HIV doesn't increase the risk of insomnia

Many HIV-positive patients have insomnia or daytime sleepiness, investigators from the US military report in the online edition of Clinical Infectious Diseases. However, the prevalence of sleep disorders was no higher in HIV-positive patients than in matched controls. Risk factors for insomnia included depression and increased waist size. There was no evidence that HIV treatment of any kind increased the risk of insomnia.

“We found that HIV-infected persons have a high prevalence of sleep disturbances,” comment the authors. “Despite the high prevalence of insomnia, HIV-infected persons did not have a statistically significant higher rate compared with matched HIV-uninfected persons.  These data suggest that in the HAART [highly active antiretroviral therapy] era, patients with early-diagnosed, early-treated HIV infection may have similar rates of sleep disturbances as the general population.”

It has long been recognised that insomnia is common in patients with HIV. However, most of the studies exploring the prevalence of sleep disturbances in patients with HIV were conducted before combination antiretroviral therapy became available.

Research conducted since then has tended to focus on the association of treatment with efavirenz (Sustiva, also in Atripla) and sleep quality. Moreover, much of the research is limited because it did not include an HIV-negative comparator group.

Investigators from the US military therefore designed a study assessing the prevalence and causes of insomnia and daytime sleepiness in a cohort of HIV-positive patients, who were matched with HIV-negative controls.

All the patients were aged between 18 and 50 years. They completed validated questionnaires enquiring about insomnia and sleepiness during the day.

A total of 193 HIV-positive patients and 50 HIV-negative controls were included in study. The participants had a mean age of 36 years, 95% were male and 50% were white.

The mean body mass index (BMI) for the HIV-positive patients was 27.5 kg² and 25% were assessed as obese. Lipodystrophy was noted in 52% of patients and 7% were depressed. The mean CD4 cell count at enrollment was 587 cells/mm³. Two-thirds of patients were taking antiretroviral therapy and 55% had an undetectable viral load.

Insomnia was reported by 46% of HIV-positive patients. The mean amount of sleep per night was 6.5 hours and 46% reported less than seven hours sleep. Just under a quarter (23%) of HIV-positive patients rated the quality of their sleep as “bad.”

Daytime dysfunction caused by sleepiness was reported by 53% of patients, and 30% of individuals with HIV had evidence of drowsiness during the day.

Use of sleep medication at least once a week was reported by 18% of patients.

The prevalence of insomnia among the HIV-negative controls was 38%. This was not significantly different to the 46% prevalence reported by patients with HIV. Nor did the proportion of HIV-negative controls who reported sleepiness during the day differ significantly. Moreover, similar proportions of HIV-positive and HIV-negative patients reported the regular use of sleep medication (18% vs. 16%).

The investigators then undertook a series of analyses to establish the factors associated with sleep disturbances in the HIV-positive patients.

Univariate analysis showed a significant association with fewer years of education (p  = 0.005), obesity (p = 0.04), increased waist size (p < 0.001), smoking (p = 0.01), a history of serious head trauma (p = 0.006), depression (p = 0.006) and peripheral neuropathy (p = 0.02). Patients of officer rank had a lower risk of insomnia compared to personnel in enlisted ranks (p = 0.04).

Subsequent multivariate analysis that controlled for potential confounders showed that only depression (p = 0.01), waist size (p = 0.002) and fewer years of education (p = 0.006) increased the risk of insomnia.

“The strongest factor associated with insomnia among HIV-infected in our study was depression,” observe the investigators. “This finding is consistent with other studies, and exemplifies that psychological morbidity is a major factor in insomnia among HIV-infected persons.”

The authors believe this finding has implications for patient care: “treating depression might improve sleep quality, and the treatment of sleep disturbances may decrease the incidence of depression.”

There was no evidence that HIV therapy or the use of any individual antiretroviral drugs were associated with insomnia.

Follow-up showed that patients with insomnia were more likely to report a decline in measures of neurocognitive function than patients without insomnia (p = 0.01).

“Insomnia and daytime sleepiness are common among HIV-infected persons, but in the setting of early HIV diagnosis and management, the prevalence of these disorders does not seem higher than matched HIV-uninfected persons,” conclude the authors. “Prompt diagnosis and management of sleep disturbances are advocated and may improve quality of life.”