Alterations of nocturnal sleep in patients with HIV infection

Mechanisms underlying HIV-associated cognitive impairment and emerging therapies for its management

People living with HIV are affected by the chronic consequences of neurocognitive impairment (NCI) despite antiretroviral therapies that suppress viral replication, improve health and extend life. Furthermore, viral suppression does not eliminate the virus, and remaining infected cells may continue to produce viral proteins that trigger neurodegeneration. Comorbidities such as diabetes mellitus are likely to contribute substantially to CNS injury in people living with HIV, and some components of antiretroviral therapy exert undesirable side effects on the nervous system. No treatment for HIV-associated NCI has been approved by the European Medicines Agency or the US Food and Drug Administration. Historically, roadblocks to developing effective treatments have included a limited understanding of the pathophysiology of HIV-associated NCI and heterogeneity in its clinical manifestations. This heterogeneity might reflect multiple underlying causes that differ among individuals, rather than a single unifying neuropathogenesis. Despite these complexities, accelerating discoveries in HIV neuropathogenesis are yielding potentially druggable targets, including excessive immune activation, metabolic alterations culminating in mitochondrial dysfunction, dysregulation of metal ion homeostasis and lysosomal function, and microbiome alterations. In addition to drug treatments, we also highlight the importance of non-pharmacological interventions. By revisiting mechanisms implicated in NCI and potential interventions addressing these mechanisms, we hope to supply reasons for optimism in people living with HIV affected by NCI and their care providers.

The Interplay Between Neuroinfections, the Immune System and Neurological Disorders: A Focus on Africa

Neurological disorders related to neuroinfections are highly prevalent in Sub-Saharan Africa (SSA), constituting a major cause of disability and economic burden for patients and society. These include epilepsy, dementia, motor neuron diseases, headache disorders, sleep disorders, and peripheral neuropathy. The highest prevalence of human immunodeficiency virus (HIV) is in SSA. Consequently, there is a high prevalence of neurological disorders associated with HIV infection such as HIV-associated neurocognitive disorders, motor disorders, chronic headaches, and peripheral neuropathy in the region. The pathogenesis of these neurological disorders involves the direct role of the virus, some antiretroviral treatments, and the dysregulated immune system. Furthermore, the high prevalence of epilepsy in SSA (mainly due to perinatal causes) is exacerbated by infections such as toxoplasmosis, neurocysticercosis, onchocerciasis, malaria, bacterial meningitis, tuberculosis, and the immune reactions they elicit. Sleep disorders are another common problem in the region and have been associated with infectious diseases such as human African trypanosomiasis and HIV and involve the activation of the immune system. While most headache disorders are due to benign primary headaches, some secondary headaches are caused by infections (meningitis, encephalitis, brain abscess). HIV and neurosyphilis, both common in SSA, can trigger long-standing immune activation in the central nervous system (CNS) potentially resulting in dementia. Despite the progress achieved in preventing diseases from the poliovirus and retroviruses, these microbes may cause motor neuron diseases in SSA. The immune mechanisms involved in these neurological disorders include increased cytokine levels, immune cells infiltration into the CNS, and autoantibodies. This review focuses on the major neurological disorders relevant to Africa and neuroinfections highly prevalent in SSA, describes the interplay between neuroinfections, immune system, neuroinflammation, and neurological disorders, and how understanding this can be exploited for the development of novel diagnostics and therapeutics for improved patient care.

Comorbidities of HIV infection: role of Nef-induced impairment of cholesterol metabolism and lipid raft functionality

Combination antiretroviral therapy has dramatically changed the outcome of HIV infection, turning it from a death sentence to a manageable chronic disease. However, comorbidities accompanying HIV infection, such as metabolic and cardio-vascular diseases, as well as cognitive impairment, persist despite successful virus control by combination antiretroviral therapy and pose considerable challenges to clinical management of people living with HIV. These comorbidities involve a number of pathological processes affecting a variety of different tissues and cells, making it challenging to identify a common cause(s) that would link these different diseases to HIV infection. In this article, we will present evidence that impairment of cellular cholesterol metabolism may be a common factor driving pathogenesis of HIV-associated comorbidities. Potential implications for therapeutic approaches are discussed.

