Sleep Disturbances in HIV Disease

by Richard S. Ferri, Ph.D., ANP, ACRN, FAAN

Over 40 million Americans suffer from a chronic sleep disorder. Feeling fatigued, lack of restfulness, early morning awakening, and difficulty falling or staying asleep are classic symptoms of insomnia. The complaint of sleep disturbance can be seen throughout the trajectory of HIV disease from early infection to end-stage AIDS.

The etiology of impaired sleep and disabling daytime fatigue can be multifactorial. The activation of specific and nonspecific immunological pathways interferes with the regulation of sleep and wakefulness in HIV disease. Proinflammatory cytokines interleukin-1 DF (IL-1DF) and tumor necrosis factor-a (TNF-a) play a central role in sleep modulation. Both IL-1DF and TNF-a may impact the cyclic alteration of nonrapid eye movement (non-REM) and rapid eye movement (REM) stages of sleep, resulting in insomnia.

In addition to the biological basis for sleep disturbance, psychosocial issues can be a causative factor; these include poor sleep hygiene (the nightly rituals an individual performs prior to sleep), environmental issues, alcohol and drug use, and certain antiretroviral medications. The number of HIV patients reporting difficulty in sleeping due to an increase in stress has escalated since September 11th.

When investigating complaints of sleeplessness, clinicians should start with a comprehensive history using self-report questionnaires, sleep diaries, sleep logs, and details of nightly rituals/environment or sleep hygiene. It is also important to examine current medications and their impact on sleep as well as the use of caffeine, alcohol, and recreational drugs. The patient should also be assessed for the presence of clinical depression and other related psychiatric disorders.

Some medications used to treat HIV and related conditions have been implicated in insomnia. The non-nucleoside reverse transcriptase inhibitor efavirenz (Sustiva®) can cause central nervous system disturbances such as drowsiness, insomnia, and agitation when initially started. Patients should be advised that these side effects are usually temporary and last from 2 to 4 weeks. Zidovudine (AZT), a nucleoside reverse transcriptase inhibitor, can also cause some sleep trouble. If patients are being treated for co-infection with Hepatitis C, the use of ribavirin can result in sleeplessness. It may be necessary to alter the dosing schedule of any offending agent from just prior to bedtime to other times during the day.

The pharmaceutical treatment of insomnia can be troublesome due to drug interactions with protease inhibitors. For example, the co-administration of ritonavir (Novir®) with the hypnotic triazolam (Halcion®) increases the level of the Halcion to twice normal due to competition by the CYP3A liver enzyme pathways. Amprenavir (Agenerase®) has been shown to have a similar effect. Levels of zolpidem (Ambien®) were only increased slightly probably due to liver processing by different enzymes other than the CYP3A. In general, sleep agents should not be taken for more than 7 to 10 days, and re-evaluation is recommended if they are needed for more than 2 to 3 weeks.

Non-pharmaceutical approaches to treatment include relaxation techniques, meditation, prayer, and improving sleep hygiene. These can be used as sole interventions or in conjunction with medication.

Regardless of the intervention used, the complaint of insomnia should be clinically investigated for any underpaying etiology that may be impacting the patient.

Dr. Ferri received his Masters of Science in Primary Health Care Nursing, Adult Nurse Practitioner, from Simmons College and Ph.D. in Adult Education and Development from Columbia Pacific University, and a master of science in adult education and human resource development from Fordham University in New York. He is certified as an AIDS Certified Registered Nurse (ACRN) and has served the elected positions of president and national director for the Association of Nurses in AIDS Care (ANAC) the HIV/AIDS Nursing Certification Board (HANCB) from 19992000. He currently practices in an independent consulting firm in the areas of HIV/STD clinical management and lends his expertise to continuing medical and nursing education program development, editing, writing, and scripting for multi disciplinary audiences, workshops/seminars in HIV/STD management, mens health issues, gay and lesbian issues (domestic violence, breast cancer, prostate disease), and adolescent health care.

Dr. Ferri has co-authored eight textbooks and written more than 40 articles in such journals as RN, Nursing Spectrum, The American Journal of Nursing, The Journal of the Association of Nurses in AIDS Care, and Advance for Nurse Practitioners. He is on the editorial board/review panel of several professional journals, he has presented at more than 35 national symposia and workshops. Dr. Ferri is a Distinguished Lecturer in HIV/AIDS Nursing for the ANAC.

He is a clinical expert in HIV nursing for the International Council of Nurses, and is a Fellow of the American Academy of Nursing. In November of 2000, he was awarded the ANAC Lifetime achievement award for this contributions to AIDS care.