Sleep disorders and quality of sleep added to EACS management guidelines

6 November 2025. Related: Conference reports, Guidelines, Coinfections and complications, EACS 20 Paris 2025.

Simon Collins, HIV i-Base

One of the new sections in the updated EACS guidelines includes a new section on sleep disorders.

An image of the Insomnia Severity Index, a seven-item self-report questionnaire used to evaluate the severity of insomnia. The questionnaire is in table format, on the right of the image. The text is too small to read. Text on the left, reads: Enquire about: symptoms, duration, frequency, QOL (quality of life), sleep schedule, triggers. Referral: ISI score of 8 or more. The image is made by the European AIDS Clinical Society.

Insomnia Severity Index (click for large view)

The clinical impact of poor sleep has led to a new recommendation to ask a simple question: ‘How is your sleep?’

This recognises that people living with HIV commonly have sleep problems which can independently have poor clinical outcomes, irrespective of whether or not HIV has a causative role.

This first question should be asked when starting or changing ART and additionally every two years as part of routine management.

Excessive Daytime Sleepiness (EDS). Epworth Sleepiness Scale (ESS). How likely are you to doze off in these situations? 1. Sitting and reading. 2. Watching TV. 3. Sitting inactive in a public place. 4. Passenger in a car for 1 hour. 5. Lying down in the afternoon. 6. Sitting and talking. 7. Sitting after lunch. 8. In a car, stopped in traffic. Score: 0 equals never. 1 equals slight chance. 2 equals moderate chance. 3 equals high chance. Interpretation: 0 to 10 equals normal. 10 to 12 equals mild EDS. 13 to 24 equals moderate to severe EDS. Referral: when ESS is 11 or more. The image is made by the European AIDS Clinical Society.

Epworth Sleepiness Scale (click for large view)

Three short validated screening tools are then recommended for insomnia, excessive daytime sleepiness and sleep apnoea when abnormal symptoms are reported.

The Insomnia Severity Index (range 0 to 28) involves seven questions that cover sleep quality and impact on quality of life, with a five-point scale and a score >7 to prompt further referral.

The Epworth Sleepiness Scale (range 0 to 24) asks likelihood of sleeping in eight situations, with a 3-point rating and a score >10 prompting referral.

Lastly, the STOP-BANG questionnaire (range 0 to 8) uses eight questions (with yes/no answers) and a score >2 indicating moderate risk to prompt referrals.

Obstructive Sleep Apnoea. Stop-Bang: Y slash N. S. Do you snore loudly? T. Do you feel tired during the day? O. Has anyone observed you stop breathing during sleep? P. Do you have or are you being treated for high blood pressure? B. BMI of over 35? A. Aged over 50? N. Neck circumference of over 40 cm? G. Gender male? Commonly reported: sleepiness, difficulty concentrating, headaches, irregular nighttime breathing. Interpretation: 0 to 2 equals low risk OSA. 3 to 4 equals moderate risk, refer if BMI is over 35. 5 to 8 equals high risk OSA. Referral: when score is 3 or more. The image is made by the European AIDS Clinical Society.

STOP-BANG questionnaire (click for large view)

The guidelines also include identifying modifiable risk factors, including:

Mental health (depression, anxiety).
Alcohol excess and recreational drug use.
ART considerations:
- avoid efavirenz-based regimens in those with symptoms of poor sleep.
- dose second-generation integrase inhibitors in the morning rather than evening.
Review concomitant medication for drugs which may cause sleepiness, such antihistamines, benzodiazepines, antidepressants, opioid pain medication, muscle relaxants and some blood pressure medication.
Weight and body habits review and advice on diet and exercise.
Suboptimal sleep habits.

The EACS guidelines are now hosted on the Stanford website and are no longer produced in print or PDF format. [2]

The section on sleep health is included in the section on complications, together with information on cognition, mental health and substance use. [3]

References

EACS guidelines. Special session. Thursday 22 October 2025 (5.30 am).
https://player.vimeo.com/video/1128297512?h=b4f77cca47&title=0&byline=0&portrait=0&badge=0&autopause=0&player_id=0&app_id=58479
EACS Guidelines 2025. Versions 13.0, October 2025.
https://eacs.sanfordguide.com
EACS guidelines. Sleep disorders. (October 2025).
https://eacs.sanfordguide.com/en/eacs-part2/eacs-cognition-mental-sleep-health-substance-use/sleep-disorders