Promising results for programme to reduce sleep disturbance in people with HIV

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A poster at the virtual HIV Glasgow 2020 conference has concluded that a questionnaire on sleep quality, validated in other disease areas, appears to be reliable, simple and convenient for assessing sleep disturbance in people with HIV. The study also concludes that providing information on sleep hygiene and switching antiretrovirals when necessary can significantly improve sleep disturbance in people with HIV, including among those going through mental health issues.

Despite successful antiretroviral therapy, with a suppressed viral load and a high CD4 cell count, people living with HIV often complain of poor functional outcomes, including sleep disturbance. Dr Benjamin Goorney and his colleagues from the Salford Shine Sexual Health Clinic in Greater Manchester assessed the use of a known and validated tool to select patients who needed support.

The Pittsburgh Sleep Quality Index

The tool assessed by the study is called the Pittsburgh Sleep Quality Index, or PSQI. It is a self-report questionnaire that explores sleep quality over a one-month interval, with 19 self-rated questions and five additional ones for the bed partner or roommate, if any.

The questionnaire focuses on sleep habits with items such as: “During the past month, how many hours of actual sleep did you get at night? – this may be different from the number of hours you spend in bed.” Then it addresses more specific components of sleep quality by asking patients to score:

Glossary

statistical significance

Statistical tests are used to judge whether the results of a study could be due to chance and would not be confirmed if the study was repeated. If result is probably not due to chance, the results are ‘statistically significant’. 

integrase inhibitors (INI, INSTI)

A class of antiretroviral drugs. Integrase strand transfer inhibitors (INSTIs) block integrase, which is an HIV enzyme that the virus uses to insert its genetic material into a cell that it has infected. Blocking integrase prevents HIV from replicating.

anxiety

A feeling of unease, such as worry or fear, which can be mild or severe. Anxiety disorders are conditions in which anxiety dominates a person’s life or is experienced in particular situations.

psychosis

Mental health problems that stop someone from thinking clearly and telling the difference between reality and their imagination.

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). 

  • Their sleep quality overall.
  • How long it usually takes them to fall asleep each night.
  • How many hours of sleep they get each night.
  • The number of hours slept/spent in bed.
  • Sleep disturbances (problems sleeping due to anxiety, pain, bad dreams, difficult digestion, etc).
  • The use of sleeping medication.
  • Daytime dysfunction (due to sleep problems).

A total score of six or more (out of a maximum of 21) indicates significant sleep disturbance.

The study

Forty patients attending the Salford Shine Sexual Health Clinic for routine HIV blood monitoring were selected for PSQI assessment, of whom 37 (92.5%) had a high global score of ≥ 6. These 37 patients were all provided with:

  1. Sleep hygiene leaflets describing good sleep habits, such as not using screens for at least one hour prior to bedtime; no caffeine intake after 3pm; creating a ‘golden hour’ routine prior to sleep with recommended activities (shower, crosswords, ironing, etc.); using relaxation techniques before bed; and avoiding fatty foods in the evening.
  2. Antiretroviral switch if their current regimen was felt to be aggravating the sleep pattern.

In total, 15 patients (41%) agreed to switch to alternative antiretroviral regimens.

The PSQI was repeated at least one month following either intervention.

Results

At baseline, virologic success was significant among participants. Eighty-one per cent of them had a CD4 count over 500 and the mean CD4 count was 971. As for viral load, it was lower than 200 in 92%, and lower than 50 in 84%.  

The overall mean PSQI score was 12, which is understood as moderately severe sleep disturbance.

Participants aged between 40 and 50 years had greater sleep disturbances than those aged over 50 years, although this difference was not statistically significant. In terms of mean PSQI score, no difference was found for gender, ethnicity or duration of being HIV positive.

Past or current mental health issues (affecting 60% of patients, with a mean PSQI of 13.45) and taking antidepressants/antipsychotics (46%, PSQI 14.82) were strongly associated with sleep disturbance. In patients not facing such problems, the PSQI were 9.6 and 10.45, respectively. Sleep disturbance was also greater in patients with a recent STI (PSQI 13.5 vs 12 in those without), as well as in patients who had used recreational drugs (PSQI 13.6 vs 11.8). However, these differences were not statistically significant.

Prior to intervention, integrase inhibitors (INSTIs) were included in 67.5% of antiretroviral regimens, with dolutegravir in 68% of them. Non-nucleoside reverse transcriptase inhibitors (NNRTIs) were taken by 30% of patients. There was no difference in PSQI score between patients on INSTIs and those on NNRTIs. However, dolutegravir was found to be significantly associated with greater sleep disturbance than other integrase inhibitors (PSQI 12.6 vs 9.8).

Considered together, both interventions targeting the total of 37 participants reduced the mean PSQI by 31% (p < 0.01). Among the 22 participants who received the sleep leaflet only, the mean PSQI reduction was not statistically significant (18%). But in the 15 patients who switched their antiretroviral regimens, the sleep disturbance was reduced by 52% (p < 0.01).

Results were similar in the 22 patients with mental health issues or taking antidepressants/antipsychotics.

Beyond concluding that the PSQI questionnaire appears to be an appropriate tool for assessing sleep disturbance in people with HIV, the investigators highlight that over 90% of the selected patients had a PSQI score of ≥ 6, indicating significant sleep disturbance. They also note the high rate of antidepressant/psychotic use in this group, which turned out to be strongly associated with sleep disturbance.

The efficacy of the package of intervention brings Goorney and colleagues to recommend wider routine assessment of sleep disturbance among people living with HIV. They also highlight that their recommendation is “in line with UNAIDS’ ‘fourth 90’, of 90% improvement in good health related quality of life.”   

References

Goorney B et al. Utility of Pittsburgh Sleep Quality Index (PSQI) in people living with HIV (PLWH) for assessment and monitoring of sleep disturbance in a community HIV clinic. HIV Glasgow 2020, abstract P082.