Factors related to insomnia symptoms among people living with HIV

Objective: To evaluate the prevalence of insomnia symptoms and its relationship with nutritional aspects, gastrointestinal symptoms and chronic diseases among people living with HIV. Methods: a cross-sectional study of 307 people living with HIV in antiretroviral therapy attended by the Specialized AIDS Service of the municipality of Santos (SP), Brazil. The variables evaluated were insomnia symptoms, gastrointestinal symptoms and chronic noncommunicable diseases. Results: the prevalence of insomnia symptoms was 79.2%. There was a greater proportion of people living with HIV with insomnia symptoms who had weight changes after HIV diagnosis, unpleasant stomach sensations, poor digestion, poor appetite, respiratory and skin diseases. Conclusion: the high prevalence of insomnia symptoms was related to the presence of gastrointestinal symptoms, as well as respiratory and dermatological diseases.


INTRODUCTION
People living with HIV (PLWH) have a high prevalence of sleep disorders, which are associated with poorer functioning of the immune system. 1 According to a study conducted to characterize the sleep quality of this population, the lower the lymphocyte count TCD4, the greater the prevalence of problems related to sleep. 2 Significant changes in sleep patterns may occur soon after infection, but they also appear to be associated with long periods of exposure to antiretroviral therapy (ART).In a study of adults living with HIV who started ART early, it was found that difficulty sleeping, total sleep time reduction and daytime sleepiness were the main reported complaints. 3In a systematic review of the implications pathophysiology of insomnia in PLWH, it was pointed out that the prevalence of sleep disorders varies from 29 to 97%, and this wide variability is justified by the absence of a gold standard for the evaluation of these disorders, from subjective questionnaires to clinical evaluations. 4e occurrence of sleep disorders, may be related to the onset or aggravation of chronic diseases.Unlike the era prior to high-potency antiretroviral treatment, when opportunistic infections were the main cause of death of PLWH, this population currently has a high prevalence of chronic diseases.As regards cardiovascular diseases, dyslipidemias, diabetes and non-AIDS cancers, PLWH present higher prevalences when compared to the general adult population. 5It is worth mentioning that the presence of sleep disorders is associated not only with the chronic diseases themselves, but also to risk factors for its development, such as smoking, alcoholism and poor dietary habits. 6In addition, it is a bidirectional relationship, since chronic diseases can promote changes in the sleep-wake cycle, with consequent damages on physical and mental recovery. 6Thus, the presence of gastrointestinal symptoms and nutritional aspects, such as body mass and changes in body weight, are also strongly associated with poor sleep quality. 7 is not possible to understand the sleep problems and the factors related to their occurrence among PLWH, based on studies that have been carried out for more than 10 years, with different ART regimens.In addition, the difficulty of sleeping also results in low adherence to ART, which prevents the control of viral replication and leads to a worse prognosis of the clinical evolution of HIV. 8 Given the current HIV epidemic situation, this problem deserves attention, since sleep disorders can significantly influence the integrity of the immune system and the quality of life. 9 this context, the objective of the present study was to evaluate the prevalence of insomnia symptoms and its relationship with nutritional aspects, gastrointestinal symptoms and chronic diseases among people living with HIV (PLWH) in antiretroviral therapy.Participants who reported having at least one of the seven symptoms investigated, with a minimum frequency of three times a week, were classified as positive for insomnia symptoms in the six months prior to the study. 10e independent variables of the study were:

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1) Nutritional aspects: Body mass index (BMI) was used as an indicator of nutritional status, and its score was classified as low weight (<18.5 kg/m²), eutrophy (18.5-24.9kg/m²), overweight (25.0-29.9kg/m²) and obesity (≥30.0 kg/m²). 11 Participants also answered two questions about body weight changes, one after HIV infection and another last 12 months.Both admitted three response options: "Not changed", "Decreased ___ kg" or "Increased ___ kg"; 2) Gastrointestinal symptoms: evaluated from three drawn questions of validated version and translated into Portuguese Self-Reporting Questionnaire. 12The questions were: "Do you have unpleasant sensations in the stomach?" "You have no appetite?"and "You have poor digestion?",having as answer options "Yes" or "No"; 3) Chronic diseases: obtained from a list of 51 and tumors (0.7 %).
Although most participants reported no maldigestion, unpleasant sensations in the stomach and lack of appetite, these gastrointestinal symptoms were found to be more frequent among the PLWH who had symptoms of insomnia (Table 1).In addition, although the majority of the participants did not mention the diagnosis of respiratory and dermatological diseases, it was verified that both were more frequent among the PLWH who had symptoms of insomnia (Table 2).

