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Sleep Med Clin 2 (2007) 51–58

Steven Reid,



*, Louise McGrath,




HIV and AIDS Sleep architecture, immune function, and HIV infection Antiretroviral therapy Psychiatric disorders Alcohol and illicit drug use

Pain Management of insomnia in HIV infection Pharmacological treatments Psychological treatmentsReferences

From the earliest clinical descriptions of the disease, insomnia has been recognized as a frequent complaint among patients with HIV [1,2]. Sleep disturbance is commonly reported at all stages of HIV infection and has been ascribed to a range of etiologic factors including the neurotropic effects of the HIV virus, antiretroviral therapy, HIV-related symptoms such as fatigue and nightsweats, drug and alcohol use, and psychiatric illness [3]. Prevalence rates of insomnia in the general population range from 10% to 40%, but typically surveys show that sleep disturbance is more common among those with chronic medical illness [4–7]. The lack of large epidemiological studies makes it difficult to be certain about the prevalence of insomnia in HIV-positive populations and thosestudies available are limited by a lack of seronegative controls or small sample sizes. Many studies also fail to distinguish between insomnia as a symptom and as a disorder. However, the available evidence certainly indicates that sleep disturbance is commonly experienced in HIV and AIDS [8–10]. One cross-sectional survey used the Pittsburgh Sleep Quality Index to identify poor sleepers and foundthat 73% of a sample of outpatients had insomnia, requiring more than 1 hour to go to sleep compared with good sleepers, and on average sleeping for 2 hours less [11].

Persistent insomnia is associated with a number of adverse consequences including chronic fatigue, mood disturbance, cognitive impairment, impaired job performance, and increased health care use [5,12]. As well as having animpact on quality of life, it may also compromise treatment adherence, which is of particular importance in HIV infection [13].

Currently an estimated 40 million people live with HIV/AIDS worldwide [14]. In 2005 there were 4.1 million new HIV infections and 3 million AIDS deaths [14]. Eighty-five percent of HIV infections are accounted for by heterosexual transmission [15].Sub-Saharan Africa comprises the majority of infections but numbers are increasing rapidly in China and India [14]. In the United States it is estimated that over 1 million people are living with HIV [16]. African and Hispanic Americans are disproportionately affected with 70% of new infections occurring in these minority groups [16]. HIV disease begins with a latent infection, which over time (6 monthsto 15 years) progresses to AIDS. Early signs of HIV infection include flu-like symptoms, lymphadenopathy, poor appetite, and weight loss as well as insomnia [17]. The virus

Department of Liaison Psychiatry, St Mary’s Hospital, 20 South Wharf Road, London W2 1PD, UK Department of Psychological Medicine, Imperial College, Praed Street, London W2 1NY, UK c Department of HIV Medicine, St Mary’sHospital, Praed Street, London W2 1NY, UK * Corresponding author. E-mail address: (S. Reid).

1556-407X/07/$ – see front matter ª 2007 Elsevier Inc. All rights reserved.



Reid & McGrath

attacks CD41 T-lymphocytes, that are an integral component of the normal immune response, as well as microglial cells andmacrophages that affect the central nervous system. After the primary infection the patient is often asymptomatic until the onset of overt immunodeficiency. The clinical course is highly variable and depends on the host immunology, viral properties, and genetic factors (Fig. 1). Progression to AIDS is predicted both by CD41 count and plasma viral load. While the viral load determines the rate of...
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