Efficacy Potential of an Internet-based Sleep Program to Improve Sleep Quality in People With HIV

Sleep disturbances have been consistently reported in HIV+ individuals, and occur early in the course of infection. Among disorders of sleep commonly found in HIV, insomnia is by far the most frequent condition, affecting almost 75% of HIV-infected individuals. Compared to non-infected individuals, HIV+ patients are 17% more likely to develop insomnia. Furthermore, not only is insomnia more frequent in HIV; it is also more severe in HIV+ compared to HIV- individuals. The precise mechanisms underlying the vulnerability of this population to insomnia still remain hypothetical, and might involve neurodegenerative processes related to the infection, associated mood disorders (e.g., depression, anxiety), side effects of antiretroviral medications, and psychosocial factors. Importantly, sleep disorders in HIV have been demonstrated to affect the severity of the infection. For instance, sleep disturbances were shown to mediate the association between psychological distress and immune status (T-cytotoxic/suppressor cell counts). In addition, sleep disruption also affects responses to treatment, as illustrated by a report demonstrating that sleep disturbances mediate the association between medication adherence and self-reported HIV symptom severity. Finally, insomnia in HIV seems to be closely associated with the presence of cognitive disturbances. Indeed, virtually all HIV infected individuals with cognitive impairment present insomnia complaints, and greater sleep disturbances were associated with worse cognitive performance (e.g., executive functions, psychomotor speed) in this population. Therefore, insomnia has been shown to affect symptom severity, treatment adherence and cognition in HIV+ individuals.

Despite this demonstrated importance of sleep for the well-being of HIV patients, there are very few studies of sleep treatment interventions in HIV. Two studies have implemented an educational intervention promoting healthy sleep habits (e.g., healthy diet, reduced caffeine consumption, no exercise before bedtime, regular sleep-wake schedules), consisting of either one single session or 10 weekly sessions, with little or no consistent sleep improvement in this population. This is not surprising given that previous studies showed the very limited efficacy of interventions focusing solely on sleep hygiene in a general chronic insomnia population.

The most effective treatment for chronic insomnia currently consists of a multimodal psychological intervention, called cognitive-behavioral therapy for insomnia (CBT-I). CBT-I improves sleep to the same degree as hypnotic medications in the short term, but, in contrast to hypnotics, shows no side effects and remains effective in the long term, with sustained improvement in sleep and daytime functioning up to 2 years after completion of the therapy. CBT-I has proven effective in patients with primary insomnia (i.e. without associated medical condition), as well as in insomnia comorbid with depression or cancer. However, the efficacy of CBT-I has not been studied in HIV+ individuals with insomnia.

Digital Cognitive-Behavioural Therapy for Insomnia (CBT-I): the Sleepio program

CBT-I is an intervention aimed at breaking the patterns of maladaptive thinking and behavior that serve to maintain insomnia. It includes a range of techniques including a behavioral component (stimulus control, sleep restriction, relaxation) combined with a cognitive (managing sleep related worries, the racing mind and intrusive thoughts) and an educational (sleep hygiene) component. CBT-I is usually dispensed in group sessions, including 5 to 8 patients and a trained therapist. The different components of CBT-I are then covered in 6 to 8 weekly sessions of 60-90 minutes each. While CBT-I has been demonstrated as an efficacious treatment option, the personnel-intensive nature of CBT-I constitutes an important barrier to widespread clinical use.