Poor sleep and hepatic steatosis contribute to poorer quality of life in people with human immunodeficiency virus

Table 1 Demographics and clinical characteristics of the analysis population by metabolic-associated steatotic liver disease status, n (%)

	Entire cohort, N = 1005	Non-SLD, N = 562	MASLD, N = 443	P value
Age, years	55 ± 12.3	54 ± 13.1	56 ± 11.1	0.005
Gender				0.02
Male	683 (68)	389 (69)	294 (67)
Female	274 (27)	138 (25)	136 (31)
Transgender/gender diverse	48 (5.1)	35 (7)	13 (3.2)
Race/ethnicity				< 0.001
Non-Hispanic White	351 (35)	179 (32)	172 (39)
Non-Hispanic Black	527 (52)	329 (59)	198 (45)
Hispanic	127 (13)	54 (10)	73 (17)
Education: High school or above	844 (84)	476 (85)	368 (83)	0.01
Married/long-term partner	216 (21.5)	122 (22)	94 (21)	0.7
Food insecurity	333 (33)	199 (35)	134 (30)	0.09
Area deprivation index	55.8 (30.5)	53.5 (31.3)	58.7 (29.1)	0.001
Body mass index, kg/m2				< 0.01
< 25	232 (23)	202 (36)	30 (7)
25-29.9	357 (36)	216 (38)	141 (32)
≥ 30	416 (41)	144 (26)	272 (61)
Waist circumference, cm	99.5 ± 16	92.9 ± 13	107.7 ± 15	< 0.01
Elevated waist circumference	589 (59)	324 (58)	265 (60)	0.55
Hypertension	751 (74.7)	399 (71.0)	352 (79.5)	< 0.001
Dysglycemia	581 (57.8)	274 (48.8)	307 (69.3)	< 0.01
Dyslipidemia	710 (71)	342 (61)	368 (83)	< 0.001
Current smoker	226 (23)	161 (29)	65 (15)	< 0.01
Obstructive sleep apnea				< 0.01
Never	779 (78)	458 (81)	321 (72)
Treated	142 (14)	52 (9)	90 (20)
Symptomatic, not treated	84 (8)	52 (9)	32 (7)
HIV-related characteristics
Living with HIV, years	20.6 ± 10.5	20.5 ± 10.8	20.7 ± 10.0	0.7
CD4+ T-cell count	675 (516, 917)	672 (497, 907)	686 (539, 931)	0.3
Antiretroviral therapy
NRTI	885 (88)	485 (86)	400 (90)	0.07
NNRTI	201 (20)	116 (21)	85 (19)	0.6
Efavirenz	23 (2)	9 (2)	14 (3)	0.1
PI	124 (12)	66 (12)	58 (13)	0.6
INSTI	867 (86)	486 (87)	381 (86)	0.9
Laboratory
Total cholesterol, mmol/L	4.5 ± 1.1	4.4 ± 1.1	4.5 ± 1.0	0.1
Triglycerides, mmol/L	1.56 ± 1.39	1.28 ± 0.7	1.9 ± 1.8	< 0.01
LDL cholesterol, mmol/L	2.6 ± 0.9	2.5 ± 0.9	2.7 ± 1.0	0.07
HDL cholesterol, mmol/L	1.3 ± 0.4	1.3 ± 0.4	1.2 (0.4	< 0.01
ALT, U/L	27 ± 22	24 ± 19	32 ± 24	< 0.01
AST, U/L	27 ± 17	25 ± 17	28 ± 18	0.01
Alkaline phosphatase, U/L	79 ± 29	77 ± 27	82 ± 30	0.01
Bilirubin, direct, μmol/L	3.08 ± 1.7	3.25 ± 1.7	2.91 ± 1.37	0.06
Bilirubin, total, μmol/L	10.4 ± 8.6	10.6 ± 8.5	10.1 ± 8.6	0.1
Albumin, mmol/L	0.6 ± 0.06	0.6 ± 0.06	0.6 ± 0.06	0.8
Platelet count/μL	242901 ± 71174	240215 ± 70614	246303 ± 71813	0.1
Creatinine, μg/L	97.3 ± 79	106.1 ± 79	97.3 ± 79	0.7
Serum glucose, mmol/L	5.6 ± 1.9	5.3 ± 1.4	6.1 ± 2.3	< 0.01
HbA1c, mmol/mol	40 ± 1	38 ± 1	43 ± 1	< 0.01
Vibration-controlled transient elastography
CAP, dB/m	253 (214, 298)	218 (191, 240)	305 (281, 337)	< 0.01
LSM, kPa	5.0 (4.1-6.5)	4.8 (3.9-6.1)	5.3 (4.3-6.9)	< 0.01
LSM ≥ 8 kPa	135 (13)	49 (9)	86 (19)	< 0.01
LSM ≥ 12 kPa	38 (4)	12 (2)	26 (6)	0.001

