Abstract

Landmark studies have demonstrated that daily oral antiretroviral therapy (ART) is highly effective for HIV treatment and is related to better health outcomes. Despite this, maintaining high levels of medication adherence remains challenging for many people living with HIV (PLWH), leading to suboptimal adherence. Although attention deficit hyperactivity disorder (ADHD) is more prevalent in those with HIV than in the general population, adults with ADHD represent an understudied group in HIV research. The lack of research on this population represents a critical gap, as one study found that PLWH without ADHD were more than twice as likely to adhere to ART than PLWH with ADHD.

One contributor to the heightened risk of suboptimal adherence is the intersection of executive dysfunction and heavy alcohol use. ADHD includes impairments in executive functioning such as organization, planning, inattention, and impulse control. Executive functioning differences, a form of neurocognitive impairment, have been documented in PLWH in domains such as attention, working memory, and cognitive flexibility. Deficits in executive functioning and prospective memory have been associated with poor ART adherence. Substance use disorders (SUD) have also been related to worse adherence outcomes, with one study finding that drinking any amount of alcohol was related to a 2.5 increased odds of missed ART dose for that day. ADHD has been associated with an increased risk of SUD, particularly AUD, with a 43% lifetime prevalence of AUD among those with ADHD and rates of ADHD among those with AUD ranging from 6.6% to 21.3%. Given the above, it is important to consider the impact of ADHD and its related executive functioning and SUD risks for ART adherence.

Treatment of ADHD has been associated with improved health outcomes, including lower risk for SUD. Moreover, the use of prescription stimulants for ADHD has been associated with a lower risk for SUD, including significantly delaying the onset of SUD for adults with ADHD. Given that stimulant ADHD treatment also reduces symptoms of ADHD such as executive dysfunction and impulsivity, further research is needed to explore the impact of stimulant treatment on ART adherence.

Large scale electronic health record data (EHR) provide a unique opportunity to examine the impact of prescription stimulants on engagement and adherence to HIV treatment. The frequency of medical monitoring of prescription stimulants for ADHD as recommended by the American Academy of Family Physicians creates opportunities for potential preventative interventions with this population. Despite the above findings, there is a lack of large-scale data on the impact of prescription stimulants on ART treatment adherence for adults with ADHD.