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. Author manuscript; available in PMC: 2025 Aug 1.
Published in final edited form as: J Acquir Immune Defic Syndr. 2024 Aug 1;96(4):326–333. doi: 10.1097/QAI.0000000000003444

Associations of sleep deficiency with sexual risk behaviors and HIV treatment outcomes among men who have sex with men living with or at high risk of acquiring HIV

Allison D Rosen 1,2, Marjan Javanbakht 1, Steven J Shoptaw 2,3, Marissa J Seamans 1, Pamina M Gorbach 1,4
PMCID: PMC11207189  NIHMSID: NIHMS1988050  PMID: 38916426

Abstract

Background:

Associations of sleep deficiency and methamphetamine use with sexual health and HIV treatment outcomes are poorly understood.

Setting:

Longitudinal cohort of men who have sex with men at risk for or living with HIV (the mSTUDY). This analysis included 1445 study visits among 382 participants. Data was collected from June 2018-February 2022.

Methods:

Semi-annual study visits included self-interviews for sleep deficiency, sexual behaviors, substance use, and HIV treatment. Sleep deficiency was measured using the Pittsburgh Sleep Quality Index. Participants provided specimens for HIV viral load and STI testing (chlamydia, gonorrhea, syphilis). Associations between sleep deficiency and STI/HIV outcomes were estimated using multiple logistic regression.

Results:

Across visits, prevalence of sleep deficiency was 56%, with 33% reporting methamphetamine use and 55% living with HIV. Sleep deficiency was associated with reporting at least one new anal sex partner (aOR=1.62, 95% CI: 1.21–2.15), exchange sex (aOR=2.71, 95% CI: 1.15–6.39), sex party attendance (aOR=2.60, 95% CI: 1.68–4.04), and missing HIV medications (aOR=1.91, 95% CI: 1.16–3.14). The association between sleep deficiency and exchange sex differed for participants who did and did not report use of methamphetamine (p=0.09).

Conclusion:

Sleep deficiency was associated with sexual health and HIV treatment behaviors after accounting for methamphetamine use. Sleep health should be considered in STI/HIV prevention, particularly for those who use methamphetamine.

Keywords: sleep, sexually transmitted infections, methamphetamine

Introduction

Sleep deficiency is characterized by sleep deprivation (inadequate duration of sleep), low sleep quality, timing of sleep that disrupts circadian rhythms, and sleep disorders.1 Sleep deficiency is especially common among men who have sex with men (MSM), possibly due to factors including stress, history of trauma, and perceived safety.2–5 In fact, analysis of data from the National Health Interview Survey found that in comparison to men who identify as heterosexual or bisexual, men who identify as gay are more likely to report difficulty falling asleep, using medications for sleep, and not feeling well-rested.5 Methamphetamine use is also prevalent among MSM, and use of stimulants has been associated with disrupting circadian rhythms, difficulty falling asleep, decreased total sleep time, and daytime sleepiness.6–9 In addition, poor sleep quality, short sleep duration, problems falling asleep, and problems staying awake have been linked to a variety of sexual risk behaviors associated with acquisition of sexually transmitted infections (STI) among MSM including condomless receptive anal intercourse and receptive anal intercourse with multiple partners.10,11

The United States is facing a resurgence of the epidemics of STIs and HIV. Between 2017 and 2021, chlamydia, gonorrhea, and syphilis incidence increased by 4%, 28% and 74% respectively, and in 2019 nearly 37,000 Americans were diagnosed with HIV.12,13 It is well established that MSM share a disproportionate burden of this epidemic, accounting for nearly half of gonorrhea and syphilis diagnoses and 70% of HIV new diagnoses.12,13 The disparity in STI incidence between MSM and the general population is likely explained by a combination of social, behavioral, and biological factors including stigma and prevalence of high risk sexual behaviors that may include multiple partners and inconsistent condom use.14 In addition, there is an increased risk of STI acquisition associated with receptive anal intercourse.15,16 Lastly, HIV is prevalent among MSM, and the chronic immune activation caused by HIV infection increases susceptibility to co-infection by other pathogens.17

