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. Author manuscript; available in PMC: 2026 Apr 15.
Published before final editing as: J Acquir Immune Defic Syndr. 2026 Apr 10:10.1097/QAI.0000000000003856. doi: 10.1097/QAI.0000000000003856

Sleep Quality by Reproductive Stage among Women Living with HIV in the United States Enrolled in the Health Outcomes around Pregnancy and Exposure to HIV/Antiretrovirals (HOPE) Study

Rusul Al-Ani 1, Paige L Williams 2,3, Jessica Lee 2, Deborah Kacanek 2, Sara R Schenkel 4, Mariam Davtyan 5, Shamika Baker 3, Suzanne Siminski 6, Mary E Paul 7, Denise L Jacobson 2, Sharon Nichols 8, Kathleen M Powis 9,10; for the HOPE study team
PMCID: PMC13078638  NIHMSID: NIHMS2135115  PMID: 41962148

Abstract

Background

Sleep quality significantly impacts health. Despite evidence that women living with HIV experience higher rates of poor sleep quality compared to women who are HIV seronegative, few studies have explored sleep quality among women with HIV by reproductive stage.

Setting

HOPE is an observational study of women living with HIV (WLHIV) ages 18–45, enrolled at 14 sites across the United States and Puerto Rico.

Methods

At entry, participants reported their reproductive stage as nulliparous, pregnant, within 1-year postpartum, or >1-year postpartum (parous). Participants completed the Brief Pittsburgh Sleep Quality Index (B-PSQI), with poor sleep quality defined as a score >5. Log-binomial models were fit to estimate adjusted prevalence ratios (aPRs) of poor sleep quality by reproductive stage and predictors of poor sleep quality overall and within each reproductive stage.

Results

Of 689 participants completing the entry visit between August 2022 and February 2025, 500 (73%) had evaluable sleep quality data. Prevalence of poor sleep quality was highest among postpartum and parous women (54% and 53%, respectively), compared to nulliparous and pregnant women (48% and 44%, respectively). There was no difference in poor sleep quality prevalence by reproductive stage after adjusting for potential confounders. Screening positive for moderate/severe depression, moderate/severe anxiety, and/or post-traumatic stress disorder, as well as experiencing high perceived stress or homelessness, were associated with higher prevalence of poor sleep quality for all groups.

Conclusions:

Poor sleep quality was common in this cohort of WLHIV, regardless of reproductive stage. This work can inform interventions to improve sleep quality among WLHIV.

Keywords: HIV, reproductive stage, sleep quality, Brief Pittsburgh Sleep Quality Index

Introduction

Poor sleep quality and insufficient (less than 6 hours daily) sleep, are risk factors for type 2 diabetes mellitus, hypertension, and cardiovascular disease1–8. Many studies have evaluated sleep quality in pregnancy and/or the first year postpartum, reporting on its effect on physical and mental health, as well as how sleep quality can be impacted by physical and mental health9–12. Among women of reproductive capability, variation in sleep duration has been reported across the menstrual cycle13. Women of reproductive capability experience a higher risk of poor sleep quality compared to similarly aged men14,15, highlighting the importance of understanding whether sleep quality differs across the various reproductive states, which include being nulliparous, pregnant, within the first year postpartum, or parous but greater than one year postpartum13,16,17, and among women of reproductive capability with chronic health conditions, such as HIV.

Women represent 20% of persons living with HIV in the United States (U.S.)18. While HIV is now considered a chronic health condition due to potent and efficacious antiretroviral medications, women living with HIV (WLHIV) experience many comorbid conditions including greater risk of cardiovascular disease19,20, and higher rates of depression, anxiety, and post-traumatic stress disorder (PTSD) compared to men with HIV21. Poor mental health is associated with HIV treatment adherence challenges and sub-optimal care engagement22–25, which in turn can lead to HIV disease progression and further adversely impact sleep quality26,27. As in the general population, WLHIV report a higher frequency of poor sleep quality than men living with HIV28. Understanding sleep quality outcomes by reproductive stage and identifying modifiable variables associated with poor sleep quality by reproductive stage can inform programs/interventions to improve sleep quality among WLHIV of reproductive capability.

In this analysis, we evaluated sleep quality among WLHIV participating in the U.S.-based Health Outcomes around Pregnancy and Exposure to HIV/Antiretrovirals (HOPE) study, comparing prevalence of poor sleep quality by reproductive stage. Similarly, we compared the prevalence of various dimensions of sleep quality including sleep latency, sleep duration, sleep efficiency, and sleep disturbances by reproductive stage. We also identified risk factors for poor sleep quality by reproductive stage among HOPE participants.

Methods

Study population

The HOPE study is a prospective observational cohort study enrolling WLHIV at 14 clinical sites across 9 U.S. states and Puerto Rico29. HOPE study participants must be female, aged 18 to 45 years at enrollment with documentation of HIV infection, able to complete study assessments in English, Spanish, or Haitian Creole, and not currently incarcerated. The Harvard Longwood Campus Institutional Review Board (IRB), the single IRB of record for the HOPE study, reviewed and approved the HOPE study, and all participants signed a written informed consent for study participation.