Physiological and Psychological Correlates of Sleep in HIV Infection

Insomnia, a common problem associated with HIV disease, is most likely caused by a multitude of factors. This study investigated the correlations between a selected group of physiological and psychological factors and sleep quality in an HIV-infected population. A convenience sample of 79 ethnically diverse HIV-positive adults, ages 24 to 63, completed a number of questionnaires and released their laboratory records for CD4+ cell count and viral load information. Variables significantly related to sleep quality were HIV-related symptoms, total pain, fatigue, depression, state anxiety, and the number of adults in the household. Findings support the need for health care providers to consider factors that contribute to impaired sleep when developing effective care for HIV-infected individuals with sleep disturbance.

An insight of sleep disorders in Africa

Sleep is a recurrent physiologic and fundamental process in every human being, regardless of ethnicity, gender, birthplace, or occupation; however, the features of sleep are swayed by genetic background and environmental influences. All these factors have an intricate relationship, and arise from a complex and assorted genetic repertoire in the alleles that promote a higher genetic variation in human populations. Sleep disorders have become an uprising public health problem in the modern society; in addition, the correlation between sleep disorders and the development of late chronic diseases has been extensively studied, finding an important causality between them. Therefore, an adequate evaluation of the current situation in a developing continent such as Africa is essential to develop satisfactory health policies. In this review, we will reprise several aspects that influence the sleep-wake cycle in individuals with African heritage (including African Americans and sub-Saharan Africans), such as genetic background, HIV infection, tropical diseases, immunological markers, cultural aspects, and place them into Africa's context in order to have a better comprehension of its situation.

Sleep disturbance in substance use disorders and comorbid chronic viral infections

Sleep disruption is associated with both substance use disorders and chronic viral infections, which commonly co-occur. A greater understanding of how sleep is affected by substance abuse and comorbid chronic viral infections is needed, as fatigue, depression and other neuropsychiatric impairments caused by chronic viral infections can affect response to addiction treatment adversely.

The Bidirectional Relationship between Sleep and Immunity against Infections

Sleep is considered an important modulator of the immune response. Thus, a lack of sleep can weaken immunity, increasing organism susceptibility to infection. For instance, shorter sleep durations are associated with a rise in suffering from the common cold. The function of sleep in altering immune responses must be determined to understand how sleep deprivation increases the susceptibility to viral, bacterial, and parasitic infections. There are several explanations for greater susceptibility to infections after reduced sleep, such as impaired mitogenic proliferation of lymphocytes, decreased HLA-DR expression, the upregulation of CD14+, and variations in CD4+ and CD8+ T lymphocytes, which have been observed during partial sleep deprivation. Also, steroid hormones, in addition to regulating sexual behavior, influence sleep. Thus, we hypothesize that sleep and the immune-endocrine system have a bidirectional relationship in governing various physiological processes, including immunity to infections. This review discusses the evidence on the bidirectional effects of the immune response against viral, bacterial, and parasitic infections on sleep patterns and how the lack of sleep affects the immune response against such agents. Because sleep is essential in the maintenance of homeostasis, these situations must be adapted to elicit changes in sleep patterns and other physiological parameters during the immune response to infections to which the organism is continuously exposed.

Self-reported sleep disturbances in HIV-infected people: a meta-analysis of prevalence and moderators

OBJECTIVE

Our goal was to estimate the pooled prevalence of self-reported sleep disturbances in HIV-infected people through meta-analysis, taking into account variations in geographic region, gender, age group, CD4 counts, and instrument used to measure sleep disturbances.

METHODS

The authors conducted systematic searches of PubMed and PsycINFO to include studies that met our criteria. A random effect meta-analysis model was used to estimate the pooled prevalence of self-reported sleep disturbances in HIV-infected people. The potential moderators of self-reported sleep disturbances were explored with meta-regression analysis.