DISCUSSION
The high prevalence of insomnia symptoms was related to the presence of gastrointestinal symptoms, respiratory and skin diseases.This result is corroborated by the study findings that found a high prevalence of poor sleep quality and insomnia symptoms, as well as a greater predisposition for the development of gastrointestinal problems and skin diseases among PLWH. 15In studies on gastrointestinal problems previously performed with the adult population in general, a strong association with sleep disorders was also found, which is related to higher levels of proinflammatory cytokines. 16- 17 t is important to emphasize that there is evidence indicating that problems in the gastrointestinal tract may affect sleep physiology, just as sleep disturbances may influence the functioning of the gastrointestinal tract, making this two-way problem. 18 a study carried out in Switzerland with 268 PLWH, the perception of several health symptoms was analyzed, and insomnia was one of the ten most prevalent (42%) in relation to severity, frequency, discomfort and being uncontrollable, indicating their relevance in this population. 19In addition to insomnia, the authors also highlighted the high prevalence of dry skin (52.2%), diarrhea (47%) and gas (45%) among PLHIV.Among the most severe, lack of appetite and constipation have also been reported, as well as vomiting among the most troublesome and nausea among the least controllable.Another study, using data from a Canadian cohort, found that the most prevalent gastrointestinal symptoms among PLHIV consisted of swelling and abdominal pain (41%), diarrhea (40%), lack of appetite 25%, nausea and vomiting (21%). 20e respiratory problems in PLWH, evaluated in the present study, were also related to insomnia symptoms.According to a review study on lung infections in PLWH, respiratory problems remain associated with a high risk of mortality in this population even after the introduction of HAART. 21Among patients with respiratory problems, reports of excessive drowsiness and fatigue are common; this implies directly in the quality of life and in the functional state of the same.In a study of 58 PLWH using ART, a greater risk of drowsiness was found among those with disordered breathing during sleep. 22In addition, the authors also found an association between sleep and respiratory problems, corroborating the findings of the present study.
Skin problems were also associated with insomnia symptoms in the present study.In a study conducted over a decade ago, skin problems were identified as one of the most prevalent manifestations of HIV, with a prevalence of 75% among PLWH in outpatient care. 23There were no more recent studies on the prevalence of skin diseases in people living with HIV in clinical follow-up, however, in a study of population-based cohort recently conducted, it was observed that the risk of skin diseases was higher in patients with sleep disorders. 24The authors emphasize that a bidirectional relationship should be considered, is a cross-sectional epidemiological study carried out with 307 PLHIV in ART (sample power = 80%, G * Power 3.1.4),aged 18 years or older, attended by the Specialized Assistance Service (SAS) in AIDS of the municipality of Santos, São Paulo Brazil.Data collection was performed at the SAS, from February to June 2016, on alternating days and times (Monday to Friday, from 08:00 to 18:00, according to office hours).The instrument of data collection consisted of a structured questionnaire that was applied by undergraduate students.In a pilot study, it was verified that the majority of the participants had difficulty reading the questionnaire.Therefore, it was decided to standardize its application through interviews, in which the students performed the individual reading of each question and recorded the answers of the participants.The interviews lasted an average of 45 minutes and the undergraduates were properly trained to guide the participants without interfering with their responses.The study-dependent variable was the symptoms of insomnia, assessed using the Karolinska Sleep Questionnaire (KSQ).
since the adverse effects of psychological stress and sleep disturbance itself may further aggravate the acne in question by interrupting the circadian rhythm of cortisol secretion.It is noteworthy that all participants in the present study were on antiretroviral therapy.Among the most common adverse effects of these medications are insomnia, nightmares, nausea, lack of appetite, abdominal pain, diarrhea, constipation and heartburn, poor sleep quality, poor digestion and unpleasant sensations in the stomach.These problems, in fact, represent the most frequently reported by PLWH.25This study has some limitations.The first refers to the list of injuries and diseases used to obtain chronic diseases.Because it integrates the Work Ability Index, which consists of an instrument used for self-rated assessment of the physical and mental health conditions of workers, it was answered only by the PLWH who were engaged in paid activity.Because it is a cross-sectional study, it is not possible to infer about the temporal cause and effect relationship of the studied variables, however, according to the aforementioned studies, it is verified that such relationships exist among PLWH, corroborating the results of the present study.In some situations these relationships are bidirectional, so that the evaluated outcomes may not represent the essential cause of the symptoms of insomnia in the sample studied.Nevertheless, the need for preventive measures for both sleep problems, chronic diseases and gastrointestinal problems.CONCLUSION It is concluded that the prevalence of insomnia symptoms was high among PLWH, being more frequent among those that presented gastrointestinal symptoms, as well as respiratory and skin diseases.As discussed above, PLW Hoften suffer from the consequences of chronic sleep deprivation due to pathophysiological mechanisms of the infection itself and chronic diseases, but also due to the adverse effects of ART.Given the accumulation of determinants for the occurrence of changes in the sleep-wake cycle and its possible interference with the development of comorbidities, a strong point of this study is the description of a significant sample of IVHIV in a clinical follow-up in relation to the sociodemographic aspects of sleep and health.Considering the lack of knowledge regarding the aspects related to sleep disorders in PLWH, the presented results certainly can contribute with the discussions of public health policies for this population.COLLABORATIONS LFRN: substantial contributions in the design or design of the work; in the collection, analysis and interpretation of data; in the writing of the article or in its critical revision; in the final version to be published.PP: contributions in the writing of the article or in its critical revision; in the final version to be published.TCF and PHP: contributions in data collection, analysis and interpretation; in the writing of the article or in its critical revision; in the final version to be published.ASD: writing or article contributions or in the critical review of the article or in its critical review, in the final version to be published.ECM: contributions in the design or design of the work; in the collection, analysis and interpretation of data; in the writing of the article or in its critical revision; in the final version to be published.

Table 01 -
Proportion test of nutritional aspects and gastrointestinal symptoms as a function of insomnia symptoms among people living with HIV.

Table 02 -
Proportion of chronic diseases as a function of insomnia symptoms among people living with HIV.