Poor sleep quality and associated factors among people attending anti-retroviral treatment clinic at Finote selam general hospital, Amhara, Ethiopia.

Objective: to assess the prevalence and associated factors of poor sleep quality in adults with Human Immuno Virus Syndrome who attended an Anti-Retro-Viral Treatment clinic at Finote Selam General Hospital in Amhara, Ethiopia, in 2021.
Methods: A Hospital based cross sectional study was conducted from October 15 to November 2020 and systematic random sampling technique was used to select sample size of 399 study subjects. Sleep Quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). The data was entered to Epi data version 4.2 and analysis was done with SPSS version 25.0 software. Binary logistic regression technique was employed and variables with p-value less than 0.25 in the Bi-variable analysis were entered to the multivariable analysis. Odds ratio with 95% Confidence Interval was calculated and statistical significance was declared at P-values < 0.05.
Results: The prevalence of poor quality of sleep among PLWHA was 55.1% [95% CI: 50.1-60.2] 0.12 months duration of HIV diagnosis [AOR = 4.02,95% CI: (1.604, 10.070)], CD4 count<200 cells/mm3 [AOR = 2.76,95% CI: (1.189,6.408)]. Viral load >1000 copies [AOR = 3.41, 95% CI: (1.384, 8.417)]and having depression [AOR = 2.06, 95% CI: (1.056, 4.019)] were factors significantly associated with poor sleep quality.
Conclusion: In this study, it was discovered that above 50% of people living with HIV/AIDS had poor sleep quality. It is critical to reduce prevalence by developing prevention and intervention strategies that address the identified factors.

Introduction

Sleep quality refers to how long and how well an individual sleeps each night. It also includes how difficult it was for a person to fall asleep, stay asleep, and how many times he or she woke up during the night. Furthermore, it was a feeling of being rested and refreshed after waking up from a deep sleep. A good sleep quality was an indicator of wellbeing, whereas a poor sleep quality leads to increased co-morbidity, mortality, health-care costs, and a poor quality of life in people living with HIV (PLWH) [1,2].

Sleep disorders were common problems that were reported in 10%–40% of the general population. These issues can have an impact on one's quality of life, physical and social functioning, and even cause chronic fatigue. Sleep disorders were also more prevalent in people living with HIV than in the general population, with prevalence ranging from 30% to 100% depending on the definition and methodology used [[3], [4], [5], [6], [7]].

Alterations in sleep structure were one of the earliest and most consistent physiologic changes reported in people infected with the human immunodeficiency virus (HIV). Despite the fact that sleep disturbances were reported to be common among HIV-positive patients, they were especially/still sensitive to poor sleep quality due to a variety of biological reasons. HIV infection of the central nervous system (CNS), CNS opportunistic infections, substance abuse, antiretroviral (ARV) side effects, medical co morbidity, and immunological dysfunction are among these causes [8,9].

Most of the body's systems were in an anabolic condition during sleep, assisting in the restoration of the immune, neurological, skeletal, and muscular systems, all of which are crucial processes in maintaining mood, memory, and cognitive function, as well as other daily functions. PLWHA's quality of life, cognitive function, and emotion are all affected by sleep problems, which can contribute to poor medication adherence. It can also cause a variety of negative effects in HIV/AIDS patients, including as decreased health-related quality of life, increased daytime sleepiness, and cognitive impairment [[10], [11], [12], [13]].

Poor sleep quality has been linked to disease progression, medication side effects, financial concerns, unemployment, and a lack of knowledge about sleep-enhancing behaviors in the HIV-infected population. It may also result in a weakened immune system, decreased physical performance, impaired cell growth and repair, deteriorated neuronal connections and neuronal malfunctions, and an increase in the risk of cardiovascular morbidity and mortality, as well as the degree of suffering associated with psychiatric disorders [10,[14], [15], [16]].

Poor sleep has been linked to disease progression, medication non-adherence, and unemployment among HIV patients. Individuals whose ARV non-adherence was partly due to sleep problems may benefit from early detection and treatment of sleep disorders, which may improve ARV adherence and reduce non-adherence effects [[17], [18], [19], [20]].

