Large U.S. study finds sleep-disordered breathing more common in men with HIV

Some people develop difficulty breathing during sleep. That is, their breathing becomes intermittent and can stop for a time. When they wake up, people with sleep-disordered breathing (sleep apnea) can feel tired, lack energy, be irritable and may experience drowsiness during the daytime.

Persistent sleep apnea causes the body’s tissues to have insufficient oxygen. This can reduce the performance of the brain and muscles. Sleep apnea can also affect people’s ability to work or volunteer and safely drive a motor vehicle, and it can degrade quality of life.

Emerging research suggests that sleep apnea can contribute to the following issues:

• high blood pressure
• cardiovascular disease
• abnormal blood sugar levels
• depression

People with sleep apnea may not be aware that they have it. For this and other reasons, people with unexplained and persistent generalized ill health or bothersome symptoms such as fatigue and sleeping problems should speak to their doctor or nurse for advice rather than make assumptions about the cause of their symptoms.

In general, risk factors for sleep apnea can include the following:

• male gender
• obesity
• post-menopausal status
• abnormalities in the structure of the throat or nasal passages

A common treatment

After a diagnosis of sleep apnea, doctors can present treatment options. The most commonly used option is a machine that provides continuous positive airway pressure (CPAP). One end of a flexible light hose is connected to a CPAP machine with the other end connected to a mask or nosepiece. The hose delivers room air at a constant pressure and the mask or nosepiece helps to direct the air to the lungs. CPAP machines help people with sleep apnea breathe while sleeping. From time to time, adjustments to the airflow and mask may be needed and sleep clinic staff can advise about this.

Sleep apnea and HIV

There have not been large studies to assess the occurrence of sleep apnea in people with HIV. To begin to explore this issue, a team of researchers at several universities in the U.S. conducted a study, called the Multicenter AIDS Cohort Study (MACS), with more than 800 men—466 with HIV and 370 without HIV. Participants had their sleep assessed with sensors overnight.

The researchers found that sleep apnea was common—around 50% overall. Men with HIV were more likely to have sleep apnea than men without HIV (56% vs. 48%).  

Researchers applied extensive statistical analysis to try to find possible risk factors that could explain why sleep apnea was more common among men with HIV. However, they did not find any significant risk factors.

The researchers encouraged doctors and nurses caring for men with HIV to screen them for possible sleep apnea (when warranted), as this disorder can affect health and quality of life.

Study details

Researchers taught participants how to apply the different sensors that would be needed to assess sleep-disordered breathing so that participants could do the study in their own bedrooms. Participants received access to videos and print materials that explained how to apply the sensors. Data were collected electronically by a portable recording device loaned to participants. Sleep was assessed one time (overnight). Participants applied sensors to their head (to record brain waves and eye movements), chest (to record heart rate and breathing) and a finger (to assess the amount of oxygen in their blood). Small, soft flexible tubes were placed near the nose to assess the flow of air into the nostrils.

All participants were gay or bisexual men. The average profile of HIV-positive men when they entered the sleep study was as follows:

• age – 55 years
• body mass index (BMI) – 27.2 kg/m²
• major ethno-racial groups – White – 57%; Black 32%
• CD4+ count – 702 cells/mm³
• 94% of men had a suppressed viral load (the researchers defined this as being less than 200 copies/mL)
• 99% of men were taking HIV treatment; most commonly a regimen based on integrase inhibitors (47%)

The study took place between March 2018 through June 2019.

Results

Using a strict definition of sleep-disordered breathing, researchers found that sleep apnea was more common among men with HIV (56%) than men without HIV (48%).

Men with HIV were more likely to report daytime sleepiness than men without HIV.

Most men with HIV had sleep apnea that was either rated as mild or moderate by the researchers.

Why the difference?

Researchers undertook extensive statistical analyses to try to uncover possible risk factors that could have made men with HIV more vulnerable to developing sleep apnea than men without HIV. They considered factors such as age, race/ethnicity and BMI.

A similar analysis was done specifically among men with HIV, comparing those who had a detectable viral load (36 men) with those who had an undetectable viral load (430 men).

None of these statistical analyses yielded any fruitful information.

Bear in mind

So far, MACS is the largest study to assess sleep apnea in men with HIV. The researchers encouraged healthcare providers to screen men with HIV for sleep apnea.

Like all studies, the MACS sleep study is imperfect; its findings may not apply to all men living with HIV today. Historically, MACS has conducted many important studies. It first began enrolling men in what researchers called “waves of recruitment” in the following periods:

• 1984 to 1985
• 1987 to 1991
• 2001 to 2003
• 2010 to 2017

As a result, it is possible that some of the men who participated in the sleep study were there in part because of survivor bias. That is, they had some factor(s) that enabled them to survive in the time before HIV treatment (ART) was widely available so that they were alive today. Some of these men may also have spent years with a detectable viral load in the pre-ART era. This could have affected their health and, possibly, their subsequent risk for sleep apnea.

Note that over the past decade doctors have increasingly moved to initiate ART soon after a diagnosis of HIV is made in order to minimize injury to the immune system (and other key organ-systems) that can occur with prolonged exposure to high levels of HIV.

For the future

More research is needed to uncover the drivers of sleep apnea in men with HIV. Also, research needs to be done with women who have HIV.

Note well

Persistent sleep problems, fatigue and irritability can have many potential causes. These problems are best discussed with a doctor so that they can help uncover the cause(s).

—Sean R. Hosein

REFERENCES:

1. Punjabi NM, Brown TT, Aurora RN, et al. Prevalence and predictors of sleep-disordered breathing in men participating in the Multicenter AIDS Cohort Study. Chest. 2023; in press.
2. Punjabi NM, Brown TT, Aurora RN, et al. Methods for home-based self-applied polysomnography: the Multicenter AIDS Cohort Study. Sleep Advances. 2022 Apr 29;3(1): zpac011.