Fatigue with HIV Could Have Reversible Cause

Obstructive sleep apnea could be the cause of fatigue in many people with HIV.

Robert Owens, MD

Many of the cases of fatigue and difficulty sleeping that are common in persons with HIV infection could be caused by obstructive sleep apnea (OSA), according to assessment from a new collaboration between pulmonary and infectious disease specialists.

Robert Owens, MD, Pulmonary, Critical Care and Sleep Medicine, and Charles Hicks, MD, Infectious Disease, University of California San Diego, warn that OSA appears to be under-diagnosed, and more widely prevalent in this population than previously thought.

In addition to their own experience from referring persons from the infectious disease clinic with HIV to the sleep clinic, they note that the Multicenter AIDS Cohort Study found OSA in 70% of a subset of subjects that had received polysomnography.

"Although the prevalence of OSA was similar in their control group, this finding suggests that a substantial fraction of men living with HIV may have undiagnosed OSA," Owens and Hicks indicate.

Owens reflected on why a high prevalence of OSA in persons with HIV could have gone largely undetected, in comments to MD Magazine.

"First I think that this problem has gone overlooked because for many years HIV docs were focused on getting people on effective therapy to keep them alive, rather than focusing on a quality of life issue like fatigue," Owens said. "Second, it is hard sometimes to collaborate outside your area of expertise."

In addition to HIV providers having relatively little familiarity with OSA, Owens and Hicks point out that OSA in persons with HIV tends to occur without such traditional risk factors like older age and increased body weight. "Moreover, common OSA symptoms such as fatigue/tiredness are often ascribed to HIV itself," they note.

Working with a grant from the Creative and Novel Ideas in Research (CNIHR) Program, funded through a partnership of the International AIDS Society and the NIH-funded Centers for Aids Research (CFAR), Owens and Hicks intend to elucidate the pathogenesis of OSA in persons with HIV infection, and investigate its possible contribution to other common comorbidities in this population. "Another major problem in the HIV world is early cardiovascular morbidity and mortality," Owens said. "From my point of view as a sleep doc, OSA is associated with many cardiovascular complications.

Owens and Hicks point out, for example, that untreated OSA has been associated with ongoing inflammation, evidenced by increased levels of C-reactive protein and tumor necrosis factor α. They cite studies finding a high prevalence (26% to 48%) of OSA comorbid with mood disorders, tobacco abuse/dependence, hypertension, dyslipidemia and osteoarthritis.

"We suggest that clinicians who care for persons living with HIV consider the diagnosis of OSA when evaluating patients with fatigue, tiredness or excessive sleepiness," Owens and Hicks urge.

Following the diagnosis, continuous positive airway pressure therapy (CPAP) remains the gold standard treatment for moderate to severe OSA, and, the authors emphasize, can be used to successfully treat one of the few reversible causes of fatigue.

The viewpoint article on the prevalence and effects of OSA in persons with HIV was published online May 9 in Clinical Infectious Diseases.