MASLD: Metabolic dysfunction-associated steatotic liver disease; Non-SLD: Non-steatotic liver disease; HIV: Human immunodeficiency virus; NRTI: Nucleoside reverse transcriptase inhibitor; NNRTI: Non-nucleoside reverse transcriptase inhibitor; PI: Protease inhibitor; INSTI: Integrase strand transfer inhibitor; LDL: Low-density lipoprotein; HDL: High-density lipoprotein; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; HbA1c: Hemoglobin A1c; CAP: Controlled attenuation parameter; LSM: Liver stiffness measurement.

Table 2 Sleep quality and health related quality of life in people with human immunodeficiency virus by metabolic dysfunction-associated steatotic liver disease status

	Entire cohort, N = 1005	Non-SLD, N = 562	MASLD, N = 443	P value	MASLD and LSM < 8, N = 369	MASLD and LSM ≥ 8, N = 74	P value
Sleep quality: PSQI
PSQI >5	63.6%	63.0%	64.3%	0.7	63.4%	68.9%	0.4
Total PSQI score	6.6 ± 4.1	6.5 ± 4.1	6.7 ± 4.1	0.5	6.5 ± 4.0	7.8 ± 4.2	0.02
Daytime dysfunction	0.6 ± 0.8	0.6 ± 0.8	0.5 ± 0.8	0.07	0.5 ± 0.8	0.6 ± 0.7	0.4
Sleep disturbances	1.4 ± 0.7	1.4 ± 0.7	1.4 ± 0.7	0.9	1.3 ± 0.7	1.6 ± 0.7	0.01
Sleep duration	0.7 ± 0.9	0.7 ± 0.9	0.7 ± 0.9	0.5	0.7 ± 0.9	0.7 ± 0.9	0.9
Habitual sleep efficiency	0.8 ± 1.0	0.8 ± 1.0	0.8 ± 1.0	0.3	0.8 ± 1.0	1.0 ± 1.0	0.08
Sleep latency	1.3 ± 1.1	1.3 ± 1.1	1.3 ± 1.1	0.5	1.2 ± 1.1	1.8 ± 1.0	< 0.001
Needs medication	0.8 ± 1.2	0.8 ± 1.2	0.9 ± 1.3	0.4	0.9 ± 1.2	0.9 ± 1.4	0.8
Sleep quality	1.0 ± 0.8	1.0 ± 0.8	1.1 ± 0.8	0.6	1.02 ± 0.8	1.2 ± 0.8	0.1
Health-related quality of life: SF-36
Physical component summary score	47.3 ± 10.9	48.4 ± 10.5	45.9 ± 11.2	< 0.001	46.6 ± 10.9	42.5 ± 12.4	0.004
Physical functioning	76.6 ± 28.4	78.9 ± 27.2	73.6 ± 29.7	0.003	75.3 ± 28.6	64.9 ± 33.5	0.01
Role limitations due to physical health	71.04 ± 40.0	73.2 ± 39.2	68.4 ± 41.1	0.06	69.8 ± 40.2	61.0 ± 44.9	0.1
Pain	74.5 ± 27.7	76.2 ± 26.7	72.3 ± 28.9	0.02	73.2 ± 28.8	68.0 ± 29.1	0.2
General health	65.0 ± 22.5	66.3 ± 22.1	63.4 ± 22.9	0.04	65.2 ± 22.0	54.5 ± 25.3	0.001
Mental component summary score	48.7 ± 11.5	48.1 ± 12.3	49.5 ± 10.5	0.07	49.7 ± 10.6	48.3 ± 9.9	0.3
Role limitations due to emotional health	70.4 ± 40.6	71.0 ± 40.6	69.6 ± 40.6	0.6	70.5 ± 39.9	65.3 ± 43.9	0.4
Energy/fatigue	60.9 ± 23.5	61.10 ± 24.1	60.7 ± 22.8	0.8	61.8 ± 22.4	55.1 ± 24.1	0.03
Emotional well-being	73.1 ± 20.5	72.2 ± 21.4	74.2 ± 19.3	0.1	74.9 ± 19.1	70.7 ± 19.7	0.09
Social functioning	78.5 ± 26.0	78.0 ± 27.1	79.1 ± 24.6	0.5	79.9 ± 24.2	75.3 ± 26.6	0.2

Non-SLD: Non-steatotic liver disease; MASLD: Metabolic dysfunction-associated steatotic liver disease; PSQI: Pittsburgh Sleep Quality Index; SF-36: 36-Item Short Form Health Survey.

