Attention-Deficit/Hyperactivity Disorder, Autism Spectrum Disorder, and HIV: Implications for Risk, Outcomes, and Care for Neurodivergent People

Abstract

Neurodivergence, including autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD), is increasingly recognized as an important factor influencing health across the lifespan. Although ASD and ADHD are diagnosed categorically using standardized criteria based on the Diagnostic and Statistical Manual of Mental Disorders, the traits that define these conditions exist dimensionally across the population and are expressed with wide variability in support needs. Global ASD prevalence is approximately 1% to 2%, and emerging data suggest higher rates of autistic traits among some populations affected by HIV; however, estimates vary substantially based on methodology and diagnostic approach. ADHD affects approximately 2.5% of adults worldwide, although adult prevalence in people with HIV is not well characterized and likely underrecognized. Neurodevelopmental differences in executive function, reward processing, sensory regulation, and social communication may influence HIV acquisition risk, engagement in care, and long-term outcomes. Health care systems designed primarily for neurotypical individuals may inadvertently create barriers for neurodivergent patients. This review outlines a conceptual framework for understanding neurodivergence in the context of HIV, summarizes available epidemiologic and outcomes data, and provides practical strategies for delivering neurodiversity-affirming, accessible care.

Introduction

Neurodivergence is a term that encompasses attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD), representing a range of natural variations in human cognition, behavior, and sensory processing. These neurodevelopmental differences are increasingly recognized not as deficits, but as distinct “operating systems” that shape how individuals interact with the world, including health care environments. The prevalence of ASD is 1% globally and about 1.5% to 2.2% in developed countries.¹ Defining the prevalence of ASD with any degree of certainty in the population of people with HIV (PWH) is a challenge, as the literature has a paucity of data on this topic. A 2025 study in a Belgian cohort identified autistic traits in approximately 4% of participants, with 8% of those using preexposure prophylaxis (PrEP) for HIV showing elevated autistic traits.² However, differences in screening tools and study populations limit direct comparison with general HIV population estimates. This is an area that requires further scientific investigation.

The prevalence of ADHD is approximately 2.5% in adults worldwide.³ Robust data on ADHD prevalence among adult PWH is limited and may reflect underdiagnosis, as ADHD is known to be a life-long condition. Furthermore, the heterogeneity and geographic settings of the available studies present a challenge when attempting to define the prevalence of ADHD in adults and children with HIV. Estimates of ADHD in children with HIV vary; one study estimated the prevalence of ADHD among children with congenitally acquired HIV to be 6%,⁴ and other studies estimated up to 29%.⁵ Although the prevalence of ADHD and ASD is increasing due to improved awareness and evolving diagnostic practices,¹ diagnostic disparities exist particularly among adults, women, people of color,^6,7 and lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) individuals,⁸ resulting in underdiagnosis within these groups. ASD prevalence in transgender and nonbinary groups is significantly higher than in cisgender populations,⁹ with ASD estimates ranging from 5.5% to 29.6% in adults and ADHD prevalence estimates of 4.1% to 11% in transgender and nonbinary adults.¹⁰ One estimate is that approximately 11% of transgender and gender-diverse individuals are diagnosed with autism.¹⁰

The epidemiology of ASD and ADHD in populations with HIV remains incompletely characterized. Studies vary in geographic region, diagnostic instruments, information sources, and case definitions. As a result, cross-study and cross-population comparisons should be interpreted cautiously. Current data highlight important signals and potential disparities but underscore the need for more methodologically consistent research.

ASD and ADHD are diagnosed using standardized Diagnostic and Statistical Manual of Mental Disorders (DSM)-based criteria and validated assessment tools. However, the behavioral and cognitive traits associated with these conditions occur along a continuum within the general population. The consolidation of prior sub-types into a single ASD diagnosis in 2013 in the DSM, Fifth Edition (DSM-5) reflects the recognition of shared neurodevelopmental features expressed with considerable heterogeneity in functional impact. This dimensional reality can create challenges in diagnosis at any point in the lifespan and in epidemiologic interpretation, particularly when comparing studies that use differing diagnostic tools, thresholds, and sampling strategies.