During the entry visit, participants completed an online entry survey, which included the Brief – Pittsburgh Sleep Quality Index (B-PSQI), a validated six question instrument assessing sleep quality in the past month30. The analysis included HOPE participants who completed the HOPE online entry survey and answered any portion of the B-PSQI.

Sleep Outcomes

The six question B-PSQI, a modified version of the 18 question PSQI, was validated in 2021 and demonstrated favorable sensitivity (75.82%) and specificity (76.99%) for identifying poor sleepers, comparable to the performance of the full PSQI30. The B-PSQI score is based on 5 self-assessed dimensions of sleep quality: sleep latency, sleep duration, sleep efficiency, sleep disturbances, and overall sleep quality. Each of the 5 dimensions is scored from 0 (best) to 3 (worst), such that the total B-PSQI score can range from 0–15. Detailed B-PSQI scoring is outlined in Table 1. The primary outcome of interest was poor sleep quality, defined as a B-PSQI score of >5, a threshold recommended with high sensitivity and specificity for classifying poor sleep quality30. Participants had the option to indicate “Rather not answer” to any of the six B-PSQI questions. Participants who responded to only a portion of the six items but had a score of >5 were classified as having poor sleep quality. Four other sleep dimensions evaluated included sleep latency, defined as time required to fall asleep, sleep duration, defined as total number of hours spent sleeping, sleep efficiency, defined as sleep duration divided by the total time spent in bed, and sleep disturbances, or the number of times awakened after laying down to sleep and prior to getting up from sleep.

Table 1.

Derivation of the Brief Pittsburgh Sleep Quality Index (B-PSQI)

Sleep Dimension Question1 Responses Scoring:
Sleep Efficiency 2 1) During the past month, when have you usually gone to bed at night? ≥ 85%
75 – 84%
65 – 74%
< 65%		 0
1
2
3
2) During the past month, what time have you usually gotten up in the morning?
Sleep latency 3) During the past month, how long (in minutes) has it taken you to fall asleep each night? < 16 minutes
16 – 30 minutes
31 – 60 minutes
> 60 minutes
 0
1
2
3
Sleep duration 4) During the past month, how many hours of actual sleep did you get at night? ≥ 7 hours
≥ 6 - < 7 hours
≥ 5 - < 6 hours
< 5 hours		 0
1
2
3
Sleep disturbances 5) During the past month, how often have you had trouble sleeping because you wake up in the middle of the night or early morning? Not during the past month
Less than once a week
Once or twice a week
Three or more times a week
 0
1
2
3
Overall sleep quality 6) During the past month, how would you rate your sleep quality overall? Very good
Fairly good
Fairly bad
Very bad		 0
1
2
3
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1

Response option of “Rather not answer” included for questions in HOPE survey, although not in original validated B-PSQI

2

Sleep Efficiency: Calculated as the time spent sleeping (question 4) divided by the time spent in bed (difference between question 2 and question 1) multiplied by 100.

Exposure measures

The primary exposure of interest was the HOPE participants’ reproductive stage at the time of online entry survey completion, with reproductive stage categorized as nulliparous, pregnant or within 72 hours of giving birth (pregnant), > 72 hours of giving birth up to one year postpartum but not currently pregnant (postpartum), or more than one year postpartum but not currently pregnant (parous).

Covariates

To assess predictors of poor sleep quality, we evaluated individual, interpersonal, and community covariates assessed at entry, which we hypothesized would be associated with poor sleep quality or for which published literature reported an association. Individual covariates included age, race, ethnicity, marital status, timing of HIV acquisition (in infancy vs later in life), HIV viral load, CD4 cell count, alcohol, tobacco, marijuana, or other substance use in the last three months, screening positive for depression, anxiety or PTSD, health literacy, employment status, overnight or shift work, income, food security, and housing security. Interpersonal covariates included the number of children being parented, intimate partner violence, and self-reported experiences of discrimination. Community covariates included perception of neighborhood violence, neighborhood greenness, and neighborhood environmental noise. Standardized instruments embedded in the online survey included the Patient Health Questionnaire (PHQ-9)31, the General Anxiety Disorder screening (GAD-7)32, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Primary Care PTSD Screen (PC-PTSD-5)33, health literacy assessed via the Newest Vital Sign34, food security measured using the 6-item U.S. Household Food Security Survey Module35, exposure to discrimination based on responses to the Everyday Discrimination Scale (EDS) questionnaire36, and the B-PSQI30. To derive neighborhood green space percentage37 and the environmental noise measure38, we combined the census tract of the address where participant resided at the time of their HOPE entry visit using geocoding software with the Normalized Difference Vegetation Index (NDVI) and the National Park Service (NPS) databases, respectively39–41.