RESULTS

Twenty-seven articles comprising a total of 9246 HIV-positive participants were finally included in our analysis. The overall prevalence of self-reported sleep disturbances in HIV-infected people was 58.0% (95% CI = 49.6-66.1). Meta-regression analysis indicates that geographic region, gender, and instrument significantly explain part of the heterogeneity of the prevalence estimates between the included studies.

CONCLUSION

The findings suggest that HIV-infected people suffer from a heavy burden of sleep disturbances. It is therefore recommended that sleep quality should be routinely assessed in HIV-infected people in order to identify the medical treatment needs and the potential impact of sleep problems on antiretroviral therapy outcomes in this population.

Quality of Sleep in an HIV Population on Antiretroviral Therapy at an Urban Tertiary Centre in Lagos, Nigeria

Aim. To determine the prevalence of sleep disturbance and its associated characteristics in HIV-positive outpatients on HAART using the PSQI. Methods. Using a cross-sectional design, 300 patients attending the outpatient HIV/AIDS clinic at the Lagos State University Teaching Hospital were recruited. Baseline data obtained included the participants' demographic data, educational qualification, and marital status. Their treatment history, including duration since HIV diagnosis, the most recent CD4 cell count, and current antiretroviral therapies, was obtained from their case records. Each participant completed the PSQI questionnaire and those with scores ≥5 were diagnosed with poor sleep quality. Results. The participants were made up of 70.7% females and 29.3% males. Their ages ranged between 18 and 74 years with a mean of 38.9 ± 10.3 years. According to the PSQI, 59.3% reported poor sleep quality. The mean score of those with poor quality sleep (9.2 ± 3.3) was comparable to that of those with good quality sleep (1.26 ± 1.4). P < 0.001. Significant differences were observed in all the individual components of the PSQI (P < 0.001). On multivariate analyses, the independent associations with sleep quality were the duration since HIV diagnosis (P = 0.29), efavirenz based regimen (P < 0.001), and lower CD4 cell count (P < 0.001). Conclusions. Sleep disturbances are quite common in the HIV population even in the era of HAART. Early recognition via routine assessment and effective treatments could prevent the resultant complications and improve quality of life.

Sleep, function and HIV: a multi-method assessment

Amongst HIV+ individuals, sleep complaints have been recognized as common and debilitating; but have rarely been formally assessed or compared to controls using validated sleep tools. In this study we conducted structured interview for sleep disorders, polysomnography, 2-week home (ambulatory) monitoring and validated sleep/functional questionnaires. 56 % (14/25) of HIV+ participants and 0 % (0/19) of controls fulfilled the diagnostic criteria for insomnia. Insomnia severity scores were correlated with fatigue and anxiety symptoms. Sleep latency on 2-week actigraphy was significantly longer (P = 0.027) for HIV+ participants and associated with lower MOS-HIV scores. Sleep quality was significantly reduced in HIV+ participants based on validated questionnaires of overall sleep quality (P = 0.0017) and insomnia related symptoms (P < 0.001) even after adjusting for education and affective symptoms. HIV+ individuals are suffering with under-diagnosed sleep disorders that are negatively impacting quality of life and functional capabilities. Further studies aimed at improving recognition of sleep disorders and implementation of efficacious medical and behavioral treatment could improve functioning and disease management.

Qualitative study of the quality of sleep in marginalized individuals living with HIV

Sleep disturbances have been reported to be higher in human immunodeficiency virus (HIV)-infected individuals compared to the general population. Despite the consequences of poor quality of sleep (QOS), research regarding sleep disturbances in HIV infection is lacking and many questions regarding correlates of poor QOS, especially in marginalized populations, remain unanswered. We conducted one-on-one qualitative interviews with 14 marginalized HIV-infected individuals who reported poor QOS to examine self-reported correlates of sleep quality and explore the relationship between QOS and antiretroviral adherence. Findings suggest a complex and multidimensional impact of mental health issues, structural factors, and physical conditions on QOS of these individuals. Those reporting poor QOS as a barrier to antiretroviral adherence reported lower adherence due to falling asleep or feeling too tired to take medications in comparison to those who did not express this adherence barrier. These interviews underscore the importance of inquiries into a patient's QOS as an opportunity to discuss topics such as adherence, depression, suicidal ideation, and substance use.