Substance use has been well-established as a strong determinant of sexual behaviors that increase the risk of STI/HIV transmission among MSM.18 In particular, among those who report methamphetamine use during sexual activity there is an association with increased reports of risk behaviors such as increased number of sex partners, concurrent partnerships, transactional sex, and engaging in condomless anal intercourse with a partner who has unknown or discordant HIV-status.18–24

Sleep deficiency is also common among MSM living with HIV, who are more likely to report sleep deficiency and use of sleep medication than their counterparts who are not living with HIV.25–30 This disparity may be partially due to sleep disturbances caused by medications used to treat HIV.31–33 Specifically, sleep deficiency has been linked to behaviors that may be associated with HIV disease progression such as difficulty adhering to HIV medications, but not HIV disease outcomes such as having a detectable viral load.34,35

Further research is needed to expand knowledge of the established associations between sleep deficiency and risk behaviors, especially among MSM who use methamphetamine. This study aims to better understand how sleep deficiency and methamphetamine use are associated with both sexual and HIV risk behaviors as well as disease outcomes related to STIs and HIV. We hypothesized that sleep deficiency would be independently associated with increased odds of both risk behaviors and disease outcomes, and that the strength of these relationships would link with methamphetamine use.

Methods

Study Design

Data from this study come from the mSTUDY cohort which is funded by the National Institute on Drug Abuse (NIDA). Enrollment began in 2014 and follow-up is ongoing. Participants are recruited from a community-based organization providing a broad spectrum of services for the lesbian, gay, bisexual, and transgender community, and a community-based university research clinic both located in Los Angeles, CA. Participants attend semi-annual study visits where they complete a behavioral survey and provide biospecimens including blood and urine samples. During the height of the COVID-19 pandemic between March 2020 and June 2021, participants completed the behavioral survey remotely and did not provide biospecimens for STI and HIV viral load tests.

mSTUDY inclusion criteria are: (1) between age 18 and 45 at enrollment; (2) assigned male sex at birth; (3) ability to provide informed consent; and (4) willingness to return for follow-up visits. Participants must also be living with HIV or report high risk for HIV acquisition if not living with HIV (defined as condomless anal intercourse with a male partner in the past six months). Two independent factors, substance use and HIV status, were purposefully used to enroll the cohort, with half of participants enrolling with active substance use and half of participants enrolling while living with HIV. This analysis includes data between June 2018 and February 2022, when assessment of sleep deficiency was added to the mSTUDY behavioral survey. The University of California, Los Angeles Institutional Review Board approved the study, and all participants provided written informed consent.

Measures

The primary analyses focused on how the intersection of methamphetamine use and sleep affects sexual behaviors and HIV treatment related behaviors. Secondary outcomes included STI testing results and HIV viral load, given the limited statistical power. Sexual behaviors included reporting a new anal sex partner in the past six months, reporting concurrent sex partners in the past six months, reporting exchange sex in the past three months, and attending a circuit, hookup, or sex party in the past six months. Exchange sex was defined as giving or getting money, drugs, or a place to stay in exchange for anal sex. HIV treatment behaviors included reporting one or more missed appointments with an HIV care provider in the past six months and reporting missed HIV medication over the past weekend.

Biomarkers of disease outcomes related to sexual risk behaviors included a positive test for any STI. Chlamydia (CT) and Gonorrhea (GC) were assessed using urine tests (CT) and rectal and throat swabs (GC). Syphilis was assessed using the rapid plasma regain test (RPR), with confirmatory testing using the Treponema pallidum particle agglutination test (TPPA). The result was counted as positive if it was determined to be primary, secondary, or early latent syphilis based on standard of care health department investigation of syphilis cases as specified by the Centers for Disease Control STD prevention and Treatment guidelines.36 The disease outcome related to HIV treatment behaviors was having a detectable viral load, defined as greater than 20 copies per milliliter. These outcomes were only available for a subset of our sample given that STI and HIV viral load test results were not available due to a pause in in-person study visits during the height of the COVID-19 pandemic.

