Sleep Disturbance and Associated Factors among Adult People Living with HIV/AIDS at Dessie Referral Hospital Antiretroviral Therapy Clinic, Northeast, Ethiopia.

Sleep disturbance is the leading health problem in the era of HIV/AIDS. The exact cause of sleep disturbance was not well known, but it is related to HIV itself, antiretroviral drugs side effects, and other HIV related disorders. This study aimed to assess the prevalence of sleep disturbance and associated factors among adult people living with HIV/AIDS (PLWHA). Methods: A cross-sectional study was conducted among adult PLWHA at Dessie Referal hospital Antiretroviral therapy (ART) clinic from April 1/2019 to May 30/2019. A total of 419 study participants participated in the study. A systematic random sampling method was employed. An interviewer-administered a method of data collection with a chart review was used. Pittsburg Sleep Quality of Index (PSQI) for assessing sleep disturbance was used. A binary logistic regression was conducted. The variables having a p-value < 0.05 with 95% CI were used to declare an association. Results: The proportion of sleep disturbance was 36% (95% CI: 31- 41%). The study revealed that being female (AOR=3.45, 95% CI: 1.52-7.79), viral loads ≥ 1000 copies /ml (AOR=6.88, 95% CI: 2.79-16.9), CD4 cell count < 200 cells/mm 3 (AOR=6.85, 95% CI: 2.42-19.39), WHO stage II and III(AOR=4.29, 95%CI: 1.05-17.53), having anxiety (AOR=10,95% CI: 4.21-23.9), having depression (AOR=4.4, 95% CI: 1.95-10.1), having not a separated bedroom (AOR=3.94, 95% CI: 1.86-8.36), and living alone (AOR=6, 95% CI: 2.81-13.12) were found to be factors associated with sleep disturbance. Conclusion: In this study, more than one - thirds of the study participants were developed sleep disturbance. Being female, low CD4 cell counts, viral load ≥ 1000copies/ml, WHO stage II and III, having depression and anxiety,

cognitive functioning (13), increase the risk developing hypertension, overweight (14), and increase unprotected sexual intercourse (15) were the major complications of sleep disturbance among PLWHA.
Simultaneous occurrence of sleep disturbance with HIV infection makes clinical management more complicated, so understanding the magnitude and major factors of sleep disturbance is playing a key role to identify and treat mental health problems early as much as possible. In Ethiopia, there is limited information on the prevalence and associated factors of sleep disturbance among adult PLWHA.
Therefore, this study provides evidence on the prevalence and contributing factors for sleep disturbance.
Besides, the results of the study provide baseline information for palliative care strategies to optimize and improve the quality of life by improving the service quality.

Study Setting
A cross-sectional study was conducted among adult PLWHA at Dessie Referal hospital ART clinic from April 1/2019 to May 30/2019. The study was conducted at the Dessie Referral Hospital adult ART clinic.
The Dessie town is found in the Amhara regional province which is 451 Km from Addis Abeba. The hospital started ART service since 1998 E.C. At the moment, there were around 5920 HIV positive patients enrolled in the ART clinic of which 5664 were adults. All adult PLWHA who were attending at ART clinic were considered as source population whereas those adult PLWHA attending the ART clinic during the data collection period were taken as the study population.

Sample Size And Sampling Procedure
The sample size was determined using a single population proportion formula considering the assumptions of a 95% con dence interval, 45.8% population proportion from the previous study (14), and 5% marginal error. Taking a 10% non-response rate, the nal sample size was 419. The sampling frame was developed based on the order of coming to the clinic. The sampling unit was determined and using systematic random sampling the study participants were selected every person pattern.

Operational De nitions Sleep disturbance
Participants having a global score of Pittsburg Sleep Quality of Index > 5 were considered as having sleep disturbance whereas having a global score of PSQI ≤ 5 taken as having no sleeping disturbance (16).

Stress
On the perceived stress scale(PSS) a participant having a mean score of 0-13 will be classi ed as low stress,14-26 moderate stress, and 27-40 sever stress (17).