Comparison of polysomnographic data in age-, sex- and Axis I psychiatric diagnosis matched HIV-seropositive and HIV-seronegative insomnia patients

OBJECTIVE

There is a high prevalence of insomnia in HIV-seropositive patients. Insomnia is associated with poorer disease outcomes, cognitive impairment and HIV-associated dementia. However there is limited data characterizing the type of sleep disturbances, and the cause. Previous studies report conflicting results, and observed changes in the distribution of REM and SWS were hypothesized to result from co-morbid mood disorders, although this is not established. We carried out this study to determine if there are differences in polysomnographic (PSG) sleep data in age-, sex- and Axis I diagnoses- matched HIV-seropositive and HIV-seronegative patients.

METHODS

Eighteen HIV-seropositive insomniacs were matched to HIV-seronegative insomniacs based on age, sex and Axis I diagnoses. Participants spent 2 consecutive nights in a sleep lab recording of PSG data.

RESULTS

Multivariate analysis revealed an overall significant match-by-variable interaction (p=0.0126). Follow-up analysis show that compared to HIV-seronegative insomnia controls, HIV-seropositive insomniacs have significantly longer SOL, 8% decreased sleep efficiency, and 8-10% decreased time spent in REM sleep (p's<0.05).

CONCLUSION

This study provides preliminary evidence that even after accounting for differences in age, sex and psychiatric diagnoses, HIV-seropositive patients with insomnia have significantly worse sleep than HIV-seronegative patients with insomnia.

SIGNIFICANCE

Unlike what previous authors have proposed, our results do not support the view that comorbid psychiatric disorders like depression are responsible for the observed differences in PSG findings and the greater incidence of insomnia, in HIV-seropositive patients when compared with other groups of insomnia patients. This suggests the presence of other etiologies including neuronal damage, psychosocial stressors, or comorbid medical conditions. Further studies are needed to determine the extent to which these play a role in insomnia in the HIV-seropositive population.

Sleepiness and sleep quality in patients with HIV infection

OBJECTIVES

Patients with HIV infection frequently complain of sleep disturbances and daytime sleepiness. Only few data on these problems evaluated by standardized measures is available.

METHODS

A sample of 180 consecutive patients with HIV infection referred to the internal and to the neurological HIV clinics at the University of Münster was enrolled in this study. The data were compared to a sample of 120 age- and sex-matched control subjects. We used the Epworth Sleepiness Scale (ESS), the Pittsburgh Sleep Quality Index (PSQI), and the Beck's Depression Inventory (BDI). In addition, the clinical and immunological data of the patients were registered.

RESULTS

All scores of the ESS, the PSQI, and the BDI were significantly increased in the HIV infected patients as compared to the control group. There were no significant correlations between any of the immune parameters and the scores. Only a higher BDI score was correlated with both the ESS score and the PSQI score.

CONCLUSIONS

Patients with HIV infection and not using evavirenz show an increased daytime sleepiness and a decreased quality of sleep. These findings could not be related to the immunological state of the patients. The only specific factor influencing daytime sleepiness in HIV infected patients is probably treatment with HAART. The most important factor determining sleepiness and sleep quality in HIV infected patients is depression which was found to be independent from the immunological state and HAART of the patients.

Insomnia symptoms and HIV infection among participants in the Women's Interagency HIV Study

OBJECTIVES

This study assessed the prevalence of insomnia symptoms among women with and without HIV-infection and examined factors associated with insomnia.

DESIGN

Participants (n = 1682) were enrolled in the Women's Interagency HIV Study (WIHS); 69% were infected with HIV. This was a cross-sectional analysis of data from standardized interviewer-administered instruments and physical/gynecological exams. Analysis focused on sociodemographics, sleep measures, depressive symptoms, drug use, alcohol consumption, medications, and HIV-related clinical variables. Women were classified as having symptoms of insomnia if they reported either difficulty initiating sleep, difficulty maintaining sleep, or early morning awakening ≥ 3 times a week in the past 2 weeks.