The exposure, sleep deficiency, was assessed using the Pittsburgh Sleep Quality Index (PSQI), a widely used, validated questionnaire that measures sleep quality and disturbance in the past 30 days. Measures of subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction are combined to create a global sleep quality score ranging from 0–21 with higher scores indicative of worse sleep.37 Sleep deficiency was defined as a PSQI score above five.37

All covariates were measured via self-report in a computer assisted self-administered questionnaire completed every six months, except HIV-status which was measured with a blood test. Race/Ethnicity was categorized as Black/African American, Hispanic/Latinx/Spanish, white, and other. Unstable housing was defined as not having a regular place to stay at least one time in the past six months. Depressive symptoms were defined as a score above 23 on the Centers for Epidemiologic Studies Depression Scale (CES-D), which measures depressive symptomology in the past seven days; previous research suggests that 23 is a more accurate cutoff for people living with HIV than the more commonly used score of 16 for the general population.38 Anxiety symptoms were defined as a score above 9 on the Generalized Anxiety Disorder 7-Item (GAD-7), which screens for symptoms of generalized anxiety disorder over the previous two weeks.39 Binge drinking was defined as having six or more drinks on at least one occasion in the past six months (AUDIT-3).40 Cigarette smoking, cannabis use, and methamphetamine use were defined as using the respective substance at least one time in the past six months and were measured using a version of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) that was adapted to capture substance use in the past six months.41 Other substances, including cocaine and opioids, were not considered due to low prevalence in this cohort.

Statistical Analysis

All analyses were conducted using R version 4.0.1. and a P value less than 0.05 was considered statistically significant. Characteristics of the participants were first compared across study visits. Socio-demographics, substance use, sexual risk behaviors, STIs, HIV treatment behaviors, and HIV outcomes were compared for those who reported sleep deficiency and those who did not report sleep deficiency. Count and percentage were calculated for categorical variables, and mean and standard deviation were calculated for continuous variables. Bivariate differences between sleep deficiency and participant characteristics were compared using chi-squared tests adjusting for repeated measures.

The odds ratio for the association between sleep deficiency and each outcome of interest was estimated using logistic regression. Bivariate associations were first considered, and then multiple logistic regression was used to account for covariates. Logistic regression models were fit with generalized estimating equations to account for within-subject correlations due to repeated observations on the same subject.42,43 Multiple logistic regression models were adjusted for age at visit, race/ethnicity, unstable housing, depressive symptoms, anxiety symptoms, methamphetamine use, cannabis use, binge drinking, and cigarette smoking. Models focused on STI-related outcomes also adjusted for HIV-status, and models focused on HIV-related outcomes included only those living with HIV. Covariates were chosen based on literature review. Models were fit using the R package gee.44

Further, differences in the association between sleep deficiency and behavioral outcomes of interest were compared for those who did and did not report use of methamphetamine. Logistic regression models fit with generalized estimating equations and a coefficient for the product of sleep deficiency and methamphetamine were used to test for statistical interaction. In order to improve statistical power, a P value less than 0.1 was considered statistically significant for tests of interaction.

Results

This analysis included 1445 visits among 382 individuals between June 2018 and February 2022. The mean number of visits per participant was 3.8 (SD=1.9), with a range of 1–8 visits. Among all visits, the mean PSQI score was 6.8 (SD=4.1), and 806 (55.8%) were among participants with sleep deficiency. Across visits, the average age of participants was 35.5 years, 775 (53.7%) were living with HIV, and 615 (42.6%) identified as Latinx/Hispanic/Spanish, 592 (41%) identified as Black/African American, 170 (11.8%) identified as White, and 68 (4.7%) identified as another race/ethnicity (Table 1). The number of visits per participant did not differ by baseline age or race/ethnicity (data not shown).