The intersection of neurodivergence and HIV is clinically significant but as yet underexplored. Neurodivergent individuals may face unique vulnerabilities to HIV acquisition and experience distinct challenges across the HIV care continuum. ADHD specifically increases the risk of unsuppressed viral load.¹¹ Factors such as impulsivity, executive dysfunction, sensory sensitivities, and social communication differences can influence risk behaviors, access to prevention services, and engagement in ongoing care. As a result of neurodivergence, the cumulative impact of trauma, stigma, and health care system barriers can further complicate outcomes for this population. For HIV clinicians, understanding the nuances of neuro-divergence is essential for providing inclusive, equitable, effective, and affirming care.

This article reviews the definitions and epidemiology of ADHD and ASD, explores their impact on HIV risk and health outcomes, and offers practical recommendations for optimizing care for neurodivergent people with or at risk for HIV. Clinicians commonly report lacking the tools to care for neurodiverse patients; the information herein provides clinicians with an opportunity to build their skill-set for caring for this unique population.¹²

Neurodivergence and Health Outcomes: A Conceptual Framework

Traditional diagnostic categories such as ASD and ADHD provide important clinical anchors, yet they often fail to capture the full spectrum of neurodevelopmental, cognitive, behavioral, and psychosocial factors that shape an individual's lived experience and nuanced care needs. The term “neurocomplexity” is a useful addition to “neurodiversity” to describe the nuanced and multifactorial nature of neurodivergence.

Neurocomplexity is a term introduced by Makereth in 2023¹³ and encompasses the interplay of cognitive, behavioral, sensory, and psychosocial elements that contribute to each person's unique neurodevelopmental profile. Although ASD and ADHD are neurodifferences that each require intervention or support and can sometimes be disabling (the medical viewpoint), ASD and ADHD can also be viewed as variations of humanity that have incredibly valuable strengths and unique challenges (the neurodiversity/neuroaffirming viewpoint).¹⁴ Each model has value and is the subject of some debate; rather than focusing on one or the other, the authors seek to hold the neurodiversity view and recognize that neurocomplex patients may need more support in some areas to thrive. This strengths-based focus serves the patient and the clinician.

Recognizing neurocomplexity encourages clinicians to move beyond categoric diagnoses and adopt a more individualized, holistic approach to care. This framework supports neurodiversity-affirming practice and highlights the importance of flexible, individualized strategies in addressing the diverse needs of neurodivergent patients. HIV clinicians are familiar with these person-centered strategies, which are essential when treating complex and stigmatized conditions such as HIV, hepatitis C, and substance use disorders (SUDs).

A helpful conceptual framework used in clinical education and by neurodiversity advocates is the “operating system” analogy. Just as different brands of computers or phones utilize different operating systems and each have unique strengths, features, and ways of processing information, neurodivergent and neurotypical individuals bring equally valuable but distinctly different approaches to thinking, learning, and communicating. Neither operating system is inferior to the other.

Recent research supports this perspective. A small study utilizing magnetoencephalographic (MEG) recordings of 19 children who were autistic and nonautistic found that the brains of those with autism produced, on average, 42% more information at rest than age-matched controls.¹⁵This increased information processing may help explain the sensory processing challenges and the unique perspectives often observed in autistic individuals.

Structural brain and altered neural pathways in those with ASD and ADHD show similarities and distinct differences from neurotypical brains. This contrast is associated with the challenges that are present in each neurotype.¹⁶‘¹⁸ The variability can create challenges in communication, expectations, and health care engagement, particularly when health care systems are designed primarily for one “operating system” over another. Recognizing these distinct processing styles is essential for equitable and effective care.

