Poor Sleep Quality and Associated Factors among People Living with HIV/AIDS Attending ART Clinic at Tirunesh Beijing Hospital, Addis Ababa, Ethiopia

Background Sleep is a universal need of all higher life forms, including humans. However, sleep problems are one of the most common problems raised by patients living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Poor sleep quality is one of the hidden and unrecognized factors contributing to poor medication adherence and functional inactivity among people living with human immunodeficiency virus/acquired immunodeficiency syndrome. Methods A hospital-based cross-sectional study was conducted from April 15, 2022, to May 30, 2022, at an antiretroviral therapy (ART) clinic of Tirunesh Beijing Hospital. A systematic sampling technique was used to select study participants. A total of 413 people who are living with human immunodeficiency virus/acquired immunodeficiency syndrome were enrolled in the study. Data were collected through interviews when study participants finished their visit. Variables whose P value was less than 0.2 in bivariable logistic regression were entered into multivariable binary logistic regression to identify factors associated with poor sleep quality. Result The level of poor sleep quality among people living with HIV/AIDS was 73.7%. People living with HIV/AIDS who had poor sleep hygiene were 2.5 times more likely to have poor sleep quality compared with those patients who had good sleep hygiene. Moreover, study participants who had anxiety were three times more likely to have poor sleep quality compared with those who did not have anxiety (AOR: 3.09; 95% CI = 1.61–5.89). Study participants who had chronic diseases in addition to HIV/AIDS were 3 times more likely to have poor sleep quality compared with those who do not have it (AOR: 2.99; 95% CI = 1.15–7.79). Additionally, people living with HIV/AIDS who were stigmatized due to their disease were 2.5 times more likely to have poor sleep quality compared with their counterparts (AOR = 2.49; 95% CI = 1.43–4.21). Conclusion In this study, the magnitude of poor sleep quality among people living with HIV/AIDS was high. Being a farmer, being a merchant, having chronic diseases, having anxiety, having a CD4 count of 200–499 cells/mm3, being stigmatized, and having poor sleep hygiene were factors that had an association with poor sleep quality. Healthcare providers should screen people living with HIV/AIDS for anxiety and encourage them to practice good sleep hygiene during follow-up.


Introduction
Sleep is a universal need of all higher life forms, including humans [1]. Sleep is generated based on a circadian rhythm and homeostatic pressure that follow a period of wakefulness. Sleep helps to modify body temperature, cardiac work, and hormone production, which results in an essential restorative state and proper functioning of the organism [2]. spending more time watching television and using the internet, and disease conditions such as HIV/AIDS [1]. Hence, early recognition of sleep problems via routine assessment and implementation of efective medical and behavioral treatments is necessary to improve functioning and reduce complications [6].
Sleep problems are one of the most common problems raised by patients living with HIV/AIDS. Tis is because of social stigma and adverse efects of antiretroviral medications, such as increased metabolic disturbance and depression [7], opportunistic infections, and a decrement in the immune system [8]. Studies indicated that the magnitude of poor sleep quality is 40% to 100% among people who are living with HIV/ AIDS [9,10]. Adults who get less than seven or eight hours of sleep can experience mental and physical health defcits [3]. Te mental status of PLWHA is often problematic due to depression, anxiety, or other emotional disorders, which are triggered by serious physical symptoms, side efects of medications, fnancial burdens, stigma, and discrimination [11].
Poor quality sleep can have a negative impact on psychological health and result in an impaired immune system, poor medication adherence, physical inactivity, impaired cell growth and repair, and deteriorated neuronal connections [12,13]. Tese increase the health expenses of one's country. In contrast, good sleep quality is associated with better HIV medication adherence, lower HIV symptom severity, and better memory functioning [13]. Poor sleep quality has not only been associated with various diseases but has also led to occupational accidents, poor performance, higher health care utilization, car crash injuries [1], falls, especially in older adults [12,14], and suicidal ideation [15]. Tus, identifying and treating coexisting sleep problems increases medication adherence, improves the immune system, and slows disease progression [16].
Tere are diferent factors, such as the demographic status of the patients, disease characteristics, and substance and alcohol use, that afect the quality of sleep for people living with HIV/AIDS. Among these, because of their bidirectional association, anxiety, and depression are the most common factors associated with poor sleep quality. Poor medication adherence, low CD4 count, type of ART regimen, duration of the disease since diagnosis, and social support are the other prevalent factors associated with poor sleep quality among people living with HIV/AIDS [17][18][19][20]. Efavirenz-based regimens are associated with poor sleep quality since efavirenz causes sleep latency and decreases sleep duration [6].
Te quality of sleep and its associated factors among people living with HIV/AIDS in Ethiopia are not well studied. To increase medication adherence and quality of life, factors that hinder medication adherence and the immune system, such as poor sleep quality, should be detected and managed. Tus, this study was aimed at assessing the quality of sleep and its associated factors among people living with HIV/AIDS at Tirunesh Beijing Hospital's ART Clinic. It has served more than 47,982, 4,990, and 8,589 patients in 2020 in outpatient, inpatient, and emergency departments. It has a total of nearly 350 healthcare providers and 50 administrative staf. Among the total number of healthcare providers, 216 are nurses, and 107 are physicians. Tirunesh Beijing Hospital has an ART clinic in addition to other departments. Tere are 1,057 patients who are living with HIV/AIDS and are on follow-up at the ART Clinic of Tirunesh Beijing Hospital. Tere are 3 nurses and 1 physician working at the ART Clinic. Te ART clinic has a total of 3 rooms. Te study was conducted from April 15, 2022, to May 30, 2022.