Depression
Participants who had a mean score > 8 considered as having depression were as a score of 8 ≤ was considered as no depression. Participants who had a mean score > 8 considering as having anxiety ≤ 8 no anxiety from anxiety (18).

Data Collection Tools And Procedures
A structured interviewer-administered questionnaire with a chart review was employed to collect data. The questionnaire includes socio-demographic factors, clinical factors, personal and behavioral factors, and psychosocial factors. A validated PSQI tool was used. Its Cronbach alpha is (0.88) (19,20). Sleep disturbance assessed with the 19 item questionnaires with 7-components including, subjective sleep quality, sleep latency, sleep duration, habitual sleep e ciency, sleep disturbances, use of sleeping medications, and daytime dysfunction during the last one month. Perceive stress scale (PSS) was used to assess the client's stress condition. It had 10 item stress scales ranging from 0-4 points Likert scale with a score of minimum 0 and maximum 40 (17).
Anxiety was measured using the hospital anxiety scale. The tool had a 7 Likert scales ranging from 0-3 with minimum 0 and maximum of 21 scores, which the higher score indicated had anxiety (18).
Depression was measured using the hospital depression scale. It had a 7 Likert scale ranging from 0-3 points with score minimum 0 and maximum scores of 21, the minimum score indicates no depression and the higher score indicates having depression (18). Four BSc nurses (three data collectors and one supervisor were used. The data were collected from April 1/2019 to May 30/2019.

Data Processing And Analysis
Data were coded and entered into Epi Info Version 7 then exported to SPSS version 20 for analysis. Both descriptive and analytical statistical procedures were utilized. Descriptive statistics such as percentage, mean, median, standard deviation, and inter-quartile range (IQR) were used. Tables and bar graphs were also used for data presentation. A binary logistic regression model was used to identify factors associated with sleep disturbance. All explanatory variables enter into the multivariable logistic regression model to control the possible effect of confounders. The effect of variables on sleep disturbance was declared based on a 95% CI and p-value < 0.05. Model tness was checked using Hosmer and Lemeshow goodness of a t test.