RESULTS

Overall, HIV-infected women were 17% more likely to endorse insomnia symptoms than uninfected women (OR = 1.17, 95% CI: 1.04-1.34, P < 0.05). The adjusted prevalence of insomnia symptoms varied by HIV status and age groups. Among women ages 31-40 years, those with HIV infection were 26% more likely to endorse insomnia symptoms than their counterparts (OR = 1.26, 95% CI: 1.01-1.59, P < 0.05). No significant differences were observed in the likelihood of reporting insomnia symptoms based on HIV treatment type. Multivariate-adjusted regression analyses showed that depression was the most consistent and significant independent predictor of the likelihood of reporting insomnia symptoms across all age strata.

CONCLUSIONS

Insomnia symptoms are common among both HIV-infected and uninfected women. Prevalence of insomnia did not vary significantly by HIV status, except among younger women. Younger women with HIV infection are at greater risk for experiencing insomnia symptoms.

Quality of sleep: associations with antiretroviral nonadherence

Poor quality of sleep (QOS) is frequently reported in HIV-positive individuals; however, despite its clinical and public health significance, few studies have examined the correlation between QOS and antiretroviral (ARV) adherence. The objective of this study was to estimate the prevalence of sleep disturbances, determine the characteristics of those with poor QOS, and establish the relationship between QOS and ARV nonadherence among HIV-positive individuals. We conducted a cross-sectional secondary data analysis of 2845 HIV-positive adults taking ARV therapy from the Healthy Living Project baseline cohort. Mean self-reported ARV nonadherence was estimated using a 3-day measure. QOS was assessed using three questions regarding sleep pattern changes, amount of bother from difficulty falling/staying asleep, and amount of bother from vivid dreams. Over 68% of individuals reported sleep pattern changes, 50.3% reported difficulty falling/staying asleep, and 20.5% reported bother from vivid dreams. Depression, suicidal ideation, unemployment, use of illicit substances, history of incarceration, and HIV viral load were all independently associated with poor QOS. Individuals reporting feeling bothered about difficulty falling/staying asleep had a 1.66 higher odds of nonadherence (95% confidence interval [CI]=1.18, 2.33; p=0.004). Those reporting the highest degree of bother from difficulty falling/staying asleep and from vivid dreams had a 1.42 (95% CI=1.13, 1.78; p=0.002) and 1.31 (95% CI=0.98, 1.75; p=0.07) higher odds of nonadherence, respectively. With higher incremental reports of poor QOS there were considerable increases in ARV nonadherence. Recognition and timely treatment of sleep difficulties may result in reduced ARV nonadherence with beneficial clinical and public health implications.

Sleep and psychoneuroimmunology

The brain uses a variety of mechanisms to survey the immune system constantly. Responses of the immune system to invading pathogens are detected by the central nervous system, which responds by orchestrating complex changes in behavior and physiology. Sleep is one of the behaviors altered in response to immune challenge. The role of cytokines as mediators of responses to infectious challenge and regulators and modulators of sleep is the focus of this article.

Psychopharmacologic treatment of patients with HIV/AIDS

Psychiatric disorders are common among patients with HIV/AIDS, and psychopharmacologic treatment is a cornerstone of management. The efficacy of psychopharmacologic treatment for depression in HIV/AIDS is relatively well established. However, literature on the treatment of other disorders is limited, which means that we still must determine how standard treatment guidelines may need to be modified in consideration of several key aspects of HIV illness. These include the broad differential diagnosis for psychiatric symptoms and the potential for interactions between psychotropic medications and antiretroviral medications. This paper reviews the literature on psychopharmacologic treatments of key psychiatric disorders in HIV/AIDS as well as differential diagnosis and drug-drug interactions.

