Short Sleep Duration and Correlates among Sero-positive HIV Patients in Nigeria, West Africa

Introduction: Short sleep duration is a salient issue because it is a major public health concern and has more wide-reaching problems among HIV/AIDS patients. Short sleep duration was said to be associated with lower CD4 count, higher viral load values, depression, high blood pressure, high body mass index and disease progression. It was also documented that patients receiving sleep. Conclusion: Almost half of the respondents were poor sleepers with associated high blood pressure and increased body mass index (BMI). Both effects of the virus and antiretroviral drugs may cause short sleep duration. Health providers managing HIV positive patients, need to take complaints of short sleep duration seriously, because they can indicate an increased risk for low CD4 counts, high viral load, depression, high blood pressure and increase body mass index. There is the need for targeting efforts to improve short sleep duration for the majority of adults living with HIV/AIDS and tailoring appropriate interventions.


INTRODUCTION
Sleep naturally restores body functions including immune system. Short sleep duration interferes with normal physical, mental and emotional functioning and had been reported in HIVinfected individuals since the 1980's [1,2].
The amount of time spent sleeping is called sleep duration [3,4]. Short sleep is when sleep hours is less than or equal to 5 hours per night [5]. Short sleep duration (<5 hours) has been associated with lower reports of self-rated overall health than normal (>7hours) [6]. It has also been associated with low socioeconomic status [7]. National sleep foundation found out that adults need 7 -9 hours of sleep [8].
Short sleep duration is common in HIV-infected patients [9]. These abnormalities are more frequent in subjects receiving efavirenz. Vivid dreams, difficulties in falling asleep, and/or numerous night awakenings are frequently reported by patients after beginning Efavirenz medication [10]. The first United States National Health and Nutrition Examination Survey (NHANES-1) reported that short sleep duration was associated with a 60% increased risk of hypertension [11]. Cross sectional studies from USA [12][13][14][15], France [16], Japan [17], Canada [18,19], Spain [20], Germany [21], and the United Kingdom [22] found significant association between short sleep and obesity. Short sleep was also found to be associated with lower CD4+ T-cell counts and higher viral load [23]. Our aim was to determine the prevalence of short sleep duration among HIV patient on HAART and to evaluate the associated factors.

METHODS
This is a descriptive cross-sectional study conducted among 400 HIV/AIDS patients on Highly Active Anti Retroviral Therapy (HAART) attending the lentiviral clinic of Kwara State Specialist Hospital, Sobi, Ilorin from January to April 2015.
The sample size was estimated using the Leslie Kish's Formular for estimate minimum sample size in health studies [24]. Pretesting was carried out at the Kwara State Civil Service Hospital, using 40 respondents (10% of the sample size) from the HIV clinic.
Institutional ethical approval was obtained. All concerted HIV positive patients above 18 years were recruited. Exclusion criteria include the use of illicit drugs or alcohol, and the presence of acute medical condition that could affect the patients sleep or ability to complete the questionnaire. Weekly, 50 patients were seen on HAART and systematic sampling of odd numbers was used in selecting 25 weekly until a total sample size of 400 was obtained. The patient demographic data was evaluated. Recent laboratory results for CD4 cell count, and current antiretroviral therapy, was obtained from their case records.
Two or more blood pressure measurement separated by a two-minute interval, with the patient either supine or seated, and after standing for at least 2 minutes. Verification in the contra lateral arm was done. The patients Health Questionnaire (PHQ-9) is a brief, 9-items patients report depression assessment tool. It was specifically developed for use in primary care general medical settings. Psychometric evaluation of the PHQ-9 reveal a sensitivity ranging from 62% to 92% and specificity between 74% -88%. Respondents who scored one and more were assessed clinically for depression. Scoring and level of depression was assessed viz: (1-4) Minimal depression, (5-9) Mild depression, (10)(11)(12)(13)(14) Moderate depression, (15)(16)(17)(18)(19) Moderately severe depression, and (20-27) Severe depression. Some direct depression care, such as care support, coordination, case management, and treatment was embarked on [25].
The Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep duration. Psychometric properties have demonstrated good reliability internal consistency 0.89, test retest reliability 0.85 and good construct validity for the English language version. The respondents were categorized into three groups namely: Sleeping more than 7 hours, 5-7 hours and less than 5 hours. Subjects with <5 hrs are poor sleepers while those with >7 hrs were good sleepers.
The data were analyzed using the epidemiological information (Epi-info) 2005 software package. The 2 by 2 contingency tables were used to carry out Chi-square test and to find out the level of significance and values less than 0.05 were regarded as statistically significant. Table 1 shows the socio-demographic factors of the respondents. Four hundred HIV-infected patients were recruited with a mean age of 39yrs (SD 9). Eighty four (21%) were male, while 316 (89%) were female. Table 2 shows the association between sleep duration and socio-demographic factor. One hundred and eighty three respondents (45.8%) slept <5 hours, while 58 (14.5%) sleep >7hours. A significant number of the respondents who sleep for < 5 hours 149 (81.4%) had depression. 74% had normal blood pressure and 21% were in the pre-hypertensive stage while only 2% and 3% were in the stages 1 and 2 respectively.  Table 4 shows the association between present CD4 count and sleep duration. The lower the CD4 count, the more the short sleep duration. Those who sleep < 5 hours had significantly low CD-4 count.

