Quality of sleep and associated factors among people living with HIV/AIDS on follow up at Ethiopian Zewditu Memorial Hospital,2018

Background: Sleep disturbance is a common complaint in people living with HIV/AIDS. Individuals with it are less likely to adhere to their treatment, have decreased quality of life, have decreased work productivity, and have increased risk of psychiatric disorders, cardiovascular morbidity, and disease progression. However, sleep condition remains under-recognized by clinicians and is not well studied in Ethiopia. Therefore it is necessary to produce scientic evidence to ll the clinical knowledge gap and recommend the focus area of management. The aim of the study was to assess sleep quality and its associated factors among people living with HIV/AIDS. Methods: An institution-based cross-sectional study was utilized among 408 participants who were selected by a systematic random sampling technique at Zewditu memorial hospital from April to May 2018. The Pittsburgh Sleep Quality Index questionnaire was used to measure sleep quality. Ethical clearance was obtained from the joint ethics committee of the University of Gondar and Amanuel Mental Specialized Hospital. Oral informed consent was obtained from each participant. Binary and multivariable logistic regression models were tted. Odds ratios (OR) with the corresponding 95% condence interval (95%CI) was computed to assess the strength of the association. Results: The magnitude of poor sleep quality was 55.6%. Being female [AOR=3.40, 95% CI: (1.80, 6.41)], depression [AOR =3.52, 95% CI: (1.95, 6.32)], CD 4 count ≤ 200 cells/mm 3 [AOR=3.18,95%CI: (1.65,6.13)], duration of HIV/AIDS diagnosis [AOR=3.43,95% CI: (1.61,7.29)], current use of tobacco [AOR=5.69, 95% CI: (2.04,15.9)] and chat or caffeinated drinks [AOR=2.65, 95% CI: (1.06,6.64)] and poor sleep hygiene [AOR=3.55, 95% CI: (1.85, 6.78)] were signicantly associated with poor sleep quality. Conclusions: More than half of the study participants were found to have poor sleep quality. A range factors inuence

program at ZMH in July 2003, and in March 2005 it received technical assistance from Johns Hopkins University's (JHU) TSEHAI Program. ZMH became the largest HIV clinic in Ethiopia and a leading hospital in the treatment of ART patients. Currently, it treats over 7299 each month. There were 17,857 HIV-positive patients having HIV care follow-up in the hospital in 2018. The study population was patients who were attending at ART clinics during the data collection period. All adults who were seriously ill and unable to communicate were not included in the study.
Sample size and sampling technique Sample size (n) was calculated based on single population proportion formula, by assuming 95% con dence level, the prevalence of poor sleep quality among HIV/AIDS patients which was found to be 59.3% in Nigeria [20] and a precision of 5% between the sample and the parameter was taken. α =0.05(95%) =1.96 By considering a 10% non-response rate the nal sample size was 408. We used a systematic sampling technique to select the four hundred eight (408) HIV/AIDS patients who were included in our survey. We determined the sampling interval by dividing the total study population who had to follow up during the average 1-month data collection period (3264) by total sample size (408). Hence, the sample interval is 8.
We selected the rst study participant by lottery method and the next study participants were chosen at regular intervals (every 8 th interval) and interviewed by data collectors.
Data collection tools and procedures Data were collected by trained nurses by face-to-face interviewing of the participant (people who are HIV/AIDS positive and attending ART service). The questionnaire was pre-tested by taking 5% of the calculated sample size. The questionnaire contained socio-demographic characteristics (age, income, education, occupation, marital status, and others). Semi-structured questionnaires were used to collect data on clinical factors.
Data on the magnitude of sleep quality was collected by using the Pittsburgh Sleep Quality Index (PSQI), a self-report measure instrument composed of 19 items evaluating seven components of sleep. Each part was scored (range: 0-3; higher scores indicating worse sleep). A total global PSQI was derived by summing the seven components (range: 0 to 21; higher scores indicating poor sleep quality). A global PSQI score >5 yielded a diagnostic sensitivity of 89% and speci city of 86.5 %( к=0.75, p≤0.001) in distinguishing "good" from "poor" sleepers. "Good sleep" was de ned as global PSQI scores of 0-5 and "poor sleep" was global PSQI scores of 6-12 [21].
Hospital anxiety and depression scale (HADS) were used to assess anxiety and depression. The HADS has two subscales: the anxiety subscale (HADS-A) and the depression subscale (HADS-D). It has a cutoff point ≥ 8 for each subscale [22]. HIV/AIDS related stigma scale was used to assess stigma. It is a 12-item screening tool developed by Annelies Van Rie, Sohini Sengupta. The tool has 4-point Likert response. Each items were scored with 0 (strongly disagree) and 3 (strongly agree). Participants who scored above the mean score were considered as stigmatized [22,23].
Sleep hygiene index (SHI), a 13-item self-report measure designed to assess the practice of sleep hygiene behaviors. Each item is rated on a ve-point scale ranging from 0 (never) to 4 (always). Total scores range from 0 to 52 with a higher score representing poor sleep hygiene [24]. Social support measured using Oslo 3 items social support scale (OSS-3)[25].

Data quality control issues
Training was given to the data collectors and supervisors on the data collection tool and sampling techniques by the researcher. Supervision was held regularly during the data collection period both by the researcher, co-investigators and supervisors to check on a daily basis for completeness and consistency.