According to the findings, those living with HIV not only had poor sleep quality, but they also had more acute and distressing symptoms. As a result of the sadness associated with HIV, such people were less likely to stick to their antiretroviral drug regimens. Noncompliance can lead to disease progression, the formation of resistant strains, and treatment failure, as well as sleep difficulties that can affect their quality of life and work performance. Determining the quality of sleep and its effects may aid in the prevention of HIV-related problems or the use of antiretroviral therapy (ART) [6,15,21,22].

Even though the prevalence of sleep disorder in PLWHA was high in different countries with a wide range of medical and psychological complications, there was no adequate information on the prevalence and associated factors of sleep quality among adult PLWHA in Ethiopia. As a result, this study attempted to fill these gaps by assessing the prevalence and associated factors of sleep quality in adults receiving ART at Finote Selam Hospital.

Methods and materials

Study area

The study was conducted at Finote Selam General Hospital at ART clinic. Finote selam town was found in west Gojjam zone, Amhara regional state. It was capital city of west Gojjam zone, which was found at 387 Km from Addis Ababa, 176 Km from Bihar Dar. Finote Selam General Hospital is, currently works with 375 staffs from these 235 of them were clinical staffs, and 100 of them were supportive staffs and 40 of them were in different training programmes. The Hospital serves for more than 1.5 to 2.0 million populations in the catchment area. The hospital was built in 1954 as Tuberculosis and leprosy center in west Gojjam. It becomes a hospital since 1972 E C and started ART service since 1998 E C. At the time of study conducted, there were around 1890 clients on ART service.

Study design and period

The study was conducted from October to November 2020, using an institution-based cross-sectional study design.

Inclusion and exclusion criteria

All adults aged 18 and up who attended an ART clinic at Finote Selam General Hospital during the data collection period were included in the study, but ART patients who were seriously ill and unable to communicate were excluded.

Sample size determination

The sample size was calculated using the single population proportion calculation with a 95% confidence interval, a 5% margin of error, and the prevalence of poor sleeping quality among HIV/ADIS patients (p = 55.6%) from a study conducted at Zewditu Memorial Hospital in Addis Ababa, Ethiopia [23]. The required sample size was calculated as follows: n = (Z/2) 2p (1-p)/d2 (Kelsey, 1996), n= (1.96)2(0.556) (1–0.556)/(0.05)2 = 379; adding a 10% non-response rate, the required sample size was calculated as 417 study individuals.

Sampling procedures

417 patients were chosen using a systematic sampling technique. The sampling interval was calculated by dividing the total population of the study by the sample size. The total number of ART patients currently enrolled in ART services was 1902. Approximately 880 of them were followed up on during the average 1-month data collection period. This was due to a problem with covid-19 and a model known as appointment spacing. The sampling interval (K) was set at two. The first study participant was chosen by lottery method.

Data quality assurance

By reviewing the literature on similar studies on sleeping quality, the questionnaire was adapted. The questionnaire was first written in English, then translated into Amharic (local languages), and finally retranslated back into English to ensure consistency. Three data collectors and one data collection supervisor were received one day of training on the study instrument, data collection procedures, and ethical confidentiality principles. Before the actual data collection period, a pretest was conducted on 5% of the sample size (21 study participants) to check the clarity, flow, cultural, and moral fitness of the questionnaires, as well as the time required to fill them in Bure Asrade Memorial Hospital. Each day of the data collection period, the collected data was checked for completeness and consistency.

Data collection procedures and tools

The questionnaire includes questions about respondents' sociodemographic characteristics, sleep quality, clinical factors, substance use, anxiety and depression, environmental factors, HIV-related perceived stigma, and social support. The Pittsburgh Sleep Quality Index (PSQI), a 19-item self-rated scale that examined Sleep Quality and disturbances over a 1-month period, was used to assess sleep quality [23]. This tool primarily addresses seven sleep components in the last month: sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction. The total PSQI score was calculated by adding the seven component scores, yielding a score ranging from 0 to 21. A score of more than 5 points indicates poor sleep quality. Anxiety and depression were assessed using the hospital anxiety and depression scale (HADS) [24]. The use of any substance in the previous three months was used to assess current substance use. If a study participant used any substance at least once in his or her lifetime, the substance's ever use was assessed. The Oslo-3 scale is used to assess social support. Individuals with scores of 3–8, 9–11, and 12–14 on the scale were classified as having poor, moderate, or strong social support, respectively [25]. The 12 items HIV-related perceived stigma assessment tool was used to assess stigma [26]. Three data collectors conducted face-to-face interviews in the adult ART Out Patient Department over a one-month period. One supervisor was in charge of monitoring the data collection process.