Sleep and Psychoneuroimmunology

Personal experience indicates we sleep differently when sick. Data reviewed demonstrate the extent to which sleep is altered during the course of infection of host organisms by several classes of pathogens. One important unanswered question is whether or not the alterations in sleep during infection are of functional relevance. That is, does the way we sleep when sick facilitate or impede recovery? One retrospective, preclinical study suggests that sleep changes during infection are of functional relevance. Toth and colleagues [102] analyzed sleep responses of rabbits to three different microbial infections. Those rabbits that exhibited robust increases in NREM sleep were more likely to survive than those that exhibited long periods of NREM sleep suppression. These tantalizing data suggest that the precise alterations in sleep through the course of infection are important determinants of morbidity and mortality. Data from healthy subjects demonstrate a role for at least two cytokines in the regulation of spontaneous, physiologic NREM sleep. A second critical yet unanswered question is whether or not cytokines mediate infection-induced alterations in sleep. The hypothesis that cytokines mediate infection-induced alterations in sleep is logical based on observations of the impact of infection on levels of cytokines in the peripheral immune system and in the brain. No attempts have been made to intervene with cytokine systems in brain during the course of infection to determine if there is an impact on infection-induced alterations in sleep. Although substantial progress has been made in elucidating the myriad mechanisms by which cytokines regulate and modulate sleep, much remains to be determined with respect to mechanistic and functional aspects of infection-induced alterations in sleep.

Modulation of autonomic balance by tumors and viruses

Autonomic balance, a function generally under host control, is subject to modulation by other signalers. In some cases, modulation of host autonomic function through behavioral and physical stressors exerted by another individual may have negative consequences for the stress recipient by inducing sympathetic bias. Modulation of autonomic function may sometimes benefit one party at the expense of another. Tumors and HIV are examples of illegitimate signalers who may induce host sympathetic bias to promote their own growth and evade host immune surveillance. Paraneoplastic and paraviral syndromes such as hypertrophic osteoarthopathy, QTc prolongation, insomnia, and cachexia could be viewed as epiphenomena related to the tumoral and viral manipulation of host autonomic balance. In a more general framework, other paraneoplastic and paraviral syndromes may represent epiphenomena related to modulation of endocrine, cytokine, and autonomic functions by tumors and viruses to promote their own survival. Spatial distribution of cancers and viruses within the host may reflect affinity for strategic locations that facilitate manipulation of a variety of host functions including autonomic, endocrine, and cytokine regulation. A more general for understanding spatial distribution of diseases based on gradients of autonomic balance in the body are explored. Darwinian perspectives are discussed.

Temporal variation of autonomic balance and diseases during circadian, seasonal, reproductive, and lifespan cycles

Many diseases show patterns of temporal variation that remain unexplained. We hypothesize that oscillation of autonomic balance over different time intervals plays a role in these variations. In the Darwinian struggle, organisms must perform various functions related to fitness such as survival, energy acquisition, and reproduction in a prioritized fashion. Autonomic systems enable differential allocation of effort to various functions under different conditions, some of which vary in patterns that are predictable such as circadian, menstrual, seasonal, and life cycles. For many species, daytime functions such as seeking food and avoiding predators are achieved with sympathetic activity while night-time functions such as internal processing are achieved with parasympathetic activity. For organisms that maintain thermal homeostasis year-round, cooler temperature seasons may demand sympathetic bias to drive adaptive thermogenesis. Reproduction may necessitate autonomic shift to sympathetic bias during the luteal phase and pregnancy to modulate immune balance towards a more tolerant Th2 bias. Many diseases including infectious, cardiovascular, inflammatory, pulmonary, metabolic, fertility, oncologic, and neurologic conditions also show variation in prevalence over these cycles. The co-variation of autonomic balance and diseases over time intervals suggests that autonomic balance, by its direct effects as well as its indirect effects through modulation of T helper immune balance, plays an under-recognized role in diseases. The theory is extended to the co-variation of autonomic balance and diseases over the lifespan. Termination of organisms during senescence, achieved by emergence of autonomic imbalance and other systemic dysfunctions, is explored from a Darwinian perspective.

Physical and mental fullness as descriptors that influence sleep in women with HIV

Through individual interviews, this qualitative study examined the subjective experience of sleep quality in the lives of 6 women with HIV infection. Three major themes emerged: living differently, sleep patterns, and strategies to normalize sleep. The women in this study revealed that they were living differently than before their infection and their experience of sleep had similarly changed. Four adaptive mechanisms were used to normalize sleep: automaticized behaviors, processing alternatives, yielding to a lack of control, and vigilant self-monitoring. This article includes discussion and implications for future research.