Analysis
Data were analyzed using SPSS version 20. Description statistics (frequencies, proportions, means, and standard deviations) were used to present the sociodemographic and the prevalence of domestic violence. Both bivariate and multivariate logistic regression analysis were carried out to see the association of each independent variable with the outcome variable. A p-value of less than 0.05 was considered statistically signi cant, and an adjusted odds ratio with 95% CI was calculated to determine the association.

Ethical clearance
Ethical clearance was obtained from the joint ethics committee of the University of Gondar and Amanuel Mental Specialized Hospital and Addis Ababa health bureau. The purpose and importance of the study were explained to each participant before they proceed into actual activities. Con dentiality was maintained by anonymous questionnaire and informed consent was obtained from each participant.

Results
A total of 396 study participants were interviewed, giving a response rate of 97.1%. The mean age of the respondents was 38.57 years with SD (± 10.76). The proportion of male to female participants was almost equal (50.3-49.7%). More than half of the client's 276 (69.7%) were Orthodox by religion and most of the respondents were married 208 (52.5%) and regarding the education level of the respondents 176(44.4%) had attended secondary school (Table 1) HIV related clinical characteristics of the participants Among the study participants, the majority 294(74.2%) was on clinical stage I, 219 (55.3%) had greater than 200 cells/mm 3 of CD 4 count, 296 (74.7%) on the rst line regimen of ART drugs and 272 (68.7%) had duration of HIV/AIDS diagnosis greater than 10 years (Table 2).

Poor sleep quality and Factors associated among people with HIV/AIDS
The magnitude of poor sleep quality among people living with HIV/AIDS was found to be 55.6%.
Multivariable logistic regression revealed female sex, depression, CD4 less than 200 cells/mm 3 count, duration of HIV/AIDS diagnosis, current use of tobacco, current use of chat or caffeinated drinks and poor sleep hygiene were signi cantly associated with poor sleep quality.
The magnitude of poor sleep quality was found to be more than 3

Discussion
This study was a rst attempt to ascertain the magnitude of sleep quality and its possible association with various variables among people living with HIV/AIDS in Ethiopia. The results from the current survey revealed that a remarkable proportion of people living with HIV/AIDS had experienced poor sleep quality.
In this study, poor sleep quality was signi cantly associated with female gender among people with HIV/AIDS. This could be due to the fact that females are more prone to stress due to the burden of excessive household responsibilities and changes in hormonal level. This result is supported by a study carried out in Nigeria [20].
The current study also found that depressed respondents were signi cantly associated with poor sleep quality as compared with non-depressed respondents. This may be due to depressed individuals have decreased serotonin neurotransmitters that results in diminished cognitive performance affects normal sleep pattern. This nding is in agreement with studies done in China [15], Europe and USA [16,[26][27][28][29] CD 4 count less than 200cells/mm 3 were a signi cant factor to develop poor sleep quality among people with HIV/AIDS. Probably, immune system is directly linked to the brain by a complex network of nerves, hormones, and neuropeptides. This network of speci c physiological pathways is the primary determinant of neuropathology to have a direct impact on health including sleep. The nding of this study coincides with a study done in Nigeria [19,20] and Mexico [26].
Similarly, shorter duration of HIV diagnosis were signi cantly associated with poor sleep quality as compared longer duration of diagnosis. The possible reasoning might be HIV-positive patients feel stigmatized and this may contribute to frequent psychological stress and emotional disturbances. The result supported by research conducted in Nigeria [20].
Furthermore, use of substances within the current three months (i.e. tobacco, chat or caffeinated drinks) were signi cantly associated with poor sleep quality. The possible reasons behind these is biological effect of the substances on the brain results in disturbance of circadian rhythms which is associated with symptoms of poor sleep quality. This nding agrees with a study conducted in France [16], US geographic areas [30,31] and studies conducted in Ethiopia at community level [32,33].
Finally, in the present study there is a strong relationship between poor sleep hygiene and poor sleep quality. Even if, the nding of this study has no corresponding literature among the same population, it's supported by study undertaken in India to identify the relationship between sleep hygiene practices and sleep quality among cancer patients [34].

Conclusion
In summary, this study revealed that more than half of people living with HIV/AIDS were found to have poor sleep quality. Being female, diagnosis of depression, lower CD4 count, shorter duration of HIV/AIDS diagnosis, current use of tobacco, chat or caffeinated drinks and poor sleep hygiene were factors signi cantly associated with poor sleep quality. The ndings suggest that routine screening of sleep disturbances among people living with HIV/AIDS is highly recommended. It's also better to integrate mental health program with HIV/AIDS assessment and ART service delivery programs.
Abbreviations AOR: Adjusted odd ratio; CI: Con dence interval; PSQI: Pittsburgh Sleep Quality Index Declarations -Ethics approval and consent to participation Ethical approval was obtained from joint Ethical Review Committee of University of Gondar and Amanual Mental Specialized Hospital (No Committee reference number). Written consent was taken from the participants for their voluntary participation. Con dentiality was maintained throughout the study process. Consent to publication: N/A -Availability of data and materials.
All data generated or analyzed during this study are included in this published article. The data sets of the current study is available from [Nebiyu Mengistu, email: nebiyumen@gmail.com ; Mobile: +251931333504, Dilla university, Dilla] upon reasonable request -Competing interests We declare that there is no any nancial or non-nancial con ict of interest -Funding The sources of funding for the current research is from Amanuel Mental specialized Hospital. The funding organization did not have any role in the design of the study, collection, analysis, interpretation of data and in writing the manuscript.