HIV significantly affects sleep, with many affected people living in a state akin to chronic jet lag. A new study with Wits researchers published in The Lancet HIV describes how people living with HIV (PLWHIV) experience higher rates of sleep issues even when virally suppressed, which has been associated with a higher risk for heart disease, depression and cognitive decline.

“Sleep is the missing vital sign in HIV care,” say Professors Xavier Gómez-Olivé and Karine Scheuermaier, the Wits contributing authors to the study. Despite how common poor sleep in PLWHIV is, most health care providers don’t routinely ask patients about their sleep, leaving a major gap in care that affects daily function and long-term health. In turn, PLWHIV do not always raise the issue of sleeping difficulties.

The researchers call for sleep equity and the treatment of healthy sleep as a fundamental health right, not a luxury.

“We routinely check viral load and blood pressure, but not whether our patients are sleeping. Poor sleep undermines everything else. This includes immunity, cognition, mental health, and treatment adherence,” explains Gómez-Olivé, associate professor at the SAMRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt).

In the study, authors recommend a resource-aware, contextually relevant framework to help clinicians recognize and manage sleep problems early.

The hidden burden of disordered sleep

In rural Bushbuckridge, 500km northeast of Johannesburg and bordering the Kruger National Park, Gómez-Olivé’s team measured body-clock rhythms in adults with and without HIV. Both groups went to bed and woke up at similar times, yet PLWHIV showed delayed biological clocks with a potential effect on sleep quality.

Roughly 60% of people living with HIV reported non-restorative sleep, a figure far above that in the general population. Most of these cases do not meet the formal diagnostic thresholds of insomnia or obstructive sleep apnea, so they remain invisible in clinic records.

“Formal sleep disorders have clear criteria,” explains Scheuermaier, associate professor of the Department of Physiology and the head of the Wits Sleep Lab within the Brain Function Research Group. “Disordered sleep is different. We see that it is fragmented, light, and unsatisfying, but still clinically important. Many people with HIV fall into this gray zone, so their symptoms go untreated.”

Even with successful antiretroviral therapy (ART) and viral suppression, sleep problems shorten the span of healthy life. On average, PLWHIV live as long as others, but don’t have the same years of good health.

Why HIV disrupts sleep

The review identifies three interacting causes of disordered sleep in the study population, namely inflammation and immune activation, treatment side effects and circadian misalignment. The latter is because HIV-related proteins, such as Tat, may delay the circadian clock.

These biological disruptions combine with psychological and social pressures such as depression, stigma, chronic pain, and unsafe living conditions to make restful sleep elusive. “Sleep can’t be separated from mental health or social context,” says Gómez-Olivé. “When people live with uncertainty or stress, the body stays on alert, and rest becomes difficult.”

A stepwise approach for clinicians

The authors propose a practical pathway that any health care provider can apply, even outside specialized sleep clinics. It begins with a single question: “Have you had trouble falling or staying asleep, or felt unusually sleepy during the day?”

From there, clinicians can follow four steps:

1. Screen using brief tools such as the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), or STOP-BANG questionnaire for apnea risk.
2. Identify and address modifiable factors—depression, pain, substance use, ART side effects, and environmental stressors—before diagnosing a formal disorder.
3. Treat or refer. If insomnia is formally diagnosed (using the DSM-5 definition), cognitive behavioral therapy for insomnia (CBT-i) remains the first-line treatment and can be delivered through app- or SMS-based programs in low-resource settings. For suspected sleep apnea, portable home tests offer an affordable option.
4. Reassess periodically, as sleep problems evolve with age, treatment changes, and comorbidities.

“Sleep disorders are often seen as peripheral to HIV management. But addressing them could reduce cardiovascular risk, improve mood, and strengthen adherence, which are all core outcomes in chronic care,” says Scheuermaier.

Countries in the global North already count the economic cost of insufficient sleep through lost productivity and health-care spending. South Africa and the continent should follow suit, treating sleep as a public-health metric rather than a private concern.

Integrating sleep assessments into routine HIV visits, the authors argue, would be a small but transformative step. It would be one that could improve learning, productivity, and overall well-being in communities most affected by HIV.

“Sleep health is the foundation of everything else,” says Gómez-Olivé. “If we want to extend both life and quality of life in Africa’s HIV response, we need to start paying attention to that.”