Study Design.
A hospital-based cross-sectional study design was conducted.

Population.
All people who are living with HIV/AIDS and are on follow-up at the ART clinic of Tirunesh Beijing Hospital were the source population. All people who were living with HIV/AIDS and on follow-up at the ART clinic of Tirunesh Beijing Hospital during the data collection were considered the study population.

Eligibility Criteria.
All people who are living with HIV/ AIDS and whose age is 18 years or older were included. On the other hand, the seriously ill and those who are unable to communicate were excluded from the study.

Sample Size Determination. Sample size calculation.
Te sample size was calculated using the single population proportion formula with a 95% confdence level, 5% margin of error, and proportion of poor sleep quality among patients living with HIV/AIDS. Proportion, which is 57.6%, was taken from the study conducted on Hawassa [21].

Data Collection
Tool. Data were collected using a structured questionnaire, and a face-to-face interview was used for data collection. Te tool had three parts. Te frst part focused on sociodemographic status; the second part assessed the quality of sleep; and the third part assessed factors associated with poor sleep quality, such as anxiety, depression, physical activity, and sleep hygiene. Sleep quality was measured by the Pittsburgh Sleep Quality Index, which is a standardized tool [22]. It has 19 items with seven components. Component 1 is subjective sleep quality; component 2 is sleep latency; component 3 is sleep duration; component 4 is habitual sleep efciency; component 5 is sleep disturbances; component 6 is the use of sleep medicine; and component 7 is daytime dysfunction. Factors such as anxiety and depression were assessed by the Hospital Anxiety and Depression Scale (HADS). HADS has an anxiety subscale and a depression subscale. Sleep hygiene was assessed by the Sleep Hygiene Index (SHI). It is a tool that has 13-item self-report measures designed to assess the practice of sleep hygiene behaviors. Each item is rated on a fve-point scale ranging from 0 (never) to 4 (always), with a total score of 0 indicating good sleep hygiene and 52 representing poor sleep hygiene. Te Oslo Social Support Scale (OSS) was used to assess the respondent's support system which has 3 items. Te HIV/AIDS-related stigma scale was used to assess stigma. It is a 12-item screening tool. All parts of the questionnaire were initially prepared in English version and translated into Amharic, then back to English to check their consistency.

Data Collection Procedure.
After preparing the questionnaire, 3 nurses who have bachelor's degrees for data collection and a master's degree for supervisory duties were recruited. Two days of training were given for each of them on the meaning of every item of the questionnaire and the techniques of data collection, such as ways of greeting, ways of taking consent, ways of monitoring data quality, and ways of addressing ambiguous items. After this, data were collected through face-to-face exit interviews. To prevent repeated interview, the data collectors verifed whether the client had been interviewed before or not. Additionally, a chart review was conducted to collect data about WHO stage, CD4 count, type of ART medication, height, and weight. Te supervisor and principal investigator closely monitored the data collection process.

Poor Sleep Quality.
Te global score of the PSQI is calculated based on the PSQI scoring manual. Ten, the global score was categorized into poor sleep quality and good sleep quality. Participants who scored above 5 on the Pittsburgh Sleep Quality Index were categorized as having poor sleep quality [23].
Poor sleep hygiene: the median score was computed. Participants who score above or equal to the median score of the sleep hygiene index [24]. Anxiety: individuals with a sum score of ≥8 from the total sum score will be considered as screened positive for anxiety [24,25].
Depression: individuals with a sum score of ≥8 from the total sum score will be considered as screened positive for depression [24,25].

Stigmatized.
After computing the mean score, participants who scored above the mean score of HIV/AIDSrelated stigma were categorized as stigmatized [26].