Table 1.

Characteristics of mSTUDY participants across visits, June 2018 – February 2022.

Total Visits Sleep Deficiency1 No Sleep Deficiency
(n=1445) (n=806) (n=639)
n (%) n (%) n (%) P
Socio-Demographics
Age at Visit, mean (SD) 35.5 (7) 35.5 (6.9) 35.6 (7.2) 0.78
Race/Ethnicity 0.43
 Latinx/Hispanic/Spanish 615 (42.6) 365 (45.3) 250 (39.1)
 Black/African American 592 (41) 315 (39.1) 277 (43.3)
 White 170 (11.8) 89 (11) 81 (12.7)
 Other 68 (4.7) 37 (4.6) 31 (4.9)
HIV-Positive 775 (53.7) 445 (55.3) 330 (51.7) 0.46
Unstable Housing2 246 (19.0) 167 (23.4) 79 (13.6) <0.01
Unemployed 342 (24.2) 204 (25.8) 138 (22.2) 0.26
Depressive Symptoms3 398 (27.5) 321 (39.8) 77 (12.1) <0.01
Anxiety Symptoms3 307 (21.5) 247 (31.0) 60 (9.5) <0.01
Substance Use, past 6 mos.
Methamphetamine Use 476 (32.9) 309 (38.3) 167 (26.1) <0.01
Cannabis Use 728 (50.4) 449 (55.7) 279 (43.7) <0.01
Binge Drinking4 597 (41.3) 362 (44.9) 235 (36.8) 0.01
Cigarette Smoking (current) 314 (21.8) 203 (25.2) 111 (17.4) <0.01
Sexual Risk Behavior and STIs
New anal sex partner, past 6 mos. 704 (48.9) 437 (54.5) 267 (41.8) <0.01
Concurrent sex partners, past 6 mos. 250 (34.7) 160 (38.6) 90 (29.3) 0.01
Exchange sex, past 3 mos.5 88 (11.3) 68 (15.3) 20 (6) <0.01
Attended circuit, hook up, or sex party, past 6 mos. 184 (13) 131 (16.6) 53 (8.5) <0.01
Positive STI (chlamydia, gonorrhea, and/or syphilis)7 105 (15.2) 61 (15.7) 44 (14.5) 0.57
HIV Risk Behaviors and Outcomes 6
Missed ≥1 appointment with HIV care provider, past 6 mos. 213 (28.2) 138 (31.8) 75 (23.2) 0.14
Missed HIV medications, past weekend 198 (27.7) 139 (34.2) 59 (19.1) <0.01
Detectable viral load (>20 c/ml)7 140 (34.1) 84 (35.3) 56 (32.4) 0.98
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1

Sleep deficiency defined as Pittsburgh Sleep Quality Index (PSQI) score above 5

2

Unstable housing defined as not having a regular place to stay at least once in the past six months

3

Depressive symptoms defined as Center for Epidemiologic Studies Depression Scale (CES-D) score above 23; Anxiety symptoms defined as Generalized Anxiety Disorder 7 (GAD-7) score above 9.

4

Binge drinking defined as having 6 or more drinks on one occasion

5

Exchange sex defined as gave or got money, drugs, or a place to stay in exchange for anal sex

6

Among participants living with HIV

7

Among 692 visits with STI testing and 411 visits with HIV viral load testing.

While there were no meaningful differences by age, race/ethnicity, and HIV-status in terms of sleep deficiency, unstable housing was reported at nearly twice as many visits where sleep deficiency was reported compared to visits without sleep deficiency (23.4% vs. 13.6%, p<0.01) (Table 1). Substance use was also higher in visits where sleep deficiency was reported. For instance, 38.3% of those with sleep deficiency reported methamphetamine use as compared to 26.1% of those without sleep deficiency (p<0.01). Both depressive symptoms and anxiety symptoms were significantly higher among participants who reported sleep deficiency (p<0.01).

