The study was carried out in the internal medicine departments of the Carnot District Hospital, the Infectious and Tropical Diseases Department of the Friendship University Hospital and the Internal Medicine Department of the Bangui Community Hospital. It was a descriptive and analytical cross-sectional study, covering the period from 1^st March 2021 to 30^th September 2021.

It consisted of all PLHIV admitted to hospital during the study period. The sampling was exhaustive, we included all patients under ARV treatment dated at least 1 month and hospitalized in the three care centers.

We included all PHAS aged 18 years and older, who had been treated with ARVs for one month or more and admitted to hospital during the study period. Malnourished patients are defined by body mass index (BMI) < 18.5 kg/m².

Hospitalized HIV-positive people whose medical records did not contain either the CD4 count or the HIV CV were not included in the study.

Data were collected using an anonymous questionnaire following the interview, the clinical examination of the patient and the use if the medical record following informed consent. For each patient included, we collected sociodemographic, clinical and biological data. The dependent variable was the occurrence of malnutrition in PLHIV, and the independent variables were the sociodemographic characteristics of the patients (age, sex, level of education, profession, and origin), clinical parameters (history/background, BMI, ART line, duration under ARV treatment) and paraclinical parameters (CD4, blood count, viral load).

The implementation of the study has received prior authorization from the Ethics and Scientific Committee of the Faculty of Health Sciences of the University of Bangui. Data entry and analysis were carried out using the EPI-info 7 software. The Odds Ratio (OR) with 95% confidence interval (CI) was used to measure the strength of the association.

During our study, 123 malnourished PLHIV were collected out of a total of 205 hospitalized PLHIV, representing a prevalence of 60%. The frequencies of malnutrition were 38% in women, versus 22% in men. The average age of our sample was 37.8 ± 10.6 years. This average age was 36.7 ± 10.3 years for the group of malnourished PLHIV. The sex ratio was 0.7. The average household size was 5 people. The average BMI of patients was 17.6 ± 3.1 kg/m². The median CD4 count was 208 cells/mm³. The median duration of infection since diagnosis was 36 months. Data on sociodemographic and clinical characteristics are reported in Table1 and Table2.

There were statistically significant associations between the occurrence of malnutrition, age < 36 years (p = 0.02; OR = 2 [1.1 - 3.4]), duration of antiretroviral treatment < 12 months (p = 0.03; OR = 2 [1.1 - 3.4]), WHO VIH stage III and IV (p = 0.03; OR = 3.3 [1.1 - 10]), tuberculosis (p = 0.01; OR = 2.1 [1.2 - 3.9]), hemoglobin < 12 g/dl (p = 0.02; OR = 2.3 [1.2 - 4.5]). We observed a significant difference between the occurrence of malnutrition and neuromeningeal cryptococcosis (p = 0.01), TCD4 Lymphocytes 0 - 49/mm³ (p = 0.00; OR = 2.4 [1.5 - 3.5]), 50 - 199/mm³ (p = 0.00; OR = 3.6 [1.6 - 8.2]), 350 - 499 mm³ (p = 0.00; OR = 5.6 [1.7 - 17.8]), HIV viral load deleted (p = 0.00; OR = 6.5 [1.7 - 24.5]), HIV viral load detectable(p = 0.00; OR = 105 [28.4 - 388.4]). The frequency of malnutrition is very high in HIV-positive people who have been put on a combination based on 2INRT + DTG or EFV than those on 2INRT + LPV-r or ATV-r without significant difference (Table 3).

Table 1.Sociodemographic characteristics of study participants, recruited during hospitalization in the infectious and tropical diseases departments of the Amitié University Hospital and the Internal Medicine Departments of Carnot District Hospital and the Bangui Community University Hospital from March 1^st, 2021 to September 30th, 2021.

Table 2.Clinical characteristics of study participants, recruited during hospitalization in the infectious and tropical diseases departments of the Amitié University Hospital and the Internal Medicine Departments of Carnot District Hospital and the Bangui Community University Hospital from March 1^st, 2021 to September 30^th, 2021.

Possible combinations of 2INRT according to the national CAR protocol: TDF + 3TC or TDF + FTC or ABC + 3TC.

Table 3.Relationship between the occurrence of malnutrition and the sociodemographic, clinical and paraclinical characteristics of the study participants, recruited during hospitalization in the infectious and tropical diseases departments of the Amitié University Hospital and the Internal Medicine Departments of Carnot District Hospital and the Bangui Community University Hospital from March 1^st, 2021 to September 30^th, 2021.