Statistical Analysis

The availability of sleep quality data was assessed for each participant, with participants classified as (1) completing all B-PSQI sleep items, (2) completing enough items to ascertain if sleep quality scores were > 5 despite any unanswered items, (3) completing some sleep items but not enough to derive a sleep quality outcome, and (4) completing none of the B-PSQI sleep items.

We summarized individual, interpersonal, and community characteristics of HOPE participants included in our analysis by reproductive stage, using medians and interquartile ranges (IQRs) for continuous variables and percentages for categorical and ordinal variables. Individual, interpersonal, and community covariates were compared between those included in the analysis and those with no or insufficient data to derive their sleep quality outcome.

A log-binomial model was fit to estimate the prevalence ratio (PR) with 95% confidence intervals (CIs) of poor sleep quality in pregnant, postpartum, and nulliparous participants as compared to parous participants. Parous participants served as the reference group because they represented the largest proportion of HOPE participants. Unadjusted and adjusted PRs of poor sleep quality were estimated for each of the covariates noted above. The primary outcome of poor sleep quality was evaluated for those participants who answered sufficient items to derive this measure. Sensitivity analyses were conducted by imputing the total sleep quality score for participants who had responses for at least 3 of the 5 dimensions. For these participants, the total score was estimated using the mean of their available dimension scores. Secondary analyses were conducted for each of the 5 sleep dimensions by dichotomizing scores of 2 or 3 (worse sleep) vs 0 or 1 (better sleep) and fitting log-binomial models, as described above.

To evaluate predictors of poor sleep within each reproductive stage and in the overall population, univariable log-binomial regression models were fit separately within each subgroup. Potential predictors of interest known to be associated with sleep quality in other studies were assessed, estimating their magnitude of association and precision based on 95% CIs. Although CD4<200 cells/mm3 was deemed a more clinically relevant predictor of HIV disease severity than CD4<500 cells/mm3, the latter predictor was considered in models due to the low proportion with CD4<200 cells/mm3 overall (8%) and particularly in pregnant and postpartum groups, leading to model instability. All analyses were conducted using SAS Version 9.4 (SAS Institute, Cary, NC).

RESULTS

Participant characteristics

Between April 18, 2022, and February 1, 2025, 689 individuals enrolled in the HOPE study and completed an entry visit online survey. Participant characteristics are presented in Table 2, overall and by reproductive stage. Over half (56%) were parous and more than a quarter (29%) had acquired HIV in infancy. Overall, 76% of participants were virally suppressed at entry, and 67% of participants had a CD4 cell count ≥ 500 cells/mm3.

Table 2.

