Multidimensional Sleep Health in PLWH on DTG- vs DOR-Based ART: A Mixed-Methods Pilot Study

Background With the successful scale-up of antiretroviral therapy (ART), HIV infection has transitioned from a fatal disease to a chronic, manageable condition. This has led to substantial reductions in AIDS-related mortality globally and marked improvements in life expectancy among people living with HIV (PLWH), including in South Africa where ART coverage and viral suppression rates continue to rise. As a result, HIV care has increasingly shifted toward long-term health optimization, with growing attention to non-communicable diseases (NCDs) such as cardiovascular disease, obesity, and metabolic dysfunction.

Sleep disturbance is increasingly recognized as a potentially important but underappreciated contributor to morbidity in PLWH. Poor sleep is highly prevalent in this population and has been associated with adverse cardiometabolic, neurocognitive, and functional outcomes. Reported prevalence estimates of sleep disturbance in PLWH are as high as 50% or more, significantly exceeding that of the general population. However, most existing data rely on subjective questionnaires such as the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), and screening tools for obstructive sleep apnoea (OSA). While these tools are useful for identifying symptoms, they are less sensitive to subtle or early physiological changes in sleep and may not adequately capture sleep as a multidimensional construct.

Contemporary sleep science conceptualises sleep health as a multidimensional construct encompassing satisfaction, alertness, timing, efficiency, duration, and regularity, rather than simply the absence of sleep disorders. Instruments such as RU-SATED have been developed to capture these domains; however, few studies have applied multidimensional sleep health frameworks in PLWH, and even fewer have evaluated how sleep health differs across antiretroviral regimens.

Objective sleep assessment using overnight polysomnography (PSG) provides a gold-standard method for characterising sleep architecture and physiology. PSG enables measurement of sleep stages (N1, N2, N3, and REM sleep), sleep continuity, respiratory events, oxygen desaturation, arousals, and other physiological parameters. Sleep architecture reflects the distribution of time spent across sleep stages, each of which plays distinct physiological roles. In healthy adults, sleep typically consists of approximately 50% N2, 20% N3 (slow-wave sleep), 25% REM sleep, and 5% N1 sleep, cycling throughout the night. N3 sleep is particularly important for physical restoration and metabolic regulation, while REM sleep is involved in emotional regulation and cognitive processing. Disruption of these stages, as well as sleep fragmentation and altered sleep continuity, has been associated with adverse health outcomes including cardiovascular disease, neurocognitive decline, and metabolic dysfunction.

Although PSG studies in PLWH are limited, existing evidence suggests consistent abnormalities in sleep architecture and continuity. Studies have reported reduced sleep efficiency, increased wake after sleep onset, altered distribution of sleep stages, reduced slow-wave sleep, and disrupted REM patterns in PLWH compared with HIV-negative controls. These abnormalities appear to persist even in virologically suppressed individuals on ART. Some evidence suggests that PLWH may exhibit increased vulnerability to sleep disruption in the presence of comorbid conditions such as obstructive sleep apnoea, with more pronounced effects on sleep architecture than in HIV-negative populations. Importantly, most PSG studies in PLWH have been conducted in predominantly male cohorts, limiting generalisability to women.