Across all study visits, nearly half reported new anal sex partners (48.9%), with 34.7% reporting concurrent partnerships and 11.3% reporting exchange sex. Among the subset of study visits with STI testing results (n=692), STI positivity was 15.2% (Table 1). Across visits where sleep deficiency was reported there was a higher prevalence of new anal sex partners (54.5% vs. 41.8%, p<0.01), concurrent partners (34.7% vs. 38.6%, p=0.01), exchange sex (15.3% vs. 6.0%, p<0.01), and sex party attendance (16.6% vs. 8.5%, p<0.01) as compared to visits without reports of sleep deficiency. Differences in HIV treatment-related behaviors were also noted for those with and without sleep deficiency: 34.2% of those with sleep deficiency reported skipped doses of HIV medications as compared to 23.2% in visits where sleep deficiency was not reported (p<0.01).

Bivariate associations between sleep deficiency and all behavioral outcomes are presented in Table 2. Adjusting for sociodemographic characteristics and substance use, sexual behaviors were associated with sleep deficiency: those with sleep deficiency had nearly 3 times the odds of reporting exchange sex as compared to those without sleep deficiency (adjusted odds ratio (AOR) 2.71; 95% confidence interval (CI) 1.15–6.39) or attending a sex party (aOR 2.60; 95% CI 1.68–4.04). Among participants living with HIV, the odds of having missed HIV medications was almost twice as high among those with sleep deficiency (aOR=1.91; 95% CI: 1.16–3.14) as compared to those without sleep deficiency. Sleep deficiency was not associated with STI positivity (aOR = 1.06, 95% CI: 0.62 – 1.81) or detectable viral load (aOR=1.06, 95% CI: 0.59 – 1.89) (Table 2). The relationship between sleep deficiency and outcomes of interest were also assessed longitudinally, and no differences in sleep deficiency or outcomes of interest were observed over time (data not shown).

Table 2.

Association of sleep deficiency with sexual risk behaviors, STIs, HIV risk behaviors, and HIV outcomes across visits, June 2018 – February 2022.

Model Outcome1 OR (95% CI) AOR (95% CI)2
Sexual Risk Behaviors and STIs
New anal sex partner, past 6 mos. 1.67 (1.30, 2.13) ** 1.62 (1.21, 2.15)**
Concurrent sex partners, past 6 mos. 1.52 (1.04, 2.21) * 1.58 (0.98, 2.56)
Exchange sex, past 3 mos.3 2.86 (1.59, 5.11) ** 2.71 (1.15, 6.39)*
Attended circuit, hook up, or sex party, past 6 mos. 2.15 (1.48, 3.10) ** 2.60 (1.68, 4.04)**
Positive STI (chlamydia, gonorrhea, and/or syphilis) 1.09 (0.72, 1.68) 1.06 (0.62, 1.81)
HIV Risk Behaviors and Outcomes 4
Missed ≥1 appointment with HIV provider, past 6 mos. 1.54 (1.04, 2.27) * 1.39 (0.85, 2.28)
Missed HIV medications, past weekend 2.21 (1.47, 3.31) ** 1.91 (1.16, 3.14)*
Detectable viral load (>20 c/ml) 1.14 (0.71, 1.82) 1.06 (0.59, 1.89)
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Abbreviations: OR=odds ratio, AOR=adjusted odds ratio, STI=sexually transmitted infection,

*

p<0.05,

**

p<0.01

1

Exposure for all models was sleep deficiency, defined as score above 5 on Pittsburgh Sleep Quality Index (PSQI)

2

Adjusted for age at visit, race/ethnicity, unstable housing, depressive symptoms, anxiety symptoms, methamphetamine use, cigarette smoking, binge drinking, and cannabis use; models with sexual behavior as the outcome also adjusted for HIV-status.