Data Quality
Control. Te quality of the data was assured at diferent steps. Te frst measure taken to assure data quality is the adoption of a standardized questionnaire. After adoption, it was translated into Amharic and back to English for consistency by experts. Tis is helpful to access quality and accurate data from study participants. Additionally, the data were collected by trained data collectors, and strict supervision was performed while the data were collected. At the end of each data collection, the questionnaires were checked by supervisors for completeness. Te second measure was during coding time, during data entry into software, and during analysis. Te quality of the collected data was reviewed and checked during the data cleaning process by running simple frequency tests after data entry for its consistency. Inconsistent records were checked by referring to the hard copy questionnaire. Moreover, a pretest was made on 5% of the total sample size at Zewuditu Memorial Hospital two weeks before the actual data collection period.

Data Processing and Analysis.
After data collection, completely collected, recoded, and cleaned data were entered into Epidata version 4.1 and exported to Statistical Package and Service Product (SPSS) version 26 for analysis. During analysis, frequency, percentage, and other descriptive statistics were used. Te results of the study were presented using text, tables, and fgures. Te chi-square test and binary logistic regression model were enrolled by considering the 95% confdence level and a P value of 0.05. Multivariable binary logistic regression was done by taking variables that have a P value of ≤0.2 from bivariable logistic regression to identify factors associated with poor sleep quality. Multivariable logistic regression was enrolled by using the backward likelihood ratio method. Te Hosmer and Lemeshow test was utilized to check whether the data ft the model or not before data analysis. Te presence of multicollinearity and the assumption of the chi-square test were checked.

Ethical Consideration.
Ethical clearance was obtained from the Addis Ababa Public Health Research and Emergency Management Directorate prior to starting data collection (Reference No.: A/A/12855/227; Date: 29/07/ 2014.C). Ten, a supportive letter was given to Tirunesh Beijing Hospital. Te purpose and importance of the study were explained, and informed consent was obtained from each participant. Confdentiality was maintained at all levels of the study. To maintain confdentiality, the names of respondents were not registered. Participants' involvement in the study was on a voluntary basis; participants who are unwilling to participate in the study and those who wish to quit their participation at any stage will be informed to do so without any restriction.

Sociodemographic Characteristics of Respondents.
A total of 413 study participants were enrolled in this study. Among these, 388 completed the questionnaire, with a response rate of 93.94%. From a total of 388 study participants, 211 (54.4%) were female. Te mean age of respondents was 39.78 (SD-9.7), and 351 (90.5%) of them were from 25 to 55 years of age. Among the total study participants, 117 (30.2%) were single in their marital status; 103 (26.5%) of them had no permanent job; 79 (20.4%) lived in rural areas; and 58 (14.9%) were farmers. A total of 162 (41.8%) study participants had an educational status of college or above. Slightly above one-tenth (11.6%) of the total study participants had a body mass score of less than 18.5 kg/m 2 (Table 1).

Disease-Related Characteristics.
Of the total study participants, the duration of their disease was above fve years for 190 (49%), and the stage of their disease was above stage one for 72.2% of them. Over one-ffth of the total study participants took second line antiretro viral drugs (ART), and only 5 (1.3%) of them took an efavirenz-based regimen. Te recent CD4 count for 78.6% of study participants was less than 500 cells/mm 3 . Additionally, of the total study participants, nearly one-third (32.7%) had poor or fair drug adherence ( Table 2).

Substance Use.
Among the total study participants, 67 (17.5%) of them had smoked cigarettes in the past month, and 153 (39.4%) of them drank alcohol. Additionally, oneffth (25.5%) of the total study patients had a history of chewing tobacco for the past month (Table 3).

Psychosocial Factors, Sleep Hygiene, and Physical Activity.
Among the total study participants, 329 (84.8%) had anxiety and 351 (90.5%) had depression. Two hundred and forty respondents were stigmatized, and 239 (61.6%) got poor social support. A total of 199 (51.3%) respondents had poor sleep hygiene. From a total of 155 study participants, 33 (21.9%) of them did not have health-enhancing physical activity (Table 4).s

Quality of Sleep by the Pittsburgh Sleep Quality Index (PSQI) Subscale.
From the total of 388 study participants, only 30 (7.7%) reported their sleep quality as very good, 250 (64.4%) of them fell asleep within 30 minutes, and more than three-fourth of them slept the recommended sleep duration. Moreover, 352 (90.7%) respondent slept for at least 85% of the time they were in bed. Te quality of sleep for 248 (64%) of the study participants was disturbed at least once a week and above. Sleep disturbances kept 324 respondents from performing their daytime tasks (Table 5).

Overall Sleep Quality.
Among the total 388 respondents, 286 (73.7%) of them had reported poor sleep quality.