Data processing and analysis

Data were cheeked for completeness, consistency and entered using Epi-Data version 4.2. Then data were exported to SPSS version 25.0 for further analysis. Descriptive results were described in terms of tables, graph and texts. Binary logistic regression technique was used and Variables with less than 0.25 p-values in the bivariable analysis were fitted to the multivariable analysis. Odds ratio with 95% CI was calculated and statistical significance was considered at P-values <0.05 in the multivariable analysis. Model fitness was checked by using Hosmer and lemeshow test.

Ethical consideration

The Ethical Review Committee (ERC) of Debre Markos University College of Health Sciences provided an ethical clearance letter. The purpose of the study was explained to the respondents, and written consent was obtained from each study participant. The respondents' right to refuse or withdraw from the study was fully respected, and the information provided by each respondent was strictly kept confidential.

Results

Socio-demographic characteristic

A total of 399 people were included in the study, with a 95.7% response rate. Among the respondents, 260 (65.2%) were females, and 358 (89.7%) were followers of the orthodox religion. The respondents' mean age was 41.58 years with a standard deviation of 10.12 years, 164 (41.1%) were married, and almost all 383 (97%) were Amhara by ethnicity. Nearly 128 (32.1%) of respondents had a primary education, and 103 (25.8%) worked as merchants. Two hundred twenty-six (226) (56.6%) of those polled had a monthly income of more than 1656 Ethiopian Birr (ETB). (Table 1).

Table 1

Socio-demographic characteristics of adults with HIV/AIDS attending ART clinic in Finote Selam General Hospital, Amhara, Ethiopia, 2020. (n = 399).

Variable	Category	Frequency	Percentage
Age	18–24	9	2.3
	25–54	337	84.5
	55–64	49	12.3
	≥65	4	1
Sex	Male	139	34.8
	Female	260	66.2
Religion	Muslim	32	8
	Orthodox	358	89.7
	Protestant	9	2.3
Marital status	Single	83	20.8
	Married	164	41
	Divorced	118	29.6
	Widowed	34	8.5
Ethnicity	Amhara	383	96
	Oromo	12	3
	Other	4	1
Educational status	Unable to read and write	125	31.3
	Primary	128	32.1
	Secondary	70	17.5
	Tertiary and above	76	19
Occupation	Civil servant	63	18.1
	Merchant	103	29.5
	Farmer	32	8
	Daily labor	61	15.3
	House wife	82	20.6
	Others	58	14.5
Monthly income	<1656ETB	173	43.4
	≥1656ETB	226	55.6

Other job status includes Drivers, Students, NGO, Female Sex worker, carpenter, Retires, Jobless and beggar.

Clinical characteristics of the respondents

Among 399 respondents, 230 (57.6.6%) were in WHO clinical stage I, 315 (78.9%) had more than 12 months of HIV diagnosis, 305 (76.4%) had a CD4 count of more than 200 cells/mm3, 359 (90%) were on first line ART drugs, 60 (15%) had chronic medical illness, 260 (65.2%) had an appointment spacing system, and 355 (89%) had no opportunistic infection (Table 2).

Table 2

HIV related clinical characteristics of adults with HIV/AIDS attending ART clinic in Finote General Selam Hospital, Amhara, Ethiopia, 2020 (n = 399).

Variable	Category	Frequency	Percentage
WHO clinical Stage	Stage I	230	57.6
	Stage II	94	23.6
	Stage III	70	17.5
	Stage IV	5	1.3
duration since HIV diagnosis	<12 months	84	21.1
	>12 months	315	78.9
Cd4 Count	<200 counts	94	23.6
	>200 counts	305	76.4
ART regimen type	first line regimen	359	90
	Second line regimen	40	10
Chronic medical illness	Yes	60	15.0
	No	339	85.0
Types of chronic medical conditions	Hypertension	13	21.7
	Diabetes mellitus	10	16.7
	Cardiac	7	11.7
	Tuberculosis	10	16.7
	Asthma	16	26.7
	Cancer	4	6.7
Appointment spacing	Yes	260	65.2
	No	139	34.8
Viral load count	≥1000	64	16.0
	<1000	335	84.0
Drug adherence	Good	355	89.0
	Fair/not good	44	11
Body Mass Index	Normal	298	74.4
	Over nourished	67	16.8
	Under nourished	34	8.5
Presence of Opportunistic Infection	Yes	82	20.6
	No	317	79.4

