Introduction: Several studies done in developed countries have reported that sleep disturbances occur frequently in people living with HIV/AIDS. However, there are limited data on the burden of insomnia among HIV infected persons in Sub-Saharan Africa.
Aim: The aim of this study was to determine the prevalence and associated factors for Insomnia among HIV patients receiving care at a tertiary institution in south western Nigeria.
Methods: A cross-sectional study was conducted among consecutive adult HIV patients attending an HIV clinic. HIV negative patients attending the general outpatient unit of the hospital were the control group. A semi-structured questionnaire was designed to obtain sociodemographic data and insomnia among the participants was assessed using the insomnia severity index questionnaire. The hospital anxiety and depression scale was used to assess for other psychiatric co-morbidities.
Results: A total of 853 participants were enrolled for the study (424 HIV positive and 429 HIV negative controls). The mean age of HIV positive patients and controls is 42.2±9.5 years and 43.4±12.4 years respectively. There was statistically significant difference in the prevalence of insomnia in the HIV seropositive patients compared to the controls 49.3% and 34.3% respectively ( chi2 = 19.801, p value < 0.0001). Factors associated with insomnia on multivariate analysis were depression (AOR 2.557, 95% CI = 1.556-4.200, p value < 0.0001) and low CD4 count (AOR 2.001, 95% CI = 2.000-2.002, p value < 0.028).
Conclusion: The prevalence of insomnia is high among HIV positive patients and the associated factors were depression and low CD4 count. It is imperative to address this prevailing challenge in this group of patients for improved treatment outcome.
HIV/AIDS is a pandemic disease with a huge burden in Sub-Saharan Africa. The global estimate is that 36.7 million people were living with HIV (PLHIV) in 2016 with more than two-thirds in Sub-Saharan Africa . PLHIV often suffer from sleep disturbance with a prevalence ranging from 29 to 97 % among HIV seropositive patients. Sleep disturbance is a major HIV-related health issue which is often under-reported by the patients to their attending physicians . Insomnia is defined as difficulty with initiating and maintaining sleep that is associated with daytime distress. It is a well-recognized finding in PLHIV, often associated with fatigue, adherence, poor disease outcomes, quality of life and comorbid psychiatric disorder like depression/anxiety in PLHIV [3,4]. Insomnia in HIV seropositive patients has been linked to the neuronal damage by viral neurotoxic and inflammatory mechanism, adverse effect of antiretroviral drugs, substance abuse and psychiatric disorders in PLHIV [2,3].
Several studies have shown the vital role of sleep in health, absence of which could significantly impact on the immune function and disease progression [5,6]. This is particularly critical in HIV infected individuals whose disease is characterised by immune dysfunction and occurrence of opportunistic infections as it progresses which could be worsened by insomnia. There is however a paucity of data on insomnia in the HIV-seropositive population in Sub-Saharan Africa. Previous studies on insomnia in PLHIV have been limited by lack of power, inadequate control groups and use of Pittsburgh Sleep Quality Index which is not a diagnostic tool to identify sleep disorder . Hence, this study aimed at determining the prevalence of insomnia in PLHIV, comparing the findings with age and sex matched controls who are HIV sero-negative patients and determining the associated risk factors for insomnia.
A cross-sectional study was conducted among patients accessing care for HIV infection at Ekiti State University Teaching Hospital (EKSUTH), Nigeria. The hospital is the major tertiary hospital located in Ekiti state situated in the south-western region of Nigeria with an estimated population of 2,384,212 as at 2006 population census .
Ekiti state has a prevalence of HIV of 2.9% as at the last survey in 2014, one of the lowest prevalence of HIV in Nigeria, below the national average of 3% [8,9]. Adult HIV patients on follow up who were diagnosed as HIV infected and have been on treatment for at least 6 months were recruited for the study. The HIV patients receive treatment at the Medical Outpatient Department (MOPD) where they are seen by specialists in HIV medicine. Critically ill individuals, patients with opportunistic infections and non-consenting individuals were excluded from the study. The control group of HIV negative patients who consented to HIV screening and attended the General Outpatient Department (GOPD) who were age and sex matched.
We calculated the sample size using online statistical software from Open Source Epidemiologic Statistics for Public Health . An estimated sample size of 327 was obtained from a population of 2150 HIV patients in our facility, using a hypothesized percentage frequency of outcome factor in the population of 50% and confidence limit of 5%. Twenty percent of the calculated sample size was added to account for incompletely filled questionnaires thereby making a total of 392. We further increased this number to 424 to increase the power of the study.
A pretested semi-structured questionnaire was administered by two trained research assistants who obtained information on socio-demographic profile, presence of symptoms, CD4 count, viral load, medication use, HIV screening results and clinical stage of HIV. In addition, the Insomnia Severity Index (ISI) was used to assess the prevalence among the PLHIV and the control group. Furthermore, the Hospital Anxiety Depression Scale (HADS) was also used to assess the prevalence of anxiety and depression among the respondents. This consists of seven items relating to depression and anxiety and either condition was defined as HADS score ≥ 8 .
Insomnia was the main outcome of interest. Each participant was assisted in filling the Insomnia Severity Index, seven-item questionnaire assessing the nature, severity and impact of insomnia. Each item has a 5-point Likert scale used for rating. Studies have shown a cutoff score of 14 has a sensitivity and specificity of 94% which could distinguish most cases of insomnia from normal controls, hence we adopted this cutoff for our study [9,10,12-14].
Obtained data was analysed using SPSS statistical software version 20 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were initially used to explore the data and to present results of prevalence and socio-demographic data. Categorical variables were expressed in proportions while continuous variables in mean (standard deviation). A comparison of categorical variables was done using Pearson’s Chi-square test while student’s t-test was used for comparing means. Multivariate associations of socio-demographic and clinical factors with insomnia were determined by logistic regression. Factors with a P value <0.05 in univariate models were included in the multivariate model. All p-values of less than 0.05 were considered statistically significant.
Ethical approval was obtained from the Ekiti State University Teaching Hospital’s ethics and research committee. Informed verbal and written consent was obtained from every participant and they were ensured of anonymity and confidentiality by assigning numerical codes to each questionnaire.