Depression and anxiety mediate the association between sleep quality and health-related quality of life in people living with HIV

Sleep disturbances are highly prevalent among people living with HIV (PWH) and frequently co-occur with psychiatric comorbidities such as depression and anxiety. Although these factors independently predict health-related quality of life (HRQoL), the extent to which psychiatric symptoms explain the relationship between sleep quality and HRQoL—particularly within the Chinese context—remains unclear. Understanding these pathways is critical for optimizing holistic HIV care. We conducted a cross-sectional study involving 426 PWH attending outpatient clinics in Nanning, China, between January and September 2024. Participants completed the Sleep Quality Scale (SQS), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and the MOS-HIV Health Survey. Multivariable linear regression and restricted cubic spline models were employed to examine the association between sleep quality and HRQoL. Parallel mediation analyses were subsequently performed to quantify the mediating roles of depression and anxiety. After adjusting for sociodemographic and clinical covariates, better sleep quality was independently associated with higher HRQoL (adjusted B = 1.59 per unit increase in SQS, 95% CI 1.03–2.14), exhibiting an approximately linear dose–response relationship. Mediation analysis revealed that depression and anxiety significantly explained this association, accounting for 80.57% and 32.96% of the total effect, respectively. Notably, subgroup analyses indicated that the inverse association between sleep quality and HRQoL was more pronounced among participants with rural household registration ( Hukou ). Our findings suggest that the detrimental impact of poor sleep on HRQoL in PWH is largely driven by elevated depressive and anxiety symptoms. This underscores the need to view sleep disturbances not merely as secondary comorbidities, but as integral components of mental health burden that degrade quality of life. Integrated care models that concurrently target sleep hygiene and psychiatric distress are warranted to improve overall well-being in this population.