2. Fatigue Management Strategies
Fatigue management studies (N
= 7) took diverse approaches, including exercise, cognitive behavioral therapy (CBT), the use of symptom management guidelines, and treating a co-morbid symptom with the goal of reducing fatigue. There were two studies which examined exercise programs to reduce HIV-related fatigue 
, and two studies that examined CBT, delivered in person 
or via an app 
. One study examined the use of symptom management guidelines with hospitalized patients living with HIV and fatigue 
; one study examined the treatment of depression to determine the effects of reducing depression on fatigue 
; and one study examined the treatment of sleep disturbances to determine the effect of reducing sleep disturbances on fatigue 
. The Zhu et al. 
study was conducted in China; the other six were conducted in the US. Four studies were randomized controlled trials (RCTs), two studies were pilot RCTs, and one was a pre-/post quasi-experimental design. Sample sizes ranged from 30 to 234. In those studies that reported this information, intervention doses varied widely, from three times/week for 12 weeks to treatments at two, four, and six weeks. Data were collected at baseline and then at widely varying intervals, with one study collecting data for a year, while most stopped data collection after three months or less post-intervention. Two studies used the HIV-Related Fatigue Scale, and the other five studies each used different fatigue measures, making comparison of results difficult.
In a randomized controlled trial, Barroso et al. (2016) analyzed data from a sample of people living with HIV who were randomized to receive enhanced usual care for depression, or a depression treatment model called measurement-based care (MBC). Participants (n = 234) in this depression treatment trial who experienced a stronger depression response (greater improvement in depression scores) had larger decreases in fatigue. However, even among those who demonstrated a full depression response, nearly three-quarters continued to have either moderate or severe fatigue, supporting the belief that these are two separate constructs and must be treated as such. The treatment group experienced improvements in depression.
We also found two exercise interventions for fatigue management. The Jaggers et al. study implemented a supervised exercise program of aerobic and resistance training 
, and while there was a decrease on the POMS (Profile of Mood States) fatigue sub-scale from pre- to post-intervention, it was not statistically significant. Goulding et al. 
enrolled a sample of older people to complete 12 weeks of moderate intensity exercise, then randomized them to complete another 12 weeks of moderate or high intensity exercise 
. High intensity exercise was associated with greater improvements in vitality/fatigue in weeks 13–24 compared to moderate intensity.
In the area of mind/body interventions, CBT also showed potential to improve fatigue. Doerfler and Goodfellow 
found that individual CBT when compared to usual care was effective in reducing fatigue in PLWH on ART; however, the intervention did not have a sustained effect at the 90-day measurement. In the second study using CBT, Barroso et al. 
developed an app based on cognitive behavioral stress management (CBSM). At three months, findings showed an improvement in fatigue, with completers (those who completed at least 80% of the intervention modules) having a sustained, significant reduction in fatigue intensity and impairment of fatigue-related functioning.
Another two studies used behavioral-educational strategies to manage fatigue. Zhu et al. (2018) implemented an HIV symptom management guideline in an inpatient unit in Shanghai, China, with fatigue being one of the targeted symptoms. Frequency of fatigue was lower in the intervention group but was not statistically significant 
. Finally, in a randomized controlled pilot study, Lee, Jong, and Gay 
tested a behavioral-educational intervention to reduce fatigue through education about daytime behaviors and nighttime sleep behaviors. Participants were living with HIV, between 45–75 years old, unemployed, and fatigued. At the conclusion of the study, the intervention group had significantly improved fatigue severity scores and symptom burden over time, especially in the frequency of fatigue.