Neurodivergent individuals are at increased risk for a range of adverse health outcomes, including higher rates of mental health conditions and SUDs, and experience more barriers to preventive care.¹⁹ ADHD is associated with a higher risk of SUD across all substances. Meta-analyses and large population studies consistently show that people with ADHD have 2- to 4-times higher odds of developing SUD than those without ADHD. Comorbid ADHD occurs in 25% of adolescents and 21% of adults with SUD. Comorbid ADHD and SUD are linked with lower remission rates of SUD, more severe and longer duration of SUD, and less successful recovery with SUD treatment.²⁰ Approximately 20% of those seeking treatment for SUD exhibit clinical traits of autism. Those with elevated autistic traits on the Social Responsiveness Scale (SRS-2, a clinically validated rating tool that evaluates the presence and severity of social impairment due to autism) were more likely to have opioid or stimulant use disorders than those without elevated traits.^20,21 In the context of HIV, these challenges may be compounded by difficulties with executive functioning (eg, appointment and medication adherence),²² sensory sensitivities (eg, aversion to traditional clinical settings, medical procedures, diet, and medications), and social communication (eg, patient-physician communication), which can impact risk behaviors, access to testing, and engagement in care.

Neurobiology and Risk-Taking Behaviors in Neurodivergence

Dopaminergic signaling plays a central role in the reward pathway in the brain. This is particularly important in the neurobiology of ADHD, and to a lesser extent, certain presentations of ASD. Dysregulation of dopamine pathways is associated with core features of ADHD, including impulsivity, inattention, lack of drive, and increased risk-taking behaviors. Pleasure-seeking behaviors such as sexual activity and substance use activate dopaminergic pathways; therefore, neurobiologic differences in patients with ADHD can contribute to challenges with self-regulation, executive function, and decision-making,³ which in turn may increase behaviors such as unprotected sexual activity or substance use, potentially placing individuals at a greater risk of HIV acquisition. Although the role of dopamine in ASD is more heterogeneous, some individuals with ASD also exhibit reward-processing differences and impulsivity that may further compound these risks.^23,24 There is also some evidence that SUD in those with ASD has an increased risk of mortality compared with those without ASD.^23,25 Recognizing the influence of dopaminergic mechanisms on behavior is essential for understanding the intersection of neurodivergence and HIV, and can help clinicians develop neurodiversity-affirming prevention and intervention strategies.

Health Outcomes and Longevity in ADHD and ASD

A growing body of research demonstrates that ADHD and ASD are each associated with increased risks for adverse health outcomes and reduced life expectancy.²⁶ Furthermore, people with both ADHD and ASD experience more severe health outcomes than people with either condition alone.²⁶ For individuals with untreated ADHD, the impact on longevity is particularly striking. A 2022 systematic review and meta-analysis of a number of large cohort studies found that an ADHD diagnosis is associated with a more than 2-fold increased risk of early mortality in childhood and a more than 4-fold increased risk by age 45 years, compared with individuals without ADHD.²⁶ Notably, for each 4-year interval that adults with ADHD go untreated, their risk for early mortality is twice that of adults without ADHD. Estimated reduction of life expectancy (ELE) for those diagnosed with ADHD ranges from 8.4 to 12.7 years.²⁷ The primary causes of increased mortality rates in people with ADHD include accidental injuries, suicide, and comorbid psychiatric disorders and SUDs, all of which are more prevalent in individuals with untreated ADHD.²⁷ Adults with ADHD report substantially less life enjoyment and satisfaction than adults without ADHD, further highlighting the broad impact of the condition.²⁸ Mental health challenges and SUDs are also more prevalent in PWH,²⁹ which increases the complexity of care for individuals with diagnoses of ADHD/ASD and HIV.

