This Week in HIV Research: To Sleep, Perchance to Dream

PLWH are at higher risk of insomnia, and at an earlier age, than HIV-negative controls, but few are treated for this issue, researchers reported in Open Forum Infectious Diseases.

The cross-sectional study investigated sleep disorders among 357 PLWH, 246 of whom were > 50 years old, and 126 HIV-negative controls, all of whom were > 50 years. Twenty-one percent of older PLWH and 23% of younger PLWH reported insomnia, compared to 5% of controls.

By contrast, rates of restless leg syndrome (13% vs. 14%) and sleep apnea (6% vs. 8%) were similar between all PLWH and controls.

Among PLWH, those with insomnia reported worse quality of life than those without the sleep disturbance, but fewer than 30% of PLWH with insomnia had been diagnosed or treated for the problem. Cognitive behavioral therapy is the standard treatment for this condition; in PLWH, persistent inflammatory effects, higher rates of stigma, and greater mental health burdens may require adjusting this therapy, the researchers argued.

“Further research should focus on insomnia pathogenesis in [PLWH] and development of effective screening and intervention strategies for [PLWH],” they concluded.

Diagnoses of non-HIV chronic diseases in older PLWH are on the rise, but the reasons behind the rise may be complex, according to results published in Open Forum Infectious Diseases of a single-site study in a Ryan White-funded HIV clinic in the U.S. Southeast that served both urban and rural patients.

The study, which was conducted by University of Virginia researchers (the clinic was not named in the manuscript), compared multimorbidity among two cohorts of participants aged ≥ 45 years. One cohort was recruited among the clinic population in 2006 (n = 149) and the other in 2016 (n = 323). The clinic population itself aged during that span; in 2006, 70% of the cohort was between the ages of 45 and 54, with 30% age 55 or older; in 2016, 48% of the cohort was between 45 and 54, with 52% age 55 or older.

The researchers found that 19% of participants in the earlier cohort and 30% in the later one were diagnosed with at least two chronic diseases. That said, researchers noted that the Affordable Care Act was passed in 2010, between the two cohorts. Although the clinic is located in a state that did not expand Medicaid eligibility, more participants had health insurance in 2016 than in 2006. That fact, combined with ACA coverage requirements, may account for the increase in diagnoses due to better health care access, the study authors suggested: Multimorbidity was particularly less common among those with private health insurance, possibly because of better preventive care coverage, such as pharmacotherapy for smoking cessation.

Findings were nuanced with respect to racial and sex-based differences: In 2006, Black participants (who comprised roughly half of each cohort) were less engaged in care than those of other races, but no such disparity was found in 2016; study authors hypothesized that this may in part because during the intervening decade, the clinic had hired additional case managers and implemented a peer coaching program.

In 2016, multimorbidity was much more common among women than men, which the study authors said may be related to higher obesity rates among women on newer antiretrovirals, such as TAF and INSTIs.

“The RWHAP [Ryan White HIV/AIDS Program] and RWHAP Part D could invest in addressing these disparities related to insurance and gender,” study authors concluded.

Once PLWH achieve an undetectable viral load, most remain at viral loads (VLs) below 200 copies/mL long-term, an Italian study published in AIDS showed.

Using retrospective data from the longitudinal ICONA cohort, researchers calculated the total number of days the 8,241 PLWH study participants (20% of whom were women) had a viral load above 200 copies/mL following initial viral suppression. The analysis began with data from December 2010.

Over the following 10 years, 97% of the cohort’s cumulative patient days were spent with an undetectable viral load, with that trend increasing in recent years (which the researchers anecdotally associated with the rise of the “undetectable equals uninfectious” prevention campaign). However, some subgroups had trouble maintaining viral suppression: women, those born outside Italy, people who inject drugs (PWID), and unemployed participants.

Specifically:

• Women started antiretroviral therapy later and discontinued treatment more often than men.
• Foreign-born participants had fewer follow-up visits than those originally from Italy.
• Detectable viremia after suppression was most common among PWID and was related to adherence issues and stopping antiretroviral therapy.

Higher viral loads among people without a job show the importance of socio-economic determinants of health, researchers noted. They called for targeted interventions to help all of these subpopulations maintain long-term viral suppression.

The availability of HIV self-tests can increase testing rates even if they are distributed at a health care facility rather than directly obtained by people who want them, a systematic review of 33 studies that was published in Clinical Infectious Diseases found.

Six strategies were evaluated: web-based request with mail delivery of test, clinic client gives test to partner, self-test is provided at health care facility, test is distributed by peers, or HIV testing is administered by a health care worker in a health care facility or in the community. The research review found that for each strategy, rates of positive tests and linkage to care were comparable to standard HIV testing.

That said, there were some geographic differences in preferences. Participants in North America, Asia, and the Pacific favored web-based delivery, with a 93% probability of that mode being ranked the first choice. In sub-Saharan Africa (where 19 of the 33 studies took place), partner distribution was 78% likely to be the first choice, mostly because women at prenatal care facilities were getting tests to their male partners.

In all regions, getting self-tests at health care facilities was the second choice. That strategy wouldn’t reach underserved groups, but could encourage routine HIV testing, the study authors suggested.

While community delivery was modestly effective overall, it could reach people that would not be tested otherwise; that strategy should be thus targeted at specific populations, such as young people, study authors recommended. They also called for research into replicating the convenience and confidentiality of web-based delivery in low-resource areas.