Psycho-social characteristics of the participants

According to the Hospital Anxiety and Depression Scale, 107 (26%) of the respondents reported anxiety, and 148 (37.1%) had depression. (Fig. 1).

Fig. 1

Anxiety and depression among adults with HIV/AIDS attending ART clinic in Finote Selam General Hospital, Amhara, Ethiopia, 2020. (n = 399).

Poor social support and strong were found in 177 (44.4%) and 75 (18.8%) of the total respondents, respectively. (Fig. 2). Stigma had experienced by 181 (45.4%) of the participants.

Fig. 2

Social support among adults with HIV/AIDS attending ART clinic in Finote General Selam Hospital, Amhara, Ethiopia, 2020. (n = 399).

Behavioral/substance usage characteristics of respondents

Among 399 study participants, 112 (28.1%) were current alcoholic users and 30(7.5%) were current Khat chewers (Fig. 3).

Fig. 3

Types of substances used by study participants among adults with HIV/AIDS attending ART clinic in Finote Selam General Hospital, Amhara, Ethiopia, 2020. (n = 399).

Prevalence of poor sleep quality

The prevalence of poor sleep quality among PLWHA was 55.1% [95% CI: 50.1–60.2]. The overall sleep quality mean score was 6.13 with Standard deviation of ±2.81. (Table 3).

Table 3

Distribution of the Pittsburgh Sleep Quality Index components among adults on HAART in Finote Selam General hospital Amhara, Ethiopia,2021(n = 399).

Components	Mean with S. D
C-1 Subjective sleep quality	0.91 ± 0.68
C-2 Sleep latency	1.82 ± 0.91
C-3 Sleep duration	0.90 ± 0.97
C-4 Habitual sleep efficiency	1.10 ± 0.99
C-5 Sleep disturbance	0.84 ± 0.46
C-6 Using sleep medication	0.03 ± 0.20
C-7 Day time dysfunction	0.52 ± 0.52
Over PSQI score	6.13 ± 2.81

Factors associated with poor sleep quality

In bivariable analysis, factors such as sex, monthly income, WHO clinical staging, duration since HIV/AIDS diagnosis, CD4 count, chronic medical illness, appointment spacing, viral load, opportunistic infection, current alcohol, anxiety, depression, and stigma had P values less than 0.25. In a multivariable analysis, variables such as HIV diagnosis duration, CD4 count, viral load, and depression were significantly associated with poor sleep quality with a P-value less than 0.05 (Table 4).

Table 4

Factors associated with poor sleep quality among people living with HIV/AIDS at Finote Selam Hospital, Amhara, Ethiopia, 2021 (n = 399).

Characteristics	Variables	Sleep quality		COR (95% CI)	AOR (95% CI)
		Good	Poor
Sex	Male	68	71	1	1
	Female	111	149	1.29 (0.85,1.94)	1.57(0.96,2.58)
WHO Staging	Stage I	104	126	1	1
	Stage II	49	45	0.76(0.47, 1.23)	0.53 (0.29,0.95)
	Stage III	24	46	1.58 (0.91,2.77)	1.08 (0.49,2.08)
	Stage IV	2	3	1.24(0.20,7.56)	0.44 (0.06,3.51)
Duration Of HIV Diagnosis	<12 months	9	75	9.77(4.73,20.19	4.02 (1.60,10.07) ∗∗
	>12 months	170	145	1
CD4 Count	<200 CD4	13	81	7.44(3.97,13.94)	2.76 (1.19,6.41) ∗
	>200 CD4	166	139	1
Chronic Medical Illness	Yes	17	43	2.32(1.27,4.22)	2.16 (0.18,5.73)
	No	162	177	1	1
Appointment Spacing	Yes	126	134	0.65(0.43,0.99)	0.82(0.49,1.36)
	No	53	86	1	1
Viral Load Count	≥1000	8	56	7.30(3.38,15.78)	3.41(1.38,8.42) ∗
					10.812
					10.812
					10.812
					) ∗∗
	<1000	171	164	1
Stigma	No	109	109	1	1
	Has stigma	70	111	1.59(1.06,2.37)	0.88 (0.53,1.48)
Opportunistic Infection	Yes	30	52	1.54 (0.93,2.54)	0.61(0.26,1.38)
	No	149	168	1	1
Current Alcohol Use	Yes	44	68	1.37(0.88,2.14)	1.45(0.87,2.42)
	No	135	152	1	1
Depression	No depression	134	117	1	1
	Has depression	45	103	2.62 (1.71,4.03)	2.06(1.06,4.02) ∗
Anxiety	No anxiety	142	150	1	1
	Has anxiety	37	70	1.79 (1.13,2.84)	0.725 (0.35,1.51)
Monthly Income	<1656	34	109	1.76(1.18,2.64)	1.49 (0.90,2.47)
	≥1656	115	111	1	1