DISCUSSION
In this study, the prevalence of short sleep duration among the HIV positive patients was 45.8%, similar to 46% documented by Crum-Cianflone and co-workers [26] by the infectious diseases society of America, but lower than 59.4% reported by Adewole and co-workers [27] in Obafemi Awolowo Teaching Hospital, Ile-Ife, Nigeria.
The prominent age group with short sleep duration was 31-40 years, similar to 31-50years reported by Bastos and colleagues [28]. Those with non-formal education had short sleep duration than those with formal education. Crum-Cianflone [26] found out that fewer years of education was associated with sleep duration.
Short sleepers of less than 5 hours were prone to high blood pressure. Recent data reported that short sleepers were at increased risk for hypertension [29][30]. Additionally, women who slept <7 hours were at increased risk of stroke [31]. Short sleepers were also prone to myocardial infarction [32].
Many studies had shown the relationship between short sleep duration and obesity [33,34]. Cross-sectional studies conducted in adults from Canada [35], France [36], Germany [37], Japan [38], UK [39], and USA [40], shown significant associations between short sleep and obesity. Short sleep duration was associated with increase weigh gain and body mass index. This was similar to the longitudinal analysis observed where sleep duration of <7 hours were associated with increased risk of weight gain. Also similar to another study where the odds ratio for sleep duration predicting obesity was 0.50, and every extra hour increase of sleep duration was associated with a 50% reduction in risk of obesity [41]. Studies in France [42] and Canada [33] also attested to these.
There had been inconsistent reports on the relationship between CD4 cell count and poor sleep quality. Some studies [43,44] had not found any relationship whilst others had confirmed that sleep disturbances were independently related to immune status [45,46]. We noted a significant association between short sleep duration and lower CD4 count. The immune system is directly linked to the psyche by a complex network of nerves, hormones, and neuropeptides. This network of specific physiological pathways allows immune function to have a direct impact on health especially sleep. On the contrary Crum-Cianflone and co worker did not find any association between short sleep duration and HAART use.

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immune system is directly linked to the psyche by a complex network of nerves, hormones, and neuropeptides. This network of specific physiological pathways allows immune function to have a direct impact on health especially Cianflone and coworker did not find any association between short sleep duration and HAART use.
We noted that patients on efavirenz based HAART therapy had short sleep duration. Other earlier studies had also documented a corre between high blood concentrations of efavirenz and poor sleep pattern [46,47]. Gallego

Stages of Hypertension
icle no. BJMMR.19630 We noted that patients on efavirenz based HAART therapy had short sleep duration. Other earlier studies had also documented a correlation between high blood concentrations of efavirenz and poor sleep pattern [46,47]. Gallego  Also, efavirenz plasma levels were significantly higher in patients with insomnia [48 suggested that a direct inhibition of serotonergic hypothalamic pathways by efavirenz may explain this. This could be attributed to the presence of the defective CYP2B6 G516T variant allele known to be common in black Africans, which causes a variation in the rate of efavirenz metabolism thereby significantly increasing the likelihood of the occurrence of sleep disturbance. This contrast with the report of Crum [26], where no significant association those on efavirenz containing regimen was found. 6 efavirenz had shorter duration of deep sleep. Also, efavirenz plasma levels were significantly 48]. It had been suggested that a direct inhibition of serotonergic hypothalamic pathways by efavirenz may explain this. This could be attributed to the presence of the defective CYP2B6 G516T variant allele n in black Africans, which causes a variation in the rate of efavirenz metabolism thereby significantly increasing the likelihood of the occurrence of sleep disturbance. This contrast with the report of Crum-Cianflone [26], where no significant associations between those on efavirenz containing regimen was In this study, short sleepers of less than 5hours were prone to depression. This was similar to Crum-Cianflone [26] observation as well as other studies [49,50]. Sleep deprivation has effects on several domains of psychological health, including socialization, mood and stress. An increased stress response had been shown, including increased basal activity of neuroendocrine stress systems, elevations of the sympathetic nervous system, altered hypothalamic-pituitary-adrenal axis function, and increased stress reactivity [51].

5-7 hrs >7hrs
Sleep Duration icle no. BJMMR.19630 In this study, short sleepers of less than 5hours were prone to depression. This was similar to Cianflone [26] observation as well as other studies [49,50]. Sleep deprivation has effects on veral domains of psychological health, including socialization, mood and stress. An increased stress response had been shown, including increased basal activity of neuroendocrine stress systems, elevations of the sympathetic nervous system, altered adrenal axis function, and HIV positive square P-value < 0.001 Hack and Mullinton [52], observed optimismsociability declined in 15% of the respondents over consecutive days of sleep loss. One study investigated risky decision making following sleep deprivation [53] and found that not only was sleep deprivation associated with increased risky behavior.

LIMITATION OF THE STUDY
There are few limitation of the study that may reduce the generation of our finding. Like all cross sectional study, it is difficult to establish casual association between dependent and independent variable. Further studies are required to determine the frequency of the genetic polymorphism affecting efavirenz metabolism in the African population. Also the regions in Africa where this detective gene exists need to be defined.

CONCLUSION
The results of this study indicate a significant reduction of deep sleep in HIV-infected individuals.
Efavirenz related neurologic effects especially short sleep duration may be explained by alterations in sleep architecture. EEG monitoring may be a helpful tool to detect objective sleep abnormalities in patients complaining of insomnia while receiving efavirenz. Further studies are required to determine the frequency of the genetic polymorphism affecting efavirenz metabolism in the African population. Also the regions in Africa where this detective gene exists need to be defined.
There is a dose-response relationship of short sleep duration and obesity and metabolic consequences. Short sleepers are prone to hypertension and depression.
It is recommended that health professionals make a systematic inclusion of questions regarding sleep when assessing patients with HIV/AIDS. This way, it will be possible to make an early identification of the sleep-related complaints and plan interventions that avoid or minimize the worsening of the complaints and subsequent deterioration of the quality of sleep, which will eventually affect the patients' overall health and quality of life.