HIV-positive people with depression and those with wider waists ran a higher risk of insomnia (difficulty falling asleep or staying asleep) in a study of people cared for by the U.S. military healthcare system.1 Compared with people without insomnia, those with insomnia were 3 times more likely to have declines in activities of daily living.
Insomnia and daytime sleepiness are common problems in people with and without HIV. In people with HIV, several factors may cause or contribute to sleep disturbances: (1) ability of HIV to infect the central nervous system (brain and spine), (2) HIV-related central nervous system infections, (3) antiretroviral side effects, (4) mental health problems like anxiety and depression, and (5) drug or alcohol abuse. Several other factors (Table 1) may cause insomnia in people with or without HIV. Depression is marked by ongoing feelings of sadness, loss, anger, or frustration.
|Table 1. Major Causes of Sleep Disturbance and Risk Factors for Sleep Disturbance|
|Possible Causes of Sleep Disturbance||Possible Risk Factors for Sleep Disturbance|
- Caffeine, nicotine, or alcohol
- Medical conditions
- Changes in environment or work schedule
- Poor sleep habits
- Eating too much late in the evening
- Being a woman
- Age over 60
- Mental health disorders
- Work at night or in changing shifts
- Long-distance travel
Source: Mayo Clinic Health Information. Insomnia. See reference 2 below for a link with more information on this topic from the Mayo Clinic.
One study of people with HIV found that three quarters suffered from insomnia.3 But that study was done more than 15 years ago, before use of current antiretroviral combinations greatly improved the health of HIVpositive people. And the earlier study did not compare sleep patterns in HIV-positive people and HIV-negative people.
To provide up-to-date insights into sleep disturbances in people with HIV, researchers conducted the following study.
How the Study Worked
Researchers invited 18- to 50-year-old people at three U.S. military HIV clinics to join the study. Participants could be active members of the military, retired from the military, or the dependents of military personnel. Everyone is HIVnegative when entering the military and gets tested for HIV regularly.
The 200 HIV-positive people invited to join this study had tested positive for HIV while in the military, and all had free access to medical care for their infection. People who said they had thoughts of suicide or who had a major illness could not enter the study. The researchers created a comparison group of 50 people without HIV who matched the HIV group in age, gender, race, and military rank.
All study participants completed a series of question-and-answer tests to assess (1) insomnia, (2) daytime sleepiness, (3) depression, and (4) activities of daily living. The researchers also collected other information on each person's health (including information related to weight) and habits (such as smoking and use of alcohol or illegal drugs).
The study team compared sleep disturbance patterns in the HIV-positive group and the HIV-negative group. Finally, the researchers used standard statistical methods to single out risk factors for sleep disturbances.
What the Study Found
The study involved 193 adults with HIV and 50 without HIV. In the HIV group, average age was 36 years, 95% were men, 50% white, 29% black, and 13.5% Hispanic. One quarter of the HIV group was obese, and one half had HIVrelated body fat abnormalities (lipodystrophy). Only 1 person had less than a high-school education; 7% had depression (based on a standard test called the Beck Depression Inventory).
People with HIV had relatively well-controlled HIV infection. The group CD4 count averaged 567, and only 15% ever had a CD4 count below 200. Two thirds of HIV-positive study participants were taking combination antiretroviral therapy, and 55% had an undetectable viral load.
Test results showed that 89 HIV-positive people (46%) had insomnia, and 59 (29.5%) had daytime sleepiness. The HIV-positive group included 103 people (53%) who said sleepiness interfered with regular daily activities.
Testing determined that 19 people (38%) in the HIVnegative comparison group had insomnia and 10 (20%) had daytime sleepiness. These rates did not differ significantly from rates in the HIV-positive group.
Despite these relatively high rates of sleeping difficulties in people with and without HIV, only a small proportion of study participants said they took sleeping pills: 17% of HIV-positive people and 16% of HIV-negative people reported taking sleeping pills at least once a week.