Beta (CC)-chemokines as modulators of sleep: implications for HIV-induced alterations in arousal state

Sleep is altered early in the course of HIV infection, before the onset of AIDS, indicating effects of the virus on neural processes. Previous observations suggest HIV envelope glycoproteins are possible mediators of these responses. Because some beta (CC)-chemokine receptors serve as co-receptors for HIV and bind HIV envelope glycoproteins, we determined in this study whether selected CC chemokine ligands alter sleep and whether their mRNAs are detectable in brain regions important for sleep. CCL4/MIP-1beta, but not CCL5/RANTES, injected centrally into rats prior to dark onset increased non-rapid eye movements sleep, fragmented sleep, and induced fever. mRNA for the chemokine receptor CCR3 was detectable under basal conditions in multiple brain regions. These data suggest some CC chemokines may also be involved in processes by which HIV alters sleep.

Human immunodeficiency virus glycoproteins 160 and 41 alter sleep and brain temperature of rats

Sleep is altered during all stages at which it has been recorded during chronic human immunodeficiency virus (HIV) infection, including the long latent phase before the development of AIDS; the mechanisms for such alterations are not known. The HIV envelope glycoprotein (gp) 120 alters sleep of rats in a manner somewhat similar to the alterations that occur in humans infected with HIV. To further determine which components of the virus may be responsible for altered behavior, we administered centrally into rats prior to dark onset recombinant HIV gp160 or gp41. Both glycoproteins increased non-rapid eye movements sleep, fragmented sleep, altered slow frequency components of the electroencephalogram, and induced modest febrile responses. These results complement and extend those previously obtained after gp120; HIV envelope glycoproteins are capable of altering sleep.

High prevalence of insomnia in an outpatient population with HIV infection

OBJECTIVE

To determine the prevalence, characteristics, and clinical recognition of insomnia in HIV-seropositive outpatients.

DESIGN

Systematic sample of patients attending an outpatient HIV/AIDS clinic at an urban teaching hospital.

METHODS

Patients were recruited for standard interviews including Pittsburgh Sleep Quality Index (PSQI); Mini Mental State Exam (MMSE); Trail Making Test A and B, and Hospital Anxiety and Depression Scale. Abstraction of medical records was used to assess clinician identification of insomnia.

RESULTS

115 of 127 (91%) patients who were approached agreed to be interviewed for the study. Of these, 79 (69%) were male, 36 (31%) female; 38 (33%) black, 64 (56%) white, 12 (10%) Hispanic, 1 (1%) native American; 45 (39%) were injection drug users. Eighty-four (73%) respondents were classified as having a sleep disturbance according to the PSQI. Patients with cognitive impairment had a higher prevalence of insomnia (100% versus 70%; p = .034). A trend was shown for drug-using patients to report a higher prevalence of insomnia than nondrug users (86% versus 69%; p < .07). Using multivariate analysis, cognitive impairment (odds ratio [OR] = 1.4) as defined by the neuropsychiatric test battery and depression (OR = 1.2) were the best predictors of insomnia (p < .05). Only 28 (33%) patients with insomnia had any documentation of sleep disturbance in their clinical medical records.

CONCLUSIONS

Insomnia is widespread and underdiagnosed in HIV-seropositive ambulatory patients. Insomnia is especially prevalent among those with cognitive impairment. These findings suggest the importance for clinicians to inquire specifically about sleep disorders in HIV-seropositive patients. Prompt diagnosis and treatment may improve the quality of life in patients living with HIV.

Sleep quality in people with HIV disease

This study examined sleep quality in HIV infected people. The research explored the incidence of the study variables (sleep quality, anxiety, well-being, and symptom severity) and found differences on the variables between subjects who reported HIV infection through male/male sex (n = 18) as compared to injecting drug use (n = 23). The instruments were the Pittsburgh Sleep Quality Index (PSQI), the HIV Assessment Tool (HAT), and the Spielberger State/Trait Anxiety Tool. The average subject (N = 56) was male, 48 years old, a person of color and reported HIV infection through injecting drug use. General well-being was significantly correlated (Pearson product moment correlations) with sleep quality (r = .46, p = .01). Significant differences on the global PSQI (t = 3.22, p = .003) and on the well-being factor of HAT (t = -2.05, p = .04) were found in that injecting drug users reported worse sleep quality and well-being. No significant differences were determined between the two groups on any of the other study variables.