N.B ∗Indicate P-value <0.05 and ∗∗ indicate P-value <0.005. Hosmer and Lemeshow Test had P-value of 0.79.

The odds of having poor sleep quality among Participants with <12 months duration of HIV diagnosis were 4.02 times higher as compared to those who had >12 months duration of diagnosis was [AOR = 4.02,95% CI: (1.604, 10.070)].

The odds of poor sleep quality among participants with CD4 count less than 200 was 2.76 higher than those with greater than 200 CD4 count [AOR = 2.76,95% CI: (1.189,6.408)].

Respondents with viral load >1000 were 3.41times more likely to have poor sleep quality as compared to those who have <1000 viral load [AOR = 3.41, 95% CI: (1.384, 8.417)].

The odds of developing poor sleep quality among depressed participants were 2.06 higher than those without depression [AOR = 2.06, 95% CI: (1.056, 4.019)].

Discussion

The prevalence of poor sleep quality in PLWHA was 55.1% [95% CI: 50.1, 60.2] in this study. This study's findings were consistent with those of previous studies conducted in Mexico (58.6%) [27], Nigeria at Lagos State University Teaching Hospital (59.31%) [28], and Ethiopia at Zewditu Memorial Hospital (55.6%) [23],Metu hospital (57.1%) [29] and Hawassa Hospital (57.6%) [30].

On the contrary, the prevalence of this study was lower than that of previous studies in the United States, California (68%) [22] and Jimma Town (65.4%) [31]. This variation could be due to a variety of factors, such as different socioeconomic demands and cultural habits among different population groups, as well as the study setting or groups (since in Jimma the study was only conducted on urban populations): because research shows that rural residents are more likely than urban residents to report good levels of sleep quality due to factors such as sleep habits, lifestyle, and stress. This discrepancy might be also due to small sample size, sampling technique and procedure (racial/ethnic minorities) inclusion and exclusion criteria's they used (in the USA study Participation are selected conveniently and bias may occur possibly, as patient with sleep problems may have been more likely to volunteer for the study).

This result was also higher than in studies conducted in Spain (38.2%) [32], China (43.1%) [33], France (47%) [34], Brazil (46%) [35], Iran (47.5%) [36], and Nigeria (46.2%) [37]. The difference in these results could be due to a variety of factors. In China, for example, it could be in socio-cultural characteristics, sampling size, exclusion criteria (pregnant women were not included), and population (most of the respondents were males, married and employed and educated).

In France, the disparity may be due to the fact that study participants were French natives, with more than half of the respondents being male and actively employed. This finding was also higher than in previous studies conducted in Nigeria, where cases of hard drug and alcohol use, depression, and suicidal ideation were excluded from the study, and the majority of respondents were married.

According to this study, patients with a 12-month HIV diagnosis was 4.02 times more likely to have poor sleep quality than those with a longer diagnosis [AOR = 4.02, 95% CI: (1.604, 10.070)]. This could be because this session occurred during a period of highly stigmatized illness and dejection, as well as a loss of self-esteem and the development of all symptoms of depression and normal emotional responses to the reality of living with HIV. These factors may contribute to a higher rate of sleep disturbances in the months following HIV diagnosis. This is also the time when ART drugs are started, which results in ART side effects that can lead to psychological problems. ART side effects undoubtedly increase patients' concerns about their health, resulting in secondary harm to the patient. This finding was supported by research done in Nigeria [28] and Ethiopia, Zewditu Memorial Hospital [23].