There was a strong link between insomnia and symptoms of depression: insomnia affected 31% of people without depression, 71% with mild depression, 89% with moderate depression, and 93% with severe depression.
People with depression had a higher chance of having insomnia than people without depression (Figure 1). Increased waist size and illegal drugs also increased chances of insomnia, and people with fewer years of education had a higher chance of insomnia. No HIVrelated factor (including HIV infection itself) affected chances of insomnia.
Increased waist size also independently raised chances of loud snoring 4 times, while doubling chances of daytime sleepiness and poor daytime function (Figure 2).
Among people with insomnia, 22% reported a decline in activities of daily living, compared with 9% without insomnia. Statistical analysis determined that insomnia tripled chances of a decline in activities of daily living.
What the Results Mean for You
This is one of the largest studies of sleeping disturbances in people with HIV. And it's one of the few sleeping studies in HIVpositive people that had a comparison group without HIV. The study is also important because it took place in an HIV group with free access to the latest antiretroviral medications.
Almost half of HIV-positive people in this study group -- 46% -- had insomnia, and almost 30% had daytime sleepiness. Although these rates were not much higher than those in the HIV-negative comparison group, they show that sleeping problems are common in HIV-positive people. Despite these high rates of sleeping problems, few people were taking medications to help them sleep.
Almost everyone has trouble sleeping now and then, and one night of tossing and turning should not cause concern. But ongoing insomnia -- trouble falling asleep, staying asleep, or both -- can have negative consequences. Health workers at the Mayo Clinic list these possible results of persistent insomnia:2
- Lower performance on the job or at school
- Slowed reaction time while driving and higher risk of accidents
- Psychiatric problems, such as depression or an anxiety disorder
- Overweight or obesity
- Poor immune system function
- Increased risk and severity of long-term diseases, such as high blood pressure, heart disease and diabetes
This study in U.S. military clinics confirmed that sleeping poorly has a negative impact on performance of daily activities. The study also found links between overweight (increased waist size) and insomnia and between depression and insomnia. A study like this cannot determine whether overweight caused insomnia or insomnia caused overweight in these people. In the same way, this study cannot say whether depression caused insomnia or insomnia caused depression.
But it's clear that insomnia, overweight, and depression can all negatively affect health. HIV-positive people with any of these problems should talk about them with their HIV providers. All three conditions can be treated in several ways. "Good Antidepressant Pill-Taking Linked to Better Antiretroviral Pill-Taking" in this issue of HIV Treatment Alerts! discusses depression in more detail. The U.S. National Institute of Mental Health has a useful booklet on depression in people with HIV, available at the link in reference 4 below.
These researchers point out that they conducted their study in people cared for at U.S. military clinics and that most of these people learned they had HIV and started receiving care early in the course of their infection. As a result, the findings of this study may not apply to all HIV-positive people in the United States.
Still, this study underlines the high rate of insomnia and daytime sleepiness in people with HIV. If you feel you have a sleeping problem, discuss it with your HIV provider. At the same time, these researchers note, providers should realize that tests for insomnia and daytime sleepiness* are quick, inexpensive, and easy to use. The research team calls for prompt diagnosis and treatment of sleep disturbances in people with HIV as one way to improve quality of life.
* In this study researchers used the Pittsburgh Sleep Quality Index to assess insomnia and the Epworth Sleepiness Scale to assess daytime sleepiness.
- Crum-Cianflone NF, Roediger MP, Moore DJ, et al. Prevalence and factors associated with sleep disturbances among early-treated HIV-infected persons. Clin Infect Dis. 2012;54:1485-1494.
- Mayo Clinic Health Information. Insomnia.
- Rubinstein ML, Selwyn PA. High prevalence of insomnia in an outpatient population with HIV infection. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;19:260-265.
- National Institute of Mental Health. Depression and HIV/AIDS.