3

Exchange sex defined as gave or got money, drugs, or a place to stay in exchange for anal sex

4

Among participants living with HIV

Differences in prevalence of behavioral outcomes across levels of sleep deficiency and methamphetamine use are presented in Figure 1. The prevalence of all outcomes was generally highest among participants who used methamphetamine and reported sleep deficiency. The relationship between sleep deficiency and exchange sex significantly differed by methamphetamine use (p=0.09).

Figure 1.

Figure 1.

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Prevalence of sexual risk behaviors and HIV treatment outcomes by sleep deficiency and methamphetamine use across visits, June 2018 – February 2022.

Discussion

Our findings showed that after controlling for substance use and socio-demographic factors, sleep deficiency was independently associated with a range of HIV-related risk behaviors. These include having at least one new anal sex partner, exchange sex, attending a circuit, hookup, or sex party, and missing HIV medications. The lack of association between sleep deficiency and disease outcomes may indicate that sleep deficiency indirectly affects disease outcomes through its association with risk behaviors; future analyses may also need to account for a time lag between current sleep quality, reported risk behaviors, and disease outcomes.

These findings are consistent with the limited literature on sleep deficiency and its relationship to sexual risk behaviors among MSM. In this cohort, the majority of participants reported sleep deficiency – almost twice the percentage from prior, internet based studies in New York and Paris.10,11 Distinctions between our findings may be due to different measurement methods, as well as overrepresentation by design in the mSTUDY cohort of two confirmed factors linked to poor sleep: living with HIV and using substances. These internet-based surveys also found associations between poor sleep and number of anal intercourse partners, a sexual risk behavior that is correlated with those investigated in this study.10,11 Our study adds to these findings by considering additional sexual risk behaviors, including reporting a new anal sex partner, exchange sex, and attending a circuit, hook up, or sex party.

It is not possible from our data to point to the specific mechanism that might account for sleep deficiency in the setting of these HIV-related risk behaviors. Instead, it appears there may be a feedback loop by which sleep deficiency might generate mood and stress problems in the presence of substance use (especially methamphetamine), which might toggle between responding to sleep-related negative affective states, which in turn, can produce more mood and stress problems as well as substance use. In support of this idea, our findings show a potential signal between methamphetamine use and risk behaviors, which might have mediation links with sleep deficiency in MSM. Whether using methamphetamine and other substances to relieve negative affective states linked to sleep deficiency, or whether using the drugs to enhance intensity of sexual experiences for MSM, isolating the mechanism that contributes most strongly to sleep deficiency is made more complex in that methamphetamine reliably alters decision making.45–47 Sleep deficiency also impairs decision-making.48–50 The mechanism for disturbance of sleep architecture and its influence on decisions regarding risk for MSM in this study likely combines to produce stress and fatigue from poor sleep. Lastly, tiredness from poor sleep may make it difficult to maintain energy needed on the job, which may limit traditional employment options and contribute to the press to engage in exchange sex. As well, methamphetamine and other substance can enhance sleep deficiencies linked to HIV, exaggerating barriers to remembering to attend appointments for HIV care and to take daily ART medications.

Lastly, findings from this study confirmed that among MSM living with HIV there is a high prevalence of sleep deficiency.25–30 However, we did not observe a difference in prevalence of sleep deficiency between those living with HIV compared to those without. This may be due to the fact that those living without HIV in mSTUDY are not comparable to the general population of people living without HIV, as they are considered at high risk for acquiring HIV and share many of the sociodemographic and behavioral characteristics of those living with HIV.

