HIV psychiatry

Differences in sleep architecture between men living with and without HIV
Naresh M Punjabi, Todd T Brown, Darko Stefanovski, Rashmi Nisha Aurora, Sanjay R Patel, Valentina Stosor, Joshua Hyong-Jin Cho, Gypsyamber D'Souza, Joseph B Margolick

Abstract:

Study Objectives:

The landscape of HIV infection has shifted dramatically over the last few decades. An extended lifespan has led to an increase in comorbidities, including disorders of sleep. While self-reported sleep disturbances in people living with HIV are common, differences in sleep architecture between those living with and without HIV have not been previously described.

Methods:

Polysomnography data from the Multicenter AIDS Cohort Study were used to characterize differences in sleep architecture between men living with and without HIV. Parameters assessed included total sleep time, sleep stage distribution, arousal index, and frequency of sleep stage transitions. Multivariable regression was employed to adjust for demographic variables and explore effect modification by sleep-disordered breathing (SDB) severity.

Results:

Compared to men without HIV (N = 349), men with HIV (N = 447) exhibited comparable total sleep time, but lower sleep efficiency and greater wake time after sleep onset. Independent of HIV status, SDB was associated with a greater percentage of N1 sleep and lower percentages of N2 and REM sleep. However, those with both HIV and severe SDB displayed the lowest sleep efficiency, the highest percentage of N1 sleep, and the lowest frequency of sleep stage transitions from nonrapid eye movement (non-REM)-to-REM sleep compared to all other HIV and SDB subgroups.

Conclusions:

This study found an independent association between HIV, SDB, and altered sleep architecture, characterized by lower sleep efficiency, greater time in stage N1 sleep, and higher sleep stage instability. Further research is needed on the potential health implications of disrupted sleep in those with HIV and SDB.

Annotation

Findings: This study used polysomnographic data from the Multicenter AIDS Cohort Study (MACS) to compare sleep architecture between men living with and without HIV, as well as the independent and interactive associations between HV, sleep-disordered breathing (SDB), and sleep structure. The primary finding was that men living with HIV had poorer sleep quality, compared to men not living with HIV, but only in the setting of co-occurring severe SDB. Parameters showing significant differences in PWH included lower sleep efficiency, greater wake time after sleep onset, and higher proportion of time spent in sleep stage N1. Additionally, PWH with severe SDB had significantly fewer NREM-to-REM sleep and REM-to-NREM transitions, compared to all other groups. HIV-related markers such as antiretroviral therapy use, CD4 cell count, and HIV viral load were not associated with altered sleep architecture.

Strengths and limitations: The use of home polysomnography, its large sample size, and the inclusion of participants without HIV are this study’s major strengths. Polysomnography is an objective sleep measure that eliminates self-report bias. The MACS cohort’s comprehensive assessments of both people with and without HIV permitted a detailed understanding of the influence of HIV on the associations between SDB and total sleep time, sleep stage distribution and transitions between sleep stages, and arousal index. The study’s inclusion of only men limits its generalizability to other gender groups. Also, its cross-sectional design limits conclusions about causality. Evolution of antiretroviral therapy since the time that study data were collected could limit generalizability of findings to current populations. Finally, the study’s findings are limited to associations between HIV and sleep quality. The study was not designed to explore connections between sleep disturbances and other important HIV-related health outcomes such as neurocognitive functioning and cardiometabolic conditions.

Relevance: Both the research literature as well as front line clinicians can attest to the frequent occurrence of sleep-related symptoms and fatigue in people with HIV (PWH). Sleep disorders affect 60% of PWH and HIV confers additional risk of having sleep-disordered breathing (SDB). Yet, there have been no studies since the introduction of antiretroviral therapy that have examined the relationship between HIV and sleep architecture. This is the first study to explore the combined effect of HIV and SDB on sleep architecture.

This study raises several interesting questions: What is the role of HIV CNS involvement in disrupted sleep continuity, especially in the presence of severe SDB and viral suppression? Does the interaction between HIV-related neuroinflammation and hypoxemia result in more severe neurocognitive comorbidities and fatigue? Since PWH may present with sleep-related symptoms in the absence of SDB risk factors, thus potentially delaying SDB diagnosis, should PWH be routinely screened for SDB, particularly those with symptoms of fatigue and daytime drowsiness. This study’s findings also suggest the need for interventional studies of the effects of positive airway pressure and CBT for insomnia on sleep quality, quality of life and neurocognitive comorbidities. Further investigation of the medically vulnerable group identified by this study could lead to important insights about HIV CNS neuropathology and its clinical manifestations.

Towards Ending the HIV Epidemic: The Case for Incorporating PrEP Prescribing into Psychiatric Training
Keriann Shalvoy, Abigail Kay, Christopher White, Marshall Tang

Abstract:

No abstract available

Annotation:

This commentary argues persuasively that prescribing medications for HIV pre-exposure prophylaxis (PrEP) should be standard practice for all psychiatrists and that education about PrEP should begin in medical school. People with mental illness and/or substance use disorders are more likely to be at risk for acquiring and being diagnosed with HIV, and people with HIV (PWH) have higher rates of mental illness and/or substance use disorders, compared to the general population. The most common source of PrEP prescriptions is primary care and infectious disease physicians. Yet, PrEP uptake by people who could benefit has been inadequate, most notably among minority populations. Additionally, despite remarkable advances in treatment, there are over 30,000 new HIV infections annually. Patients with severe mental illness and substance use disorders are less likely to access general medical care, which uniquely positions psychiatrists to contribute to our patients’ overall health and well-being. Known barriers to psychiatrists prescribing PrEP are limited knowledge and the belief that it is beyond the scope of practice. However, the approved oral and long-acting injectable formulations do not require dose titration and need minimal laboratory monitoring, which in many cases is already part of standard psychiatric care. Significant drug-drug interactions with psychotropic medications is limited to tenofovir-containing PrEP and lithium, which may result in renal impairment and is potentially preventable by routine laboratory monitoring. Studies have demonstrated that with minimal training, psychiatrists have made treatment for tobacco use disorders part of routine practice. Addressing antipsychotic-related metabolic disorders is also becoming more common. This article’s call to include PrEP education in the didactic curriculum for all psychiatry residents is both easily achievable and overdue.