In the current study, participants with a CD4 count of 200 cells/L were 2.76 times more likely to develop poor sleep quality than those with a CD4 count greater than 200 cells/L [AOR = 2.76, 95% CI: (1.189, 6.408)]. The reason for this could be that HIV patients' immune systems were directly linked to the mind via a complex network of nerves, hormones, and neuropeptides. As a result, a network of specific physiological pathways enables immune function to have a direct effect on health, such as immune reconstitution inflammatory syndrome (IRIS) in RVI patients and the development of concurrent opportunistic diseases, which exemplifies psychological morbidity and alters sleep pattern. The finding of this study coincides with a study done in Latin America countries [ [27,28,32,33]], Nigeria [37] and Ethiopia, Zewditu Memorial Hospital [23].

Similarly, this study discovered that viral loads ≥1000 copies/ml were a significant factor in developing poor sleep quality among people with HIV/AIDS, with those with <1000 viral loads being 3.41 times more likely to have poor sleep quality [AOR = 3.41, 95% CI: (1.384, 8.417)]. This could be because an increase in viral load in peripheral circulation has been linked to disease progression to the chronic stage, which changes sleep patterns by causing more arousal and waking during sleep periods. A high copy viral load may result in viral treatment failure, whether due to virologic failure, discontinuation of HAART, or loss to follow-up, which increases morbidity and mortality and impairs sleep. This result was consistent with the findings of studies in California [22] and Ethiopia, Dessie [38].

Being depressed was 2.06 times more likely to cause poor sleep quality in people with HIV/AIDS than being non-depressed [AOR = 2.06, 95%, CI: (1.056, 4.019)]. This could be because depressed people have lower levels of serotonin neurotransmitters, which leads to a decrease in cognitive performance, which affects normal sleep patterns. Depression was found to have a directional relationship with sleep disturbances; this is because in depression, the sleep-dependent component of sleep regulation is deficient and does not rise to its normal level. As a result, the amount of slow-wave sleep is reduced, and the sleep period is also shortened. This finding was supported by studies conducted in the China [33] France [34], and Ethiopia [30,31]. Unlike previous Ethiopian studies, clinically significant factors such as social support, age, current khat chewing, and obesity are not associated with this finding. This might be due to in socio cultural and population differences.

Limitation of the study

Some of the reports were based on prior events, which can lead to recall bias. Variables such as alcohol use, khat chewing, and other substances are sensitive issues that may lead to social desirability bias, therefore their use (alcohol, cigarettes, and khat) was not quantified. Because of the cross-sectional study design, this study was unable to establish cause and effect correlations.

Conclusion

The results of this study indicate that sleep disturbances are quite common in people living with HIV. More than half of people living with HIV/AIDS were found to have poor sleep quality in this study. Factors such as; CD4 count <200 cells/μL, viral load ≥1000 copies/ml, short duration of HIV diagnosis, being female and having depression were significantly associated with poor sleep quality. According to the findings of the study, clinicians better to conduct routine screenings for mental health problems such as depression, which leads to poor sleep quality. Clinical service providers better to screen sleep pattern of ART clients and give daily basis health education on prevention and management of sleep pattern problems and have to focus on integration of mental health service with HIV/AIDS program at ART clinic.

Consent for publication

Not applicable.

Availability of data and materials

All the data included in the manuscript can be accessed from the corresponding author with an email address haileleul19@gmail.com.

Funding

There were no grants obtained for the study, which were used mostly for the study's design, analysis, and interpretation of data, as well as the preparation of the report.

CRediT authorship contribution statement

Mihret Adane: Conceptualization, Software, Formal analysis, Investigation, Data curation, Writing – original draft, Writing – review & editing. Haile Amha: Methodology, Formal analysis, Resources, Visualization, Writing – original draft, Writing – review & editing. Yilkal Tafere: Validation, Writing – review & editing, Supervision. Girma Alem: Validation, Supervision, Project administration.

Declaration of competing interest

The authors declare that they have no competing interests.