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Characteristics Of Sleep Pattern Of The Study Participants The participants went to bed on average 10:02 pm and wake up in the morning at 4: 08 am. The mean time slept each night was 7:02 hrs (SD ± 1.07hours). Two hundred twenty one (52.7%) had very good sleep quality, 120 (28.6%) had slept with > 60 minutes and 86 (20.5%) slept < 5:00 per 24:00 hours (Table 4).    (23), Paris 68% (16) and 63% (24). The discrepancy was in socio-cultural characteristics, sampling methods, study setting, design, type of tool, and data collection methods. On the contrary, the nding of this study was higher than the study conducted in South Africa 16% (25). The possible reason for this discrepancy may be due to the former study used longitudinal follow up which may lead to loss to follow.
The current study revealed that sex was the determinant factor of sleep disturbance. Being female was 3.45 times more likely to develop sleep disturbance compared to their counterparts (AOR = 3.45, 95% CI; 1.52 − 7.79). In females, during the premenopausal/menopausal period, there was a hormonal imbalance of estrogen and progesterone that decreased the level of estrogen as well progesterone level which results in a two-fold increase in the number of arousals after sleep occurs this decreased total sleep time (26).
Participants having viral loads greater or equal to 1000copies /ml were nearly 7 times more likely to develop sleep disturbance compared to those clients having viral loads less than 1000 copies/ml (AOR = 6.88, 95% CI; 2.79-16.9). This is supported by a study conducted in California (10). High viral loads in the peripheral circulation enhance the HIV to enter into the central nervous system which activates macrophages and astrocytes (27) and consequently impaired their function which decreased the release of sleep regulatory substances(TNF-alpha) (28). Viral load increments associated with the disease progression to the chronic stage which changes sleep as more arousal and waking during sleep periods (29).
The odds of experiencing sleep disturbance among adult PLWHA who were WHO stage II&III was 4.29 times compared to those WHO stage I (AOR = 4.29, 95% CI; 1.05-17.53). This is supported by a study conducted in UAS (30). Having advanced WHO clinical stage may lead to developing opportunistic infections that impair sleep quality.
Participants having a CD4 cells counts less than 200 cells/mm 3 were nearly 7 times more likely to develop sleep disturbance compared to those having CD4 cells count greater than 350 cells/mm 3 (AOR = 6.85, 95% CI; 2.42-19.39). This is supported by a study conducted in Nigeria (5) and the USA (31). Immune decrements associated with HIV infection is directly linked to the psyche by a complex network of nerves, hormones, and neuropeptides. This network has a direct impact on sleep (14). It has been well documented that CD4 + cell count decreases, whereas viral load increases with the progression of HIV, consequently the quality of sleep worsens along the course of the disease, this related to CD4 + cell count and viral load as well (32).
Participants who had depression were 4.44 times more likely to develop sleep disturbance compared to those have no depression (AOR = 4.44, 95%CI; 1.95-10.10). This is supported by a study conducted in German (23) and ve cities in the USA (7). Depression had a directional association between sleep disturbances (8). The reason is that in depression, the sleep-dependent component of sleep regulation is de cient and does not rise to its usual level. Due to this, the sleep amount of slow-wave sleep is reduced and the sleep period also shortened (33).
In the current study, participants who had anxiety were 10 times more likely to develop sleep disturbance compared to those participants with no anxiety (AOR = 10, 95% CI; 4. 21-23.9). This is supported by a study conducted in China (8) and the USA (34). The reason is that, according to the polysomnographic features that characterize patients with anxiety have longer sleep onset latency, a greater number of arousals, and greater wake time during the night, fewer transitions into non-REM sleep (35).
In the present study, participants who lived alone had 6 times more likely to developed sleep disturbance compared to those living with their family (AOR = 6, 95% CI; 2.81-13.12). This is supported by a study conducted in the USA (36). Physical and social aspects of sleeping arrangements have been negatively affected the sleep quality (32). Better family and social support were associated with better sleep quality.
Living with a supportive family can have a positive effect on mood, preventing social isolation, and promoting healthy sleep habits. Moreover, social support may help maintain a more consistent and consolidated sleep-wake schedule and may affect sleep by attenuating the effects of psychological stress on sleep (6,37).
In the is study, participants who did not live in the separate bedrooms were nearly 4 times more like to develop sleep disturbance compared to those who lived in the separate bedrooms (AOR = 3.94, 95%CI; 1.86-8.36). This is supported by a study conducted in the USA (36). Sleep can be disrupted by a variety of factors related to the location of the bedroom in the house. Lack of separate bedrooms for sleep was predisposed to extra sound and light, sense of lack of security, exposure for bright room colures, image or art, lack of privacy were negatively in uence on sleep quality (38).

Limitation
Variables such as sleep with partner and family size may affect sleep quality but this issue did not incorporate in the current study. Substances (Alcohol, cigarette, and khat) uses were not measured quantitatively.

Conclusion
The nding of this study showed that more than one-third of the study participants had sleep disturbance at the Dessie Referral Hospital ART clinic. informed consent was obtained from each participant and personal identi cation like the name, phone number, and medical registration numbers were not used to maintain con dentiality.

Consent for publication
Not applicable Availability of data and materials The datasets used and/or analyzed during the current study are available at the corresponding author for reasonable request.

Competing interests
The authors declare that there is no competing of interests

Funding
The author did not receive any fund Authors' contribution FSD wrote the proposal, participated in data collection, analyzed the data, and drafted the manuscript. YB and AWA approved the proposal with revisions, participated in data collection, data analysis and revised subsequent drafts of the manuscript. All the authors read and approved the nal manuscript.  The proportion of sleep disturbance among PLWHA at Dessie Referral Hospital, ART clinic Northeast 2019(n=419).

Figure 1
The proportion of sleep disturbance among PLWHA at Dessie Referral Hospital, ART clinic Northeast 2019(n=419).