Background Characteristics of HOPE Enrollees Overall and by Reproductive Stage

Reproductive Stage
Nulliparous (N=112) Pregnant (N=88) Postpartum (N=102) Parous and (N=387) Total (N=689)
Age at enrollment (in years)
 ≤ 25 87 (77.7%) 26 (29.5%) 22 (21.6%) 32 (8.3%) 167 (24.2%)
 26 – 30 19 (17.0%) 21 (23.9%) 28 (27.5%) 76 (19.6%) 144 (20.9%)
 31 – 35 1 (0.9%) 21 (23.9%) 34 (33.3%) 111 (28.7%) 167 (24.2%)
 36 – 45 5 (4.5%) 20 (22.7%) 18 (17.7%) 168 (43.4%) 135 (30.6%)
Perinatally acquired HIV 79 (72.5%) 15 (18.3%) 15 (16.3%) 81 (22.0%) 190 (29.2%)
Racial category
 White 19 (17.0%) 28 (31.8%) 28 (27.5%) 86 (22.2%) 161 (23.4%)
 Black 84 (75.0%) 53 (60.2%) 59 (57.8%) 257 (66.4%) 453 (65.7%)
 Other race 3 (2.7%) 1 (1.1%) 3 (2.9%) 7 (1.8%) 14 (2.0%)
 Not reported 6 (5.4%) 6 (6.8%) 12 (11.8%) 37 (9.6%) 61 (8.9%)
Hispanic or Latina 24 (21.6%) 28 (32.2%) 36 (35.6%) 117 (30.4%) 205 (30.0%)
Married (vs separated/divorced/widowed) 4 (3.6%) 18 (20.5%) 30 (29.4%) 71 (18.3%) 123 (17.9%)
Parenting at least 2 children under 18 yrs 0 (0.0%) 23 (27.7%) 56 (57.1%) 185 (49.1%) 264 (39.5%)
Physically active 35 (53.0%) 22 (46.8%) 36 (59.0%) 135 (54.4%) 228 (54.0%)
BMI>30 at entry 34 (32.4%) 56 (67.5%) 48 (53.9%) 201 (57.4%) 339 (54.1%)
Generally sleep nights (vs day) 78 (72.2%) 50 (62.5%) 57 (62.0%) 251 (70.1%) 436 (68.3%)
At least High School education 98 (88.3%) 68 (85.0%) 73 (75.3%) 301 (79.4%) 540 (81.0%)
Annual income < 20K 44 (62.9%) 36 (51.4%) 38 (48.7%) 204 (59.3%) 322 (57.3%)
Concern regarding housing stability 10 (9.0%) 14 (17.3%) 16 (16.5%) 39 (10.3%) 79 (11.8%)
Currently working 60 (54.1%) 40 (49.4%) 28 (28.9%) 193 (50.8%) 321 (48.0%)
Moderate/severe depression symptoms (PHQ9) 19 (17.6%) 10 (11.9%) 13 (14.0%) 50 (13.9%) 92 (14.3%)
Moderate/severe anxiety symptoms (GAD7) 18 (16.7%) 10 (11.9%) 13 (13.8%) 56 (15.6%) 97 (15.0%)
Positive PTSD screen (PC-PTSD-5) 19 (18.4%) 17 (21.8%) 18 (20.7%) 72 (20.6%) 126 (20.4%)
Lower health literacy (Newest Vital Sign) 48 (46.6%) 40 (51.3%) 49 (58.3%) 176 (50.6%) 313 (51.1%)
Low food security status 18 (17.5%) 18 (23.1%) 29 (30.9%) 128 (35.0%) 193 (30.1%)
Sexual, physical or emotional violence 21 (18.9%) 27 (32.1%) 21 (21.2%) 74 (19.5%) 143 (21.2%)
Perception that neighborhood violence is not a problem 34 (30.6%) 16 (19.0%) 22 (22.2%) 109 (28.7%) 181 (26.9%)
High self-perceived stress (PSS-4>5) 70 (65.4%) 40 (51.9%) 48 (53.9%) 217 (61.0%) 375 (59.6%)
Everyday Discrimination Scale >20 24 (22.0%) 14 (17.3%) 21 (22.6%) 83 (23.2%) 142 (22.2%)
Substance use in last 3 months
 Alcohol 43 (39.4%) 4 (4.8%) 21 (21.4%) 141 (37.5%) 209 (31.4%)
 Tobacco 31 (28.4%) 9 (10.8%) 17 (17.3%) 80 (21.3%) 137 (20.6%)
 Marijuana 43 (39.4%) 12 (14.5%) 20 (20.4%) 95 (25.3%) 170 (25.5%)
HIV Disease severity measures
 CD4 count < 500 cells/mm3 24 (32.0%) 27 (49.1%) 15 (23.4%) 70 (31.8%) 136 (32.9%)
 HIV viral load > 50 copies/mL 30 (28.3%) 11 (14.5%) 18 (19.8%) 82 (26.1%) 141 (24.0%)
High Noise (>55 dB) 16 (33.3%) 9 (25.0%) 16 (34.8%) 73 (39.2%) 114 (36.1%)
Low neighborhood greenness (NDVI<0.2) 15 (31.3%) 5 (14.3%) 13 (28.3%) 71 (38.2%) 104 (33.0%)
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Note: percentages are shown among those with data available for each characteristic.

A total of 436 (63%) answered all B-PSQI items, while 64 (9%) answered a sufficient portion of items to calculate sleep quality. Age distribution, race, ethnicity, education level, and other covariates were similar between the group with sufficient data to calculate sleep quality and the group for which a sleep quality score could not be calculated. (Supplemental Table 1)

Summary of sleep measures

Table 3 summarizes sleep-related outcomes, overall and by reproductive stage. Overall, half of participants (51%) had poor sleep quality. The prevalence of poor sleep quality was highest in the postpartum and parous groups (54% and 53% respectively), followed by 48% in the nulliparous group, and 44% in the pregnant group.

Table 3.

Summary of Sleep Measures Overall and by Reproductive Stage Among HOPE Participants Completing an Enrollment Survey