Factors Associated with Sleep Quality.
Variables that had an association with sleep quality at a P value ≤ 0.2 in bivariable logistic regression were sex, occupation, body mass index, presence of chronic disease, smoking, alcohol, chewing tobacco, taking substances such as shisha, recent CD4 count, anxiety, depression, sleep hygiene, social support, and stigma. However, in multivariable logistic regression, only occupation, presence of chronic disease, recent CD4 count, anxiety, sleep hygiene, and HIV-related stigma were associated with sleep quality at a P value of 0.05. Accordingly, respondents whose occupation was farming were 5 times more likely to develop poor sleep quality compared with students (AOR: 4.79; 95% CI � 1. 30-17.56

Discussion
Te quality of sleep, especially in patients with chronic illness, should be assessed since it afects cognitive, physical, and psychosocial health in a multidimensional way [27]. Patients with HIV/AIDS were afected by poor sleep quality for diferent reasons. Hence, this study was done to assess the quality of sleep among HIV/AIDS patients and its associated factors in the Tirunesh Beijing Hospital ART clinic. In this study, the quality of sleep among patients with HIV/AIDS was 73.7% (95% CI: 69.3%-78.1%). Tis fnding is higher than the fnding of previous studies conducted in Hawassa, South Ethiopia (57.6%) [21], Metu Ethiopia (57.1%) [23], and Zewuditu Memorial Hospital (55.6%) [26]. Similarly, the fndings of this study are higher than those of studies conducted abroad [6,17,18].
According to the fndings of the study, people living with HIV/AIDS whose occupation was farming were fve times more likely to have poor sleep quality compared with those who were students. Tis might happen because of poor sleep hygiene and uncomfortable living conditions. Although there are limited fndings that support these fndings, an association between poor sleep quality and employment status was observed in the previous study [28].
People living with HIV/AIDS who had a CD4 count of 200-499 cells/mm 3 were 2.69 times more likely to have poor sleep quality compared with those whose CD4 count was less than 200 cells/mm 3 . Te possible justifcation for this might be due to the presence of diferent opportunistic infections and chronic illnesses. According to the fndings of this study, the prevalence of chronic illnesses was high among those study participants whose CD4 count was 200-499 cells/ mm 3 . Tis fnding is supported by a study conducted in South Africa [29].
HIV-positive patients are vulnerable to depression and anxiety as psychological disorders [28]. In this study, people living with HIV/AIDS who had anxiety were three times more likely to have poor sleep quality compared with their counterparts. Tis might be due to the bidirectional association between poor sleep quality and anxiety [30]. Te sleep-wake cycle is regulated mainly by the hypothalamus.

AIDS Research and Treatment 5
When there is anxiety, the function of the hypothalamus pituitary axis is disturbed [31]. On the contrary, poor sleep quality results in excessive discharge of the sympathetic nervous system, which in turn results in anxiety and stress.
Tis fnding is supported by a study conducted at Zewuditu Memorial Hospital [26], Hawassa [21], and China [18]. People living with HIV/AIDS and who have had chronic illnesses were three times more likely to have poor sleep     quality compared with those who did not. Te possible justifcation for this might be the double burden of chronic illnesses and HIV/AIDS. Tis fnding is supported by a study conducted in Hawassa [21], Zewuditu Hospital, Addis Ababa [26]. Furthermore, people living with HIV/AIDS who were stigmatized due to their illness were 2.5 times more likely to have poor sleep quality compared with their counterparts. Tis might be due to the fact that people living with HIV/ AIDS who experience HIV-related stigma may experience greater feelings of loneliness, which are related to increased depressive symptoms [32]. Tis fnding is supported by a study conducted at Zewuditu Memorial Hospital [26].
More interestingly, people living with HIV/AIDS who had poor sleep hygiene were 2.57 times more likely to have poor sleep quality compared with those who had good sleep hygiene. Te possible justifcation for this might be that good sleep habits and practices promote quality sleep. Tis fnding is supported by a study conducted at Zewuditu Memorial Hospital [26] and in India among cancer patients [32].

Conclusion
In this study, the magnitude of poor sleep quality among people living with HIV/AIDS was high. Being a farmer, being a merchant, having additional chronic diseases, having anxiety, having CD4 count of 200-499 cell/mm 3 , being stigmatized, and having poor sleep hygiene were factors that had an association with poor sleep quality among people living with HIV/AIDS. Healthcare providers work hard, counsel, and advise to prevent the emergence of chronic illnesses. Additionally, during followup, people living with HIV/AIDS should be screened for anxiety regularly, and appropriate treatment should be provided. People living with HIV/AIDS who have low CD4 and whose occupation is farmer or merchant should get special support. Te Ministry of Health should expand healthcare providers who promote good sleep hygiene, particularly for people living with HIV/AIDS. Additionally, the Ministry of Health should minimize HIV-related stigma among the public through diferent strategies.