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A study of sleep and rest in people with and without HIV

The body has an internal 24-hour clock called the circadian rhythm. This clock tells the body when to sleep and when to wake up. It also affects the functioning of organs, digestion, the production of hormones and body temperature. More information about circadian rhythms in general will be provided later in this article. 

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More about circadian rhythms

Although the brain helps to set the circadian rhythm, it can also be affected by light; this includes sunlight and the light from devices such as television sets, computer monitors, tablets and smartphones. The light from these devices tends to be similar in some ways to sunlight, and this sends a signal from the eye to the brain that it is daytime. Such signals at nighttime cause the brain to reduce production of melatonin, a hormone that helps the body fall asleep. Circadian rhythms can become altered during travel (jet lag), when work occurs at late at night instead of during the day, and during some conditions that affect the brain, such as depression. Disruption of sleep/wake cycles can affect a person’s energy, wakefulness, mood and ultimately quality of life.

Research on circadian rhythms 

Studies have suggested that sleep disturbances are relatively common in people with HIV in the current era. A team of scientists at universities in Cleveland and Pittsburg conducted a study of sleep and activity patterns in adults in their mid-50s, both with (106 people) and without (105 people) HIV. About 75% of participants were assigned male at birth and 25% were assigned female at birth. All participants were healthy.

For 14 days participants wore a device on their wrist that collected data on their movement and other activities. They also kept a diary about their sleep habits. All participants with HIV were taking treatment (antiretroviral therapy; ART) and had a suppressed viral load (less than 50 copies/mL), and their average CD4+ count was 819 cells/mm3. 

Results in people with HIV

In analyzing the results, the researchers took into account factors such as socioeconomic differences and whether participants had disordered breathing during sleep (sleep apnea). 

The researchers found that even though participants with HIV had relatively high CD4+ cell counts and suppressed viral loads, they were more likely to:

  • fall asleep later
  • have interrupted sleep
  • have longer daytime naps

Overall, this suggests that people with HIV had what the researchers called “a delayed and simultaneously less robust circadian rhythm” compared to people without HIV.

The delays found in the study were modest (note that the researchers only collected measurements over 14 days). The researchers noted that it is possible that having a disordered circadian rhythm over the medium and long term could contribute to an increased risk for some of the “cardiovascular, metabolic and psychiatric morbidities observed in people with HIV.”

Results in people without HIV

Among people without HIV, studies have found that, over the long term, people who have sleep problems can develop into a state predisposing them to diabetes, excess weight gain, high blood pressure and cardiovascular disease. In addition, also in people without HIV, studies have found that altered circadian rhythms and sleep problems are associated with an increased risk for a range of problems, including the following:

  • anxiety
  • depression
  • problematic substance use
  • heart attack
  • stroke

The scientists conducting the present study stated that altered circadian rhythms can contribute to an increased risk of comorbidities by causing unfavourable changes to metabolism and hormones. The changes in circadian rhythms could also affect the balance of bacteria living in the gut, causing these bacteria to release proteins that incite inflammation. 

The researchers also noted that experiments with monkeys susceptible to SIV (simian immunodeficiency virus, which is related to HIV) have found that this virus “reduces circadian robustness.” 

No study is perfect, and the researchers could have used additional tests such as measuring the body’s response to dim light (by checking for changes in melatonin production) or body temperature. Most of the participants were male and there was no information about their lowest-ever CD4+ count prior to initiation of ART. 

Most participants were taking ART based on integrase inhibitors or protease inhibitors. Only one participant was taking efavirenz (in Atripla and other formulations); this drug can affect sleep and wakefulness as well as mental health (in rare cases). However, when researchers excluded data from the participant who took efavirenz during the study, it made no difference to the overall results.

For the future

Thanks to ART, many people with HIV will live well into their senior years. As people with HIV age, more attention needs to be paid to factors that can affect quality of life, including sleep.

Short- and long-term consequences of circadian rhythm disruption

According to the Cleveland Clinic, the following issues can occur in the short term when circadian rhythms are disrupted:

  • a delay in healing wounds
  • changes to hormones
  • digestive issues
  • fluctuations in body temperature
  • lack of energy
  • [temporary] memory difficulties

Circadian rhythm disruptions can lead to long-term health conditions in many different body systems, including the following:

  • cardiovascular system
  • metabolism
  • gastrointestinal system
  • endocrine system
  • nervous system

The Cleveland Clinic recommends several steps to help reset circadian rhythms.

To reset your circadian rhythm, your body needs to follow a healthy 24-hour schedule. Use the following tips to stay on track:

  • Try to stick to a daily routine.
  • Go outside when it’s light out to boost your sense of wakefulness. 
  • Get some form of daily physical activity.
  • Foster a restful sleep environment. Make sure you’re sleeping on a supportive mattress in a room with a comfortable temperature and proper lighting.
  • Avoid caffeine, nicotine and alcohol, especially in the evenings.
  • Limit your screen time before bedtime, as the blue light can disrupt your ability to fall asleep. Instead, try meditating or reading a book.
  • Don’t nap in the late afternoons or evenings.        

Note that in some cases a healthcare provider may recommend light treatment (with specialized light-emitting devices) to help reset circadian rhythms. The Cleveland Clinic notes that “in such cases, treatment using light occurs in the morning specifically, and it is important to avoid chronic sleep deprivation as part of treatment, which makes things exponentially worse.”

Additional advice 

The Cleveland Clinic advises that people should contact their healthcare provider in cases where the following symptoms are bothersome and persistent:

  • difficulty getting enough sleep every night
  • trouble falling asleep easily
  • waking up throughout the night
  • problems waking up in the morning
  • extreme fatigue during the day

—Sean R. Hosein

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