Limitations

It is important to keep in mind the limitations of this study. Much of the data used in this analysis is self-reported; social desirability bias may cause participants to answer questions inaccurately, especially when being asked about sensitive topics such as substance use and sexual behavior. mSTUDY uses computer-assisted self-interviewing (CASI) rather than face-to-face interviews in order to minimize potential underreporting of these behaviors. This study may also be limited by forms of measurement error other than social desirability bias. The PSQI has been widely used to measure sleep deficiency in diverse populations since its creation in 1989. Despite its frequent use in studies of alcohol use disorder, it does not appear to have been specifically validated for populations who use alcohol or other substances. In addition to substance users, mSTUDY participants belong to a number of unique populations including MSM, PLWH, and people experiencing unstable housing or homelessness. The PSQI does not appear to have been validated in any of these populations, or among individuals at the intersections of these populations. To our knowledge, the closest population that the PSQI has been validated for is people with psychiatric disorders in Japan.51 Thus, the PSQI results should be interpreted with some caution.52 Lastly, our results may be affected by uncontrolled confounding.

This study is limited by its sample size, particularly the analyses of disease outcomes and the interaction analyses; further research with larger sample sizes is needed to more formally test the extent to which sleep deficiency and methamphetamine use interact to influence risk behaviors, especially for exchange sex and concurrent partners, which reached significance or near significance in our analyses when using a less conservative P-value cutoff, which is common when testing for interaction. Additionally, sleep deficiency, substance use, and sexual health and HIV treatment behaviors are interconnected and cyclic. For instance, lack of high-quality sleep may lead to increased stress and impaired decision making that further leads to sexual risk-taking. Alternatively, engagement in risk behaviors may cause excessive worry and in turn negatively impact sleep. Because all three factors were assessed at a single study visit, the directionality of these results should be interpreted with caution. These limitations will severely limit the ability to make any causal inferences from this study. Lastly, mSTUDY is a convenience sample that is not necessarily representative of all MSM in Los Angeles. While this does not impact the internal validity of this study, caution should be taken when considering the generalizability of the results.

Conclusions

Taken together with findings from other studies, this analysis highlights the importance of sleep health among MSM living with or at high risk of acquiring HIV.53 Not only is sleep deficiency highly prevalent in this population, but it is also linked to a variety of sexual health and HIV treatment behaviors. The results of this study are especially compelling because they account for substance use (particularly methamphetamine use), which is strongly associated with both sleep deficiency and sexual risk behavior and STI/HIV acquisition. Further research is needed to better understand whether interventions focused on alleviating sleep deficiency may reduce the prevalence of sexual and HIV risk behaviors. In addition, because the relationship between substance use and sleep deficiency is cyclic, reduction in sleep deficiency may in turn reduce frequency of substance use.

This study provides valuable insights into the interconnectedness of poor sleep quality, sexual risk behaviors, substance use and HIV treatment outcomes among a population living at the intersection of multiple vulnerable and marginalized identities. By examining the relationship between these variables, we have shed light on the potential impact of sleep on sexual health and HIV-related outcomes within this highly vulnerable population. The strength of this study lies in its inclusion of participants who live at the intersection of multiply marginalized identities and social vulnerabilities including insecure housing, racial/ethnic minority status, and sexual minority identity. Understanding the association between sleep quality and these complex factors can contribute to the development of targeted interventions and comprehensive care strategies aimed at improving both sleep and sexual health and HIV care.

The lack of a link between sleep deficiency and having an STI or a detectable viral load observed in this study may suggest that sleep deficiency is only associated with risk behaviors, but not the disease outcomes with which they are associated. Additional research with larger sample sizes and in other populations or settings is needed to confirm this result as well as to investigate the ways in which risk behaviors may mediate the relationship between sleep deficiency and STI and HIV outcomes.

Acknowledgements

The authors wish to thank the mSTUDY staff and participants who make this research possible.

Sources of support:

mSTUDY is funded by the National Institute on Drug Abuse (U01DA036267) and Drs. Shoptaw and Gorbach are the MPIs.

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