Importantly, consistent treatment with ADHD medication is associated with a reduced risk for all-cause and unnatural-cause mortality, underscoring the importance of early recognition and ongoing management of ADHD symptoms. A large Swedish registry study of 148,578 individuals demonstrated that those with ADHD who were consistently treated with medication had a significantly lower risk of premature death than those who were not treated.³⁰ Furthermore, a systematic review of long-term outcomes in individuals with ADHD found that untreated ADHD is linked to poorer outcomes across nearly all domains, including physical health, mental health, education attainment, occupational functioning, and quality of life. Early and sustained treatment is associated with favorable outcomes in most reported measures.^27,31

Similarly, individuals with ASD experience higher mortality rates than the general population, with the risk especially pronounced among women.³² A 2022 systematic review and meta-analysis found that men and women with ASD have increased mortality rates, which is largely attributable to higher rates of psychiatric and medical comorbidities, including epilepsy, suicide, and cardiovascular disease.²⁶ One large population-based study found that the average life expectancy for adults with autism was up to 6 years shorter for those with ASD without intellectual disability and more than 14 years shorter for those with cooccurring ASD and intellectual disability. Individuals with autism are at higher risk of SUD and have a higher associated risk of mortality when ASD and SUD are present.²⁵ These findings do not include specific details on mortality rates for those with neurodiversity and other chronic diseases (such as HIV) but certainly additional medical needs increase the complexity of care.

Spectrums Beget Spectrums: Intersecting Dimensions of Gender, Biology, and Identity

Neurodevelopmental conditions such as ADHD and ASD are best understood as existing on spectrums, much like gender and sexual identities, rather than as fixed categories. In different situations, the same human might struggle in varying amounts, which is true for neurodivergent and nonneurodivergent individuals. In practice, these spectrums often intersect; in other words, spectrums beget spectrums. This bidirectional relationship creates unique constellations of strengths, challenges, and needs for each individual. For example, neurodivergent individuals are more likely to identify as LGBTQ+, and vice versa, reflecting the complex interplay between neurobiology, identity, and lived experience.³³ Autistic and ADHD populations are more likely to identify as LGBTQ+ than neurotypical peers and they may experience higher rates of mental health challenges, social isolation, and victimization.³⁴ Gender dysphoria and autism are often cooccurring. Recognition of these intersecting spectrums is essential for providing affirming, individualized care and for understanding the diverse ways in which people experience neurodivergence and gender or sexual diversity. The intersection of neurodivergence and LGBTQ+ identities introduces additional layers of complexity and vulnerability that must be recognized in research and clinical care settings. Neuro-divergent individuals who identify as LGBTQ+ often face compounded stigma, discrimination, and barriers to accessing affirming health care services.³⁴ These intersecting identities can further increase the risk for adverse health outcomes, including heightened vulnerability to HIV acquisition, secondary to increased exposure to minority stress, difficulties with self-advocacy, and challenges navigating health care systems that may not be equipped to provide neurodiversity and LGBTQ+-affirming care.³⁵ Addressing these intersectional needs requires a trauma-informed, culturally responsive, and individualized approach that affirms these intersecting identities and actively works to reduce structural barriers and health disparities.

Toward Enhanced Diagnostic Recognition and Access

Improving care for neurodivergent individuals in HIV-affected populations requires a multifaceted approach that addresses individual-, clinician-, and system-level barriers. Clinicians enhance the care of neurocomplex patients by adopting a sense of curiosity about neurotypes in daily clinical practice and considering selective screening for ASD and ADHD. This is particularly meaningful for patients with unexplained executive function issues (eg, is late to clinic, is disorganized, forgets to pick up refills of medications or schedule referral appointments), history of academic/occupational stressors or difficulties (eg, unable to keep a job or keep up with classes), or various challenges with miscommunication (eg, pragmatic language skill differences). Many avoidant behaviors surrounding medical care and healthy living (eg, procedures, taking pills, taste, diet) are rooted in sensory challenges. Troubleshooting and supporting those needs improves patient distress and reduces barriers to care. Practitioner support of neurocomplex PWH by utilizing this multipronged approach helps attain the shared goal of achieving viral suppression.