Reproductive Stage
Nulliparous (N=112) Pregnant (N=88) Postpartum (N=102) Parous (N=387) Total (N=689)
Poor sleep quality (B-PSQI>5)
 No 43 (52.4%) 35 (56.5%) 33 (46.5%) 133 (46.7%) 244 (48.8%)
 Yes 39 (47.6%) 27 (43.5%) 38 (53.5%) 152 (53.3%) 256 (51.2%)
 Not evaluable 30 26 31 102 189
Poor sleep quality (imputed B-PSQI>5, at least 3 non-missing)
 No 51 (55.4%) 41 (58.6%) 41 (51.3%) 152 (49.7%) 285 (52.0%)
 Yes 41 (44.6%) 29 (41.4%) 39 (48.8%) 154 (50.3%) 263 (48.0%)
 Not evaluable 20 18 22 81 141
B-PSQI
 N 71 56 64 245 436
 Mean (s.d.) 5.39 (3.06) 5.64 (3.61) 6.17 (3.29) 5.73 (3.41) 5.73 (3.36)
Self-reported Sleep quality overall
 Very good 17 (15.3%) 18 (21.4%) 16 (16.2%) 71 (18.6%) 122 (18.1%)
 Fairly good 65 (58.6%) 38 (45.2%) 45 (45.5%) 163 (42.8%) 311 (46.1%)
 Fairly bad 17 (15.3%) 21 (25.0%) 29 (29.3%) 77 (20.2%) 144 (21.3%)
 Very bad 10 (9.0%) 6 (7.1%) 6 (6.1%) 48 (12.6%) 70 (10.4%)
 Rather not answer 2 (1.8%) 1 (1.2%) 3 (3.0%) 22 (5.8%) 28 (4.1%)
Sleep disturbances: how often had trouble sleeping?
 Not during the past month 26 (23.4%) 20 (23.8%) 23 (23.2%) 104 (27.3%) 173 (25.6%)
 Less than once a week 19 (17.1%) 11 (13.1%) 13 (13.1%) 57 (15.0%) 100 (14.8%)
 Once or twice a week 31 (27.9%) 23 (27.4%) 12 (12.1%) 77 (20.2%) 143 (21.2%)
 Three or more times a week 30 (27.0%) 30 (35.7%) 39 (39.4%) 117 (30.7%) 216 (32.0%)
 Rather not answer 5 (4.5%) 0 (0.0%) 12 (12.1%) 26 (6.8%) 43 (6.4%)
Time to falling asleep (min)
 N 84 68 76 282 510
 Mean (s.d.) 29.7 (23.3) 28.0 (27.3) 32.5 (36.4) 35.9 (42.5) 33.3 (37.2)
 Long time to fall asleep (>30min) 19 (22.6%) 16 (23.5%) 20 (26.3%) 75 (26.6%) 130 (25.5%)
Hours of sleep
 N 89 61 76 291 517
 Mean (s.d.) 6.76 (1.74) 7.07 (2.03) 6.63 (2.54) 6.45 (1.90) 6.61 (2.00)
 Short sleep duration (<6 hrs) 19 (21.3%) 12 (19.7%) 16 (21.1%) 83 (28.5%) 130 (25.1%)
Sleep efficiency (hrs asleep/hrs in bed)
 N 79 58 71 262 470
 Mean (s.d.) 84.7% (23.5) 84.4% (24.0) 78.9% (63.2) 83.3% (46.2) 83.0% (44.1)
 Low sleep efficiency (<75%) 23 (29.1%) 16 (27.6%) 23 (32.4%) 74 (28.2%) 136 (28.9%)
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Notes: The category pregnant constitutes HOPE participants who completed the online entry survey while pregnant or within 72 hours after delivery. The category of postpartum constitutes HOPE participants who completed the entry online survey in their first year postpartum and were not pregnant. The category parous reflects HOPE participants with a prior birth of at least one child who were more than 1 year postpartum and not pregnant at the time they completed the online entry survey.

Using available data from the overall population of 689 participants, the mean time to fall asleep was approximately 33 minutes. Participants reported getting an average of 6.6 hours of sleep in 24 hours, with 25% getting less than 6 hours of sleep on average. Low sleep efficiency (efficiency value of <75%) was reported by 29% of participants. Almost one third of participants (32%) reported sleep difficulties ≥ 3 times a week. The nulliparous group reported the lowest prevalence of bad/very bad sleep quality and sleep disturbances and had the lowest mean B-PSQI score.

Comparisons of poor sleep quality by reproductive stage

Unadjusted and adjusted prevalence ratios (PRs) with 95% CIs for poor sleep quality (B-PSQI >5) by reproductive stage are presented in Table 4. Compared to the parous group, the prevalence ratio of poor sleep quality did not differ for nulliparous [aPR=0.95 (95% CI: 0.69, 1.32)], pregnant [aPR=0.84 (95% CI: 0.62, 1.13)], or postpartum [aPR=0.98 (95% CI: 0.75, 1.26)] groups, after adjusting for age, tobacco use, mode of HIV acquisition, marital status, food security, exposure to violence, housing situation, and experiences of discrimination, variables known to be associated with poor sleep quality42–46. The sensitivity analyses using imputed values for poor sleep quality yielded consistent results (data not shown). Table 4 also summarizes the unadjusted and adjusted PRs by reproductive stage for other B-PSQI sub-scales including sleep latency > 30 minutes, sleep efficiency < 75%, poor overall sleep quality, sleep duration < 6 hours, and trouble sleeping ≥ 3 times per week. Overall, there were no substantial differences in these domains by reproductive stage; however, postpartum women had a higher prevalence of trouble sleeping ≥3 times per week compared with parous women (aPR=1.35 (95% CI: 1.01, 1.81).

Table 4.

