Starting treatment with efavirenz causes only modest changes in sleep patterns

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Starting an antiretroviral regimen containing the non-nucleoside reverse transcriptase inhibitor, efavirenz (Sustiva) causes only modest changes to sleeping patterns, and does not have an adverse effect on quality of life, according to a small UK study published in the May edition of HIV Medicine.

Many people starting treatment with efavirenz report changes in their sleep. Amongst reported problems are insomnia, over-sleeping, vivid dreams and reduced concentration.

It is possible to electronically monitor the eight stages of sleep using electroencephalogram (EEG), electrooculagram (EOG) and electromyogram (EMG) analysis. To determine the effect which starting efavirenz has on sleep and quality of life, investigators at London’s Chelsea and Westminster Hospital recruited ten HIV-positive men, naive to antiretroviral therapy, to a study.


concentration (of a drug)

The level of a drug in the blood or other body fluid or tissue.


A mental health problem causing long-lasting low mood that interferes with everyday life.

reverse transcriptase

A retroviral enzyme which converts genetic material from RNA into DNA, an essential step in the lifecycle of HIV. Several classes of anti-HIV drugs interfere with this stage of HIV’s life cycle: nucleoside reverse transcriptase inhibitors and nucleotide reverse transcriptase inhibitors (NRTIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs). 

prospective study

A type of longitudinal study in which people join the study and information is then collected on them for several weeks, months or years. 


In HIV, an individual who is ‘treatment naive’ has never taken anti-HIV treatment before.

The study required the men to attend a sleep laboratory prior starting treatment with efavirenz and then after taking the drug for 14 days and again after three months. Their sleeping patterns were electronically recorded at these visits and they were also asked to complete a questionnaire which, amongst other things, enquired about their sleep quality, how vivid their dreams were, their daytime concentration and overall quality of life.

Before starting antiretroviral treatment, the patients had a median CD4 cell count of 158 cells/mm3 and a median viral load of 94,000 copies/ml. After 14 days of anti-HIV therapy, CD4 cell count had increased to a median of 242 cells/mm3 and median viral load had fallen to 665 copies/ml. Three months of treatment saw a further slight increase in median CD4 cell count to 244 cells/mm3 with median viral load falling to just over 100 copies/ml.

Sleep patterns changed significantly after the initiation of efavirenz treatment. At day 14, a reduction was seen in the amount of time spent in sleep stage two, thought to be associated with daytime alertness, but there was an increase in the amount of time individuals spent in stage four sleep – deep sleep – and rapid eye movement (REM) sleep. Both of these sleep stages are associated with dreaming. The investigators comment that the increase in REM sleep seen in this study contrasts with the shortening of REM sleep seen in patients with depression.These differences persisted to week twelve. Sleeping patterns at weeks two and twelve were significantly different to those seen prior to the initiation of HIV therapy (p < 0 .05).

Despite this, individuals did not report that commencing treatment with efavirenz caused any alteration in daytime alertness, the pleasantness of dreams, quality of sleep, or overall quality of life. However, an overall reduction in daytime concentration was reported and individuals also reported being more sluggish in the morning after commencing efavirenz treatment. In addition, patients reported that they were more likely to remember their dreams.

“These prospective data indicate that initiation of efavirenz-based therapy is associated with modest objective changes in sleep patterns,” write the investigators. They add some cautions about the design of their study, noting that it was single-arm with no comparator group. It was therefore impossible to say with absolute certainty that the sleep changes they observed were due to efavirenz. In addition, the investigators note that starting antiretroviral therapy can be stressful and that this could have an impact on sleep, as could changes in immune function due to successful anti-HIV treatment.


Moyle G et al. Changes in sleep quality and brain wave patterns following initiation of an efavirenz-containing triple antiretroviral regimen. HIV Med 7: 243 – 247, 2006.