough indicators of body composition and are less precise than other methods (e.g., bioelectrical impedance). However, they are sufficiently accurate for assessing the public health burden of malnutrition 
, as was the aim of this study. Lastly, for bed-bound participants we estimated height and weight to calculate BMI, which could have misclassified some patients by nutritional status.
Our patient population demonstrated a high level of malnutrition and weight loss at hospital admission in a country long considered to be an international model for HIV care. These results point to substantially unmet nutritional needs for a sizeable group of Brazilians hospitalized with AIDS. They should further reinforce for clinicians the importance of performing nutritional evaluations and simple body composition studies in all patients with HIV 
, as malnutrition is a modifiable predictor of death in these individuals 
. Improving early testing and HAART adherence strategies, especially for vulnerable populations, may continue to help reduce AIDS-related morbidity and mortality in Brazil. It is nonetheless also critical to identify new methods for interrupting the cycle of poverty, HIV, and malnutrition.