Unadjusted and Adjusted Prevalence Ratios for Poor Sleep Quality (B-PSQI>5) and Poore Sleep Subscales by Reproductive Stage

Outcome Stage PR (95% CI) P-value Adjusted PR1 (95% CI) P-value
Poor sleep quality (B-PSQI>5) Nulliparous 0.89 (0.69, 1.15) 0.37 0.95 (0.69, 1.32) 0.78
Pregnant 0.82 (0.60, 1.11) 0.19 0.84 (0.62, 1.13) 0.25
Postpartum 1.00 (0.79, 1.28) 0.98 0.98 (0.75, 1.26) 0.85
Ref: Parous 1.00 (ref) . 1.00 (ref) .
Sleep subscale:
Long sleep latency (>30 min) 		Nulliparous 0.85 (0.55, 1.32) 0.47 0.73 (0.43, 1.25) 0.26
Pregnant 0.88 (0.55, 1.42) 0.61 0.84 (0.52, 1.37) 0.50
Postpartum 0.99 (0.65, 1.51) 0.96 0.88 (0.57, 1.38) 0.59
Ref: Parous 1.00 (ref) . 1.00 (ref) .
Sleep subscale: Low sleep efficiency (<75%) Nulliparous 1.03 (0.69, 1.53) 0.88 0.98 (0.59, 1.61) 0.92
Pregnant 0.98 (0.62, 1.55) 0.92 0.96 (0.60, 1.55) 0.88
Postpartum 1.15 (0.78, 1.69) 0.49 1.07 (0.72, 1.59) 0.74
Ref: Parous 1.00 (ref) . 1.00 (ref) .
Sleep subscale: Poor overall quality Nulliparous 0.71 (0.50, 1.02) 0.06 0.71 (0.47, 1.07) 0.10
Pregnant 0.93 (0.66, 1.31) 0.70 0.84 (0.59, 1.21) 0.36
Postpartum 1.05 (0.78, 1.41) 0.76 0.94 (0.70, 1.27) 0.70
Ref: Parous 1.00 (ref) . 1.00 (ref) .
Sleep subscale: Short sleep duration (< 6 hrs) Nulliparous 0.75 (0.48, 1.16) 0.20 0.93 (0.54, 1.59) 0.80
Pregnant 0.69 (0.40, 1.18) 0.18 0.72 (0.41, 1.26) 0.25
Postpartum 0.74 (0.46, 1.18) 0.21 0.73 (0.44, 1.19) 0.21
Ref: Parous 1.00 (ref) . 1.00 (ref) .
Sleep subscale: Trouble sleeping (3+ times/week) Nulliparous 0.86 (0.61, 1.20) 0.38 0.78 (0.52, 1.17) 0.22
Pregnant 1.08 (0.78, 1.50) 0.63 1.08 (0.78, 1.51) 0.63
Postpartum 1.36 (1.03, 1.79) 0.03 1.35 (1.01, 1.81) 0.04
Ref: Parous 1.00 (ref) . 1.00 (ref) .
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1

Adjusted models account for age, tobacco use, perinatal HIV status, marital status, low food security, exposure to violence, housing concern, and positive screen for Everyday Discrimination

Predictors of poor sleep quality overall and within reproductive stages

Among the 500 HOPE participants with an evaluable sleep quality outcome, the prevalence of poor sleep quality was higher among those who screened positive for moderate to severe depression [PR=1.75 (95% CI: 1.50, 2.04)], moderate to severe anxiety [PR=1.71 (95% CI: 1.47, 2.00)], or a positive PTSD screen [PR=1.49 (95% CI: 1.26, 1.76)]. Higher prevalence was also observed among participants reporting greater discrimination on the Everyday Discrimination Scale47 [PR=1.40 (95% CI: 1.18, 1.67)], high self-perceived stress [PR=1.30 (95% CI: 1.08, 1.56)], tobacco use in the past 3 months [PR=1.28 (95% CI: 1.07, 1.53)], concerns regarding housing stability [PR=1.29 (95% CI: 1.02, 1.61)], homelessness in the past 12 months [PR=1.27 (95% CI: 1.02, 1.58)], and experiences of sexual, physical or emotional violence in the past twelve months [PR=1.28 (95% CI: 1.08, 1.53)], and low household food security in the past 12 months [PR=1.23 (95% CI: 1.03, 1.46)], compared to participants without these characteristics (Figure 1, Supplemental Table 2). In contrast, the prevalence of poor sleep quality was lower among participants who were married vs. single/divorced/widowed [PR=0.63 (95% CI: 0.47, 0.84)], who acquired HIV perinatally [PR=0.74 (95% CI: 0.59, 0.92)] compared to those who acquired HIV later in life, and among Hispanic/Latina participants [PR=0.79 (95% CI: 0.64, 0.97)], compared to participants self-identifying as non-Hispanic/Latina.

Figure 1.

Figure 1.