Table 3 Factors associated with sleep quality in people with human immunodeficiency virus based on multivariate analysis

Variable	β estimate	95%CI	P value
Age	0.02	-0.001 to 0.04	0.07
Gender, ref: Male
Female	0.68	0.12-1.24	0.02
Transgender/gender diverse	0.58	-0.53 to 1071	0.3
Race/ethnicity, ref: Non-Hispanic White
Black	0.09	-0.39 to 0.59	0.7
Hispanic	0.18	-0.76 to 1.21	0.7
No long-term partner	0.61	0.03-1.18	0.04
Education: High school or above	1.00	0.34-1.67	0.002
Waist circumference, by 5 cm	-0.06	-0.14 to 0.03	0.2
Obstructive sleep apnea, ref: No sleep apnea
Not treated	1.27	0.40-2.13	0.004
Treated	1.33	0.61-2.04	< 0.001
Current smoker	0.31	-0.27 to 0.90	0.3
Food insecurity	0.97	0.44-1.49	< 0.001
Area deprivation index	-0.002	-0.01 to 0.005	0.5
MASLD, ref: Non-SLD
MASLD and LSM ≥ 8 kPa	0.26	-0.68 to 1.21	0.6
MASLD and LSM < 8 kPa	-0.30	-0.83 to 0.22	0.3
Health related quality of life
PCS	-0.13	-0.16 to -0.11	< 0.01
MCS	-0.15	-0.17 to -0.12	< 0.01

CI: Confidence interval; MASLD: Metabolic dysfunction-associated steatotic liver disease; Non-SLD: Non-steatotic liver disease; LSM: Liver stiffness measurement; PCS: Physical component summary score; MCS: Mental component summary score.

Table 4 Factors associated with health-related quality of life in people with human immunodeficiency virus based on multivariate analysis

Variable	PCS			MCS
	β estimate	95%CI	P value	β estimate	95%CI	P value
Age	0.03	-0.02 to 0.08	0.2	-0.02	-0.08 to 0.03	0.4
Gender, ref: Male
Female	-3.10	-4.5 to -1.69	< 0.01	-0.65	-2.17 to 0.87	0.4
Others	2.807	-0.06 to 5.67	0.05	3.69	0.61-6.75	0.02
Race/ethnicity, ref: Non-Hispanic White
Black	0.54	-0.72 to 1.79	0.4	-0.6	-1.95 to 0.75	0.4
Hispanic	2.52	0.003-5.02	0.04	-1.49	-4.19 to 1.19	0.3
No long-term partner	-0.33	-1.80 to 1.14	0.7	-1.36	-2.9 to 0.21	0.09
Education: High school or above	2.55	0.86-4.24	0.003	0.22	-1.59 to 2.03	0.8
Waist circumference, by 5 cm	-0.60	-0.81 to -0.39	< 0.01	-0.07	-0.29 to 0.15	0.5
Obstructive sleep apnea, ref: No sleep apnea
Not treated	-1.12	-3.34 to 1.10	0.3	0.69	-1.69 to 3.07	0.57
Treated	-0.78	-2.62 to 1.05	0.4	0.01	-1.95 to 1.98	0.9
Current smoker	-0.59	-2.09 to 0.91	0.4	0.11	-1.49 to 1.72	0.9
Food insecurity	-2.9	-4.25 to -1.56	< 0.01	-3.77	-5.21 to -2.33	< 0.01
Area deprivation index	0.003	-0.01 to 0.02	0.7	0.03	0.007-0.05	0.007
MASLD, ref: Non-SLD
MASLD and LSM ≥ 8 kPa	-3.35	-5.76 to -0.95	0.006	1.83	-0.75 to 4.41	0.1
MASLD and LSM < 8 kPa	-1.82	-3.15 to -0.48	0.007	1.58	0.15 to 3.01	0.03
PSQI score	-0.86	-1.01 to -0.71	< 0.01	-1.17	-1.33 to -1.01	< 0.01

PCS: Physical component summary score; MCS: Mental component summary score; CI: Confidence interval; MASLD: Metabolic dysfunction-associated steatotic liver disease; Non-SLD: Non-steatotic liver disease; LSM: Liver stiffness measurement; PSQI: Pittsburgh Sleep Quality Index.