The latest plea to Mr.Sandman
Supervised by: Gilbert Mallais
Everyone knows the feeling… lying in bed for hours, trying to get comfortable, and consistently re-calculating how much sleep you will get if you fall asleep now…or now… or now. Insomnia affects about 30% of the general population(depending on the study); however when combined with another illness, such as HIV, the number jumps to 60-70%. Whether it is caused by depression, anti-retroviral treatments, or cognitive health, insomnia can be debilitating and seriously compromise the quality of life of those HIV+.
Insomnia in HIV Infection: A Systematic Review of Prevalence, Correlates, and Management(2005)
By: Steven Reid and Justin Dwyer in Psychosomatic Medicine 67:260-269.
This article conducted a thorough literature analysis of 29 existing articles on insomnia and attempted to consolidate them into one major report. Despite the numerous papers written on the subject, there have been very little attempts to find consistent and effective treatment. The authors speculate that this is likely due to the variation in testing methods and experiments making it difficult to synthesize the data and find a comprehensive conclusion.
The analyzed studies were subdivided into two types: early and later studies. Early studies on insomnia and HIV examined the body’s function during sleep and noted changes to the different phases using polysomnography. Although this is considered the best measure of sleep changes as it includes precise recordings of brain activity, breathing, heart rhythm, eye movement and muscle tone, it is also very expensive. This means that the number of people tested is usually small and patients are often only studied for 1-2 nights, which is not always representative of general sleep patterns. Despite being the most informative form of sleep study, personal accounts by the patient rarely agree with the data recorded. On the other hand, more recent studies are done by compiling questionnaires from personal experiences of those HIV+. Such surveys often include scales to rank the quality and quantity of sleep.
Due to the complex nature of HIV with changes to the immune system, drug therapies, and other related illnesses, researchers have been trying to draw relationships to insomnia, but this has generally been fruitless. To date there has not yet been a reliable relationship drawn between HIV and stage of infection based on immune cells. One study found a relationship to symptomatic late stage illness; however, this is likely due to an AIDS-defining illness and not the infection itself. It was found that cognitive impairment was one of the best predictors of insomnia in an HIV+ group. Anxiety, depression and other psychiatric disorders have well documented co-occurrence with insomnia and may also occur in those HIV+.
In addition, insomnia is a commonly listed side effect of antiretroviral therapy even though it is only occurs in 10%. A 2009 report outlined two cases where patients who started raltegravir, an HIV integrase inhibitor, experienced insomnia which went away shortly after discontinuation of the drug*. Often such rare side effects do not come out in the clinical trial and are not documented until the drug is put on the market. Efarvirenz is also believed to be an independent predictor of insomnia. In one study, 35% of those treated with drug developed insomnia during the month after treatment onset.
With all the information provided on insomnia and HIV, many questions remain unanswered and it is difficult to draw any concrete conclusions. Due to the small sample of most studies, many of the studies mentioned did not take into account other confounding variables (hidden variables that were not accounted for in the analysis and could change the results), such as amount of caffeine consumed or living conditions and did not control the data for other variables such as age, sex, race etc. These studies also lacked information on prevalence of insomnia in the group before becoming HIV+, thus we don’t know how many people had insomnia before even being diagnosed. Finally, the lack of uniformity in the definitions of ‘insomnia’ and experimental methods make it difficult to compare the information available.
Despite the clear lack of consensus in the research field, there are some small life changes which can be made before talking to your doctor about taking a sleep aid. The consumption of caffeine, alcohol, carbohydrates and refined sugars should be avoided after dinner time. Try sticking to green or white tea as a nightcap. Health permitting, do some light exercise everyday, but not in the few hours before bed! Avoid watching TV or working on your computer to fall asleep as the light will keep your brain buzzing. Set a time to put your electronics to bed then do some light reading for an hour allowing your brain to slowly turn off before you go to bed. Develop this schedule as a part of a routine. Our bodies are like machines, they work best when regularly turned on and off. So try to get up around the same time everyday and avoid sleeping in more than an hour- bummer, I know. If all else fails, talk to your doctor about going on a sleep medication and remember, do not take any herbal remedies without consulting with him/her as well!
It is surprising that despite the high level of insomnia in the HIV+ population and variable research in the field, there is little comparable information on treatments and causes. Insomnia, even in the general population, is most often left untreated. Hopefully researchers will begin testing efficacy of treatment methods in the HIV+ population in the near future. Fighting insomnia is an easy way to improve the quality of life of many HIV+ people so what are researchers waiting for…? Let’s call Mr. Sandman.
*Acute Onset Insomnia Associated with the Initiation of Raltegravir: A Report of Two Cases and Literature Review (2009)
By: Jacob Gray and Benjamin Young
Letter to the editor in AIDS patient care and STDs vol. 23 (9)