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Association of Covariates with Prevalence of Poor Sleep Quality within each Reproductive Stage

Within each reproductive stage, participants screening positive for moderate/severe depression had a higher prevalence of poor sleep quality (Figure 1, Supplemental Table 3). There were also consistent associations across reproductive stages with higher prevalence of poor sleep quality for women with moderate/severe anxiety, high self-perceived stress, positive PTSD screen, and homelessness, although 95% CIs were wider for the pregnant and postpartum groups due to their smaller sample size. However, some differences in predictors of poor sleep quality by reproductive stage were observed. For example, women in the nulliparous, postpartum, and parous groups who reported experiencing sexual, physical, or emotional violence in the past 12 months had higher prevalence of poor sleep quality [PR=1.40, PR=1.26 and PR=1.37, respectively] compared with those without such exposure. This association, however, was not observed among pregnant women [PR=0.95]. Pregnant participants reporting concern about housing instability had a higher prevalence of poor sleep quality [PR 2.24 (95% CI 1.43, 3.53)] compared to pregnant participants reporting housing stability. However, housing stability was not a significant predictor of poor sleep quality among nulliparous, postpartum, and parous participants. Lastly, for pregnant and parous groups, those reporting household food insecurity in the last 12 months had a higher prevalence ratio of poor sleep quality compared to those without food insecurity [(PR 1.88; 95% CI 1.12, 3.16 for pregnant, PR 1.25; 95% CI 1.01, 1.55 for parous)].

Discussion

In this study of WLHIV of reproductive potential, over half (51%) reported poor sleep quality in the past month. Additionally, nearly a third reported trouble sleeping, and over a quarter experienced low sleep efficiency. Prevalence of poor sleep quality was similar across reproductive stages. Overall, participants who acquired HIV perinatally had a lower prevalence of poor sleep quality compared to those who acquired HIV later in life, while participants identifying as Black or African American had a higher prevalence of poor sleep quality compared to those who identified as White or “other” race. Additionally, screening positive for moderate to severe depression or for moderate to severe anxiety was consistently associated with the highest prevalence of poor sleep quality within all four groups; this strong association aligns with the broader scientific literature reflecting the complex, bidirectional relationship where sleep disturbances can exacerbate psychiatric symptoms, and conversely, depression and anxiety can disturb sleep architecture and efficiency48,49. Other characteristics such as high self-perceived stress, positive PTSD screen, and homelessness were consistently associated with higher prevalence of poor sleep quality across reproductive stages. However, we identified some characteristics, life experiences, and social circumstances that were predictive of sleep quality only for women in certain reproductive stages. For instance, among women in their first year postpartum, 53% had a poor sleep quality; however, the only covariate significantly predictive of poor sleep quality was a positive screen for moderate/severe depression.

The HOPE study was uniquely positioned to compare sleep quality by timing of HIV acquisition, specifically between women with perinatally acquired HIV and those with non-perinatally acquired HIV, with nearly 30% of participants having acquired HIV in infancy. Overall, living with HIV since infancy was associated with lower prevalence of poor sleep quality compared to having acquired HIV later in life, with a prevalence ratio of 0.74. Lower prevalence of poor sleep quality among participants with perinatally acquired HIV may reflect their younger average age and the fact that most were nulliparous. A limited number of studies have evaluated sleep quality among pre-menopausal women with or without HIV, with the majority of studies focused on sleep quality in pregnancy and the first year postpartum11,12,17,50. In this cohort, poor sleep quality was common, but its prevalence was comparable to, and in some cases lower than, that reported in other studies. For example, one meta-analysis of 42 studies on sleep quality in the global population of pregnant and postpartum women report a prevalence of poor sleep quality of 45% in pregnant women and 67% in postpartum women17.

Among HOPE participants, having a detectable HIV viral load or a CD4 count < 500 cells/mm3 was not significantly associated with poor sleep quality. Studies of HIV disease severity and sleep quality are limited. In an Ethiopian study of 419 individuals living with HIV (mean age 36.5 years, 64% female), a HIV viral load ≥ 1,000 copies/mL and a CD4 cell count < 200 copies/mm3 were each associated with a PSQI score > 5; [aOR 6.88 (95% CI 2.79, 16.9)] and [aOR 6.85 (95% CI 2.42, 19.39)] respectively27. This difference may be due to a higher frequency of suboptimal HIV treatment in the Ethiopia cohort, where 25% of participants had a viral load ≥ 1,000 copies/mL compared with 11% of HOPE participants and19% had a CD4 cell count < 200 cells/mm3 compared with 8% of HOPE participants.

A unique feature of this study is the integration of participants’ community of residence with national databases to assess community-level noise and greenness. Unexpectedly, the associations were in the opposite direction of our hypothesis; higher noise and lower green space were associated with a lower prevalence of poor sleep quality. Given this surprising result, further research is needed to validate and explore the underlying reasons for these findings. The smaller numbers of pregnant and postpartum women in our cohort may have limited our ability to detect associations between community factors and other characteristics with poor sleep quality in these subgroups. It would also be valuable to assess a broader set of community factors, although such factors may be less amenable to modification than individual or interpersonal factors.