In CAR, given the excessive cost of caring for PLHIV, a policy to facilitate access to care has been implemented. This is based on free medication and partial subsidy of biological monitoring tests [11]. However, it is not uncommon to observe malnutrition in PLHIV despite antiretroviral treatment [12]. Our study aimed to determine in a multicenter manner the factors associated with malnutrition in hospitalized PLVIH undergoing ARV treatment. In our study, it appears that malnutrition was in 60% of patients. This situation constitutes a major public health problem care in a country where the majority of the population lives on less than a dollar a day and where social security is almost non-existent. Our prevalence was higher than those reported in Brazil Nigeria and Benin by 5.5%, 5.8% and 7.87%, respectively [13]-[15]. This frequency was observed, lower than that reported in Guinea by 79.6%. This difference could be explained by the variation in the endemicity of the disease from one region to another and the disparity of the selection criteria used in the different series. We noted a predominance in women (60.5%). Our frequency is higher than that reported in Brazil of 7.6% [13]. These results confirm those of the MICS 2018-2019 survey in CAR, which reported a female predominance in 45.5%. According to the same survey, just over one in ten women aged 15 - 49 (12.3%) have in-depth knowledge of HIV. Added to this are the natural anatomical predispositions of women to a higher risk, frequent genital infections and the higher HIV screening rate for women compared to men. [16]. The patients were mostly young adults with an average age of 37.8 years. The predominance of young adults is probably explained by the precocity of sexual intercourse in adolescence. This situation can be explained by the fact that the Central African population is essentially young with 61% of the population under 20 years old [16]. In CAR, HIV infection is a generalized epidemic affecting all social classes. The average household size in our study was 5. These results are close to the national average, which was 5.6 according to the MICS survey. In our series, more than half (54.6%) of patients lived as a couple. This result confirms that of the 2018-2019 MICS survey which showed a predominance of couples in 68.5% [16]. This could be explained by the early marriage among young people who constitute the highest age group.

It is possible to reduce the proportion of PLVIH in state of malnutrition by combatting the factors associated with it. According to the literature, there are several factors associated with malnutrition in PLHIV, namely: low socioeconomic and educational level, poor eating habit, insufficient food intake and opportunistic infections [17]. In our study, the presumptive factors for malnutrition were: age < 36 years, duration of antiretroviral treatment less than one year, WHO stages III and IV, tuberculosis, hemoglobin level less than 12 g/dl, profound immunosuppression and detectable viral load. On the other hand, we found a difference between the occurrence of malnutrition and neuromeningeal cryptococcosis. Regarding age, Kenyan and Senegalese authors had reported an association between younger age and malnutrition [18][19]. This situation could be correlated with the essentially young population exposing the latter to a high risk of extreme poverty with consequent malnutrition. The association between treatment duration of less than one year and malnutrition was also found by authors in sub-Saharan Africa in Benin [15]. In our study, we observed that patients with WHO stages III and IV had 3 times more risk of malnutrition. On the other hand, the Guinean, Senegalese and Ethiopian authors had found WHO stage IV [10][20]. According to the literature, infection or inflammation secondary to malnutrition leads to secretion of TNF and IL-6 which causes a decrease in erythropoiesis as well as a possible decrease in erythropoietin secretion [21]. The risks of malnutrition were higher in cases of immunosuppression. This trend has been reported in several studies [3][10][20]. This could be explained by the fact that the decrease in immunity exposes HIV-positive people more to opportunistic infections including diarrhea, esophageal candidiasis responsible for a decrease in intestinal intake and absorption but also intense inflammatory activity. We also observed that detectable HIV viral load is a risk factor for the occurrence of malnutrition. This situation can be explained by the fact that an acceleration of viral replication leads to an invasion of cells in the intestine, brain and other organs of the body. This situation affects nutritional status by decreasing food intake and absorption of nutrients and increasing the use and excretion of proteins and micronutrients [7].

Our study was conducted in resource-limited context where access to certain biological tests is problematic, especially in rural areas, making it impossible to perform certain biological markers of malnutrition. Our study concerns hospitalized HIV-positive people, sometimes in a comatose state, whose questioning is problematic. According to the literature, many authors report household size, education level and number of meals as the main factors of malnutrition among PLHIV. The financial difficulties in carrying out certain biological tests (transaminases, creatinine, CD4 T cells and sedimentation rates) did not allow for exhaustive data to be obtained. This resulted in limiting the number of patients to those who had a strict minimum of data to be included. Despite these difficulties, our objective was achieved with the determination of the main factors causing malnutrition in PLHIV.