3. Sleep Disturbance Management Strategies
Seven studies, examining six interventions on sleep disturbances, met our inclusion criteria. Two of the seven studies analyzed the ‘Sleep B.E.T.T.E.R’ intervention, first conducting an efficacy trial 
and then an RCT 
. Overall, nurse-led interventions to address HIV-related sleep disturbances were composed of two mechanisms targeting the biological response or sleep hygiene behaviors. Three biological response studies included acupuncture treatment 
, 30-day caffeine withdrawal 
, and transcranial direct current stimulation (tDCS) 
. The other three psychoeducational intervention studies on sleep hygiene included SystemCHANGETM-HIV intervention 
, Brief Behavioral Treatment for Insomnia 
, and ‘Sleep B.E.T.T.E.R’ 
. The total number of participants ranged from 12 to 120 across all studies and the studies took place between 2001 and 2019. One study, ‘Sleep B.E.T.T.E.R.’, included only women living with HIV and the others included all genders. Of note, the ‘Sleep B.E.T.T.E.R.’ intervention was tested in two separate studies 
, one with women-only participants, and the other with all gender participants; nevertheless, both studies demonstrated significant improvement in sleep quality. The length of the interventions ranged from 4 to 10 weeks with varied frequency and doses of intervention over time.
Three interventions were developed primarily to target the biological components of sleep quality. In 2001, the first HIV-related sleep disturbance quasi-experimental study in our search was conducted by a nurse and a professional acupuncturist. They recruited 21 participants and provided five weeks of individualized acupuncture treatment 
. Not only did they find a 32% improvement in sleep quality, they also learned that as the acupuncturist developed a personal treatment plan for each individual, pain was the most common patient-reported cause for poor sleep 
. Improvements in length of sleep (p
= 0.05) and total minutes of awakening (p
= 0.05) were statistically significant, but no change was found in the amount of time that people needed to fall asleep, also called sleep latency (p
= 0.87) 
. In 2003, Dreher conducted an RCT to test the effects of a 30-day gradual caffeine withdrawal on sleep quality in 120 PLWH. Participants with 90% caffeine reduction experienced a 35% significant improvement in sleep quality compared with participants who had a 6% caffeine reduction 
. In 2019, Cody et al. tested another two biological interventions, using speed of processing training (SOPs, an interactive computerized exercise to improve speed and accuracy to visual stimuli) or transcranial direct current stimulation (tDCS) over five weeks (1 h twice a week) in older adults (ages > 50) living with HIV, and neither of these interventions improved sleep quality 
. tDCS is defined as a non-invasive procedure to slightly change the membrane potential of neurons with a static, direct electrical current to stimulate the brain 
An additional four intervention studies tested used educational and coaching sessions to promote sleep hygiene behaviors and therefore improve quality of sleep. In 2013, the ‘SystemCHANGETM-HIV intervention’ was tested; it was comprised of ten weekly sessions on different topics of HIV management, including sleep hygiene and behavioral modification strategies based on the SystemCHANGE theory. The theory encourages small environmental or behavioral changes with a goal of improving overall health 
. The randomized controlled trial recruited 40 participants but showed no significant effect in sleep outcomes 
. In 2018, Buchanan et al. developed the intervention called the Brief Behavioral Treatment for Insomnia (BBTI) based on three principles, including sleep restriction, stimulus control, and circadian mechanism. The interventionist worked with each participant to practice these principles and provided sleep hygiene education as well. The BBTI was the first intervention study to primarily facilitate behavioral change by working with everyone to agree on a set schedule of sleeping and rising. In the feasibility test of the intervention in 12 clinically diagnosed insomnia patients, intervention participants demonstrated fewer symptoms of insomnia and had a statistically significant increase in clinical sleep outcomes 
. Furthermore, they also found that the BBTI was well accepted and rated favorably by PLWH. Another intervention, the ‘Sleep B.E.T.T.E.R’ (Bedroom, Exercise, Tension, Time to sleep, Eating, drinking and drugs, Rhythm) program, was designed in 2008 to address sleep disturbance issues by providing a 30-minute instructional session on sleep hygiene and advising participants to practice sleep hygiene in the following week (N
= 30 female participants only); the post-intervention actigraphy results showed a significant reduction in sleep disturbance only, and minimal improvement in overall sleep 
. Later in 2019, Lee and her colleagues extended the ‘Sleep B.E.T.T.E.R’ intervention to 60 min by providing additional sleep hygiene devices, such as a white noise fan, eye mask, or caffeine-free tea, and adding weekly booster sessions over four weeks 
. When the modified intervention was tested in an RCT (N
= 55), participants experienced significantly improved sleep quality.