This study has several strengths, including a large sample size, the assessment of sleep quality by reproductive stage, and the ability to examine associations between poor sleep quality and individual, interpersonal and community factors. We also acknowledge several limitations. For example, we assessed sleep quality in the past month. However, this may not reflect sleep quality over time. Additionally, sleep quality was only assessed by self-report which is subject to social desirability bias. While we tried to minimize social desirability bias by having participants complete an online survey instead of being individually interviewed, it is important to note that self-reported sleep characteristics have been found, in some studies, to be more accurate than other objective measures, such as actigraphy devices51–53. Participants were given the option of responding “Rather Not Answer” to any item on the survey, including the B-PSQI items, to provide participants with agency over the amount of information they share. As a result, not all participants responded to all six B-PSQI items. However, imputation for missingness did not appreciably alter the prevalence of poor sleep quality overall. While the primary aim of this study was to compare sleep quality across reproductive stages, we also conducted secondary descriptive analyses to assess associations between various covariates and sleep quality. These secondary analyses were exploratory in nature and were not designed to test hypotheses about each factor. As such, we opted not to control for multiple comparisons, instead providing preliminary data for future studies of sleep quality among women with HIV of reproductive potential. Additionally, we recognize that not all individual, interpersonal, or community level factors that may be associated with sleep quality were measured in the HOPE study. Qualitative work may be beneficial to help identify key individual, interpersonal, and community issues that should be included in future studies. Additionally, our study findings may not be generalizable to WLHIV in the US receiving HIV care in non-academic health care systems and those who are not retained in care.

Sleep is essential to good physical and mental health in any adult54, but particularly among WLHIV, as they are more likely to experience comorbidities, including cardiovascular disease and mental health conditions compared to men living with HIV19,20,55. Poor sleep quality can affect engagement in HIV care and the ability to achieve sustained viral suppression. While the prevalence of poor sleep quality did not vary by reproductive stage, some individual and interpersonal characteristics associated with the prevalence of sleep quality differed by reproductive stage. Interventions tailored to reproductive stage may be impactful in improving sleep quality among WLHIV, recognizing that improvements in sleep quality can improve overall and HIV-related health outcomes among WLHIV.

Supplementary Material

Supplementary Tables 1-3

Acknowledgments:

We thank the participants for their participation in HOPE, and the individuals and institutions involved in the conduct of HOPE study. The study was supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), through award R01HD101351 to the Harvard T.H. Chan School of Public Health (Principal Investigators: Paige Williams, Ellen Chadwick, Deborah Kacanek, Kathleen Powis, Protocol Co-Chairs: Deborah Kacanek, Kathleen Powis, Lynn Yee). Data management services were provided by Frontier Science (Data Management Center Director: Suzanne Siminski), and regulatory services and logistical support were provided by Westat, Inc (Project Director: Tracy Wolbach). The team is grateful to George Seage III (deceased), one of the original Principal Investigators of the HOPE study.

The following institutions, clinical site investigators and staff participated in conducting the HOPE study, in alphabetical order:

Ann & Robert H. Lurie Children’s Hospital of Chicago: Ellen Chadwick, Lela Lartey, Kathleen Malee; Baylor College of Medicine: Mary Paul, Alejandra Martinez, Lynnette Harris; BronxCare Health System: Murli Purswani, Martha Cavallo, Mahboobullah Mirza Baig, Alma Villegas-Schwalenberg; Children’s Diagnostic & Treatment Center: Lisa-Gaye Robinson, Kierra Archer, Alan Bernegger, Patricia Garvie; St. Jude Children’s Research Hospital: Katherine Knapp, Chloe Burkhead, Gheri Terry, Megan Wilkins; Tulane University School of Medicine: Margarita Silio, Dornese Jones, Medea Gabriel, Patricia Sirois; University of Alabama, Birmingham: Cecelia Hutto, Paige Hickman, Dan Marullo; University of Colorado, Denver: Elizabeth McFarland, Carrie Chambers, Robin McEvoy; University of Florida, Center for HIV/AIDS Research, Education and Service: Mobeen Rathore, Saniyyah Mahmoudi, Staci Routman; University of Miami: Gwendolyn Scott, Lorena Bracho, Anai Cuadra; University of Puerto Rico School of Medicine, Medical Science Campus: Zoe M. Rodriguez, Lizmarie Torres, Nydia Scalley; University of Southern California: Toniette Frederick, Mariam Davtyan, Cristina Hernandez, Guadalupe Morales Avendano

Note: The conclusions and opinions expressed in this article are those of the authors and do not necessarily reflect those of the National Institutes of Health or U.S. Department of Health and Human Services.

Funding

The study was supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), through awards R01HD101351 and P01HD103133

Footnotes

Portions of this work were presented at the 15th International Workshop on Women & HIV 2025, April 2025, Barcelona, Spain.

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Supplementary Materials

Supplementary Tables 1-3
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