Abstract
The prevalence of insomnia among people living with HIV (PWH) is considerably higher than in the general population. Cognitive, behavioural, and biopsychosocial explanations for this elevated prevalence have been proposed, but there is a lack of consensus in the literature. Sleep disturbance is associated with disrupted immune functioning at the cellular level and increased risk of contracting infectious diseases; therefore, insomnia may be particularly problematic for PWH. Cognitive behavioural therapy for insomnia (CBT-I) is the first-line treatment for insomnia, and is effective at treating insomnia among individuals with comorbid medical disorders. Surprisingly, no study has examined its efficacy among PWH. This pragmatic pilot study examined features of insomnia among 48 PWH and was the first study to examine sleep disturbance among PWH using American Academy of Sleep Medicine guidelines for evaluating chronic insomnia. On average, insomnia chronicity was 8.2 years and was of moderate severity. Psychiatric comorbidity was common, as were comorbid sleep disorders. Insomnia severity was associated with psychosocial variables including sleep effort, self-efficacy for sleep, depression, anxiety, stress, and social functioning-related quality of life. This study was also the first to examine safety, feasibility, acceptability, and intervention effects of CBT-I. These were examined among a subsample of 10 PWH using single-case interrupted time-series design. Thematic analysis was used to explore participant perceptions of CBT-I. Large effect sizes were observed for improvement in insomnia severity, sleep efficiency, and total wake time. Reliable and clinically significant reduction in insomnia severity was observed for all but one participant, and half met criteria for insomnia remission. Overall, CBT-I was an efficacious treatment for insomnia, and participant feedback was consistent with quantitative results. Participants viewed CBT-I as a safe and acceptable treatment for insomnia. Participant feedback identified preexisting needs, positive impacts and challenges of CBT-I, perceived mechanisms of change, and suggested modifications to tailor CBT-I for PWH. Given this preliminary support for the efficacy of CBT-I among PWH, future research should seek to demonstrate generalizability of these effects. Partnering with HIV community organizations may be important next step in conducting future research and increasing accessibility of CBT-I to PWH. Keywords: HIV, insomnia, cognitive behavioural therapy, pilot study, pragmatic trial, thematic analysis
Highlights
Insomnia DisorderSleep is essential for optimal psychological and physiological functioning, and reduced sleep quality may compromise the above functions (Robotham, 2011)
This is the first study to examine the impact of Cognitive behavioural therapy for insomnia (CBT-I), the gold standard treatment for insomnia (Qaseem et al, 2016; Schutte-Rodin et al.)
Given that half the sample continued to have elevated sleep efficiency > 90% at posttreatment despite gradually increasing their time in bed prescriptions, this population may benefit from more aggressive time in bed increases, additional sessions, or a few follow-up appointments in person or via telephone to assist with time in bed adjustments. These results suggest that CBT-I is effective at increasing sleep efficiency, but that people living with human immunodeficiency virus (HIV) (PWH) may require additional follow-up to ensure that sleep efficiency does not remain above the target range
Summary
Insomnia DisorderSleep is essential for optimal psychological and physiological functioning, and reduced sleep quality may compromise the above functions (Robotham, 2011). Insomnia is characterized by dissatisfaction with sleep quantity or quality, accompanied by difficulty initiating and/or maintaining sleep, and/or early morning awakening with inability to fall back asleep For a diagnosis of insomnia disorder according to Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; American Psychiatric Association, 2013) criteria, the sleep disturbance must cause clinically significant distress or impairment in some important area of functioning, must occur at least three nights per week for at least the past three months, and must occur despite adequate opportunity for sleep. The DSM-5 criteria specify that adequate opportunity for sleep must be present, and that dissatisfaction with sleep quality or quantity be present. The DSM-5 criteria include early morning awakenings, and no longer include nonrestorative sleep as diagnostic criteria
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