Lentiviral infection, immune response peptides and sleep

The aberrant sleep documented in subjects with human immunodeficiency virus (HIV) infection is uniquely important because of the contribution this poor quality sleep makes to the fatigue, disability, and eventual unemployment that befalls these patients. Especially given this importance in clinical care, the research on the prominent sleep changes described in HIV infection remains modest in quantity. The chronic asymptomatic stage of HIV infection is associated with the most intriguing and singular sleep structure changes. Especially robust is the increase in slow wave sleep, particularly in latter portions of the sleep period. This finding is rare in other primary or secondary sleep disorders. The sleep structure alterations are among the most replicable of several pathophysiological sequelae in the brain associated with early HIV infection. It is unlikely that these sleep architecture changes are psychosocial in etiology, and they occur before medical pathology is evident. They are not associated with stress, anxiety, or depression. Evidence is accumulating to support a role for the somnogenic immune peptides tumor necrosis factor (TNF)alpha and interleukin (IL-1 beta) in the sleep changes and fatigue commonly seen in HIV infection. These peptides are elevated in the blood of HIV-infected individuals, and are somnogenic in clinical use and animal models. The peripheral production of these peptides may also have a role in the regulation of normal sleep physiology. The lentivirus family contains both HIV and the feline immunodeficiency virus (FIV). The use of the FIV model of HIV infection may provide a way to further investigate the mechanism of a neurotropic, neurotoxic virus initiating the immune acute phase response and affecting sleep. Neurotropic lentivirus infection is a microbiological probe facilitating neuroimmune investigation.

EEG diagnostic and predictive value on HIV infection in childhood

This prospective study evaluated the electroencephalographic (EEG) diagnostic and prognostic value in childhood HIV infection. It was carried out on 125 subjects and included all Piemonte's seropositive children. The EEG was repeated every three months during the first 15 months of life, and then, at least, annually in the P1 and P2 group. Data of group P2 was compared blindly to that of the seroconverted control group of the same age and risk. EEG results were normal in P0, P1 and control patients. In group P2, EEG was abnormal in 35.5% of subjects, of these 54.6% developed an encephalopathy with a delay of 2.5 months to 2 years 11 months. EEG is therefore useful to evaluate early CNS damage and to identify onset features and evolution of encephalopathy in P2 patients.

Early signs of cognitive deficits among human immunodeficiency virus-positive hemophiliacs

A total of 181 human immunodeficiency virus (HIV)-seropositive hemophiliacs and 28 hemophilic controls were evaluated by psychometric tests and by electroencephalogram (EEG). Patients were classified from stages 1-6 according to the immunological criteria of the Walter Reed staging system. Statistical analysis of psychometric data showed an effect of the stage of the disease on test performances, indicating a decline in attention, accumulation of perceptual interferences, decline in visuoperceptual speed and visuomotor response speed and reduced verbal memory performance, especially in stage 6 patients. Comparison of performance levels with normative test data already revealed cognitive deficits in about 20-30% of the patients in stages 2-5. As regards verbal memory, especially learning and recognition of new verbal information were impaired. In contrast, there was no significant deficit for nonverbal memory processing. Compared with the controls, patients exhibited an increasing number of abnormal EEG findings in stages 2-6. As a conclusion, in the stages before acquired immunodeficiency syndrome (AIDS) develops, EEG findings as well as psychometric findings indicate central nervous system involvement of AIDS in about 20-30% of cases, whereas in full-blown AIDS there is a marked increase to 80%. Besides a more general deficit of attention and psychomotor speed as is seen in subcortical dementia, there is evidence for a particular verbal learning disorder, suggesting additional selective impairment of the brain.