Facilitating Access to Diagnostic Services

Neurocomplex conditions may present differently at varying developmental stages, depending on the individual's responses to situations and stressors. Symptoms may not be recognized until later developmental stages when environmental demands exceed the individual's capacities. Simply put, stressors can unmask ADHD and ASD; individuals may have struggled but performed well at various points in life, and their diagnoses may have been missed. Adults with ADHD and ASD are frequently missed in diagnosis, with evidence showing that increased adult diagnoses reflect improved recognition rather than true increases in prevalence.³⁶ Therefore, we cannot assume that ADHD and ASD would have been diagnosed in childhood, particularly in patients who mask heavily. Camouflaging, or masking, by a neurodivergent person is defined as the conscious or unconscious effort to hide, suppress, or compensate for their natural traits, behaviors, or ways of processing the world to appear more neurotypical and meet social expectations. Masking behaviors typically develop as an adaptive response, but they are widely correlated with increased stress and poorer mental health outcomes.³⁷’³⁸ Clinicians must be sensitive to the cost of masking in neurodivergent patients, as it plays a role every time the patient accesses the medical system.

Establishing referral pathways to neuropsychology, developmental-behavioral pediatrics, or adult psychiatry for comprehensive evaluation when indicated is important. Global shortages in clinicians who are comfortable with diagnosing ADHD and ASD remain a challenge in most clinical settings.³⁹

A variety of validated diagnostic tools are available for assessing ASD in adults. In addition to gold-standard instruments such as the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2) and the Autism Diagnostic Interview-Revised (ADI-R), several self-report-based and informant-based measures are widely used in clinical and research settings. A range of validated diagnostic tools are available to support the assessment of ADHD across the lifespan. The selection of tools should be tailored to patient age, clinical context, and the availability of informants, and should be complemented by a thorough clinical interview and collateral information when possible. ASD and ADHD cannot be assessed in a brief clinic visit; one proposed practice is to request that the patient return for an extended visit to discuss their neurocomplexity in more detail. Furthermore, some clinicians may not have the capacity to train in or utilize these tools. However, knowledge of these tools may support referral to a specialist or delegation to a collocated “champion” such as a nurse or physician with a special interest in neurodivergence. Diagnostic tools for ASD and for ADHD are presented in Table 1 and Table 2, respectively.

Table 1.

Diagnostic Tools for Autism Spectrum Disorder

Diagnostic tool (abbreviation)	Age range	Description
Autism Spectrum Quotient (AQ)	16 years or older	Self-report questionnaire measuring autistic traits in adults
Ritvo Autism Asperger Diagnostic Scale-Revised (RAADS-R)	18 years or older	Self-report tool for identifying ASD in adults, especially without intellectual disability
Developmental, Dimensional and Diagnostic Interview (3 Di)	18 years or older	Structured interview for caregivers or self-report, validated for adults
Diagnostic Interview for Social and Communication Disorders (DISCO)	Adolescence to adulthood	Semistructured interview for caregivers or self, covering a wide range of behaviors
Adult Asperger Assessment (AAA)a	18 years or older	Semistructured clinical interview for diagnosing Asperger syndrome and ASD in adults
Social Responsiveness Scale, Second Edition (SRS-2), Adult Form	19-89 years	Observer-report scale quantifying autistic traits in adults
Camouflaging Autistic Traits Questionnaire (CAT-Q)	16 years or older	Self-report tool measuring social camouflaging in autistic adults (supplemental, not diagnostic)
Autism Diagnostic Observation Schedule (ADOS-2)	18 months to adulthood	Observational instrument
Autism Diagnostic Interview-Revised (ADI-R)	18 months to adulthood	Structured interview
Childhood Autism Rating Scale (CARS)	18 months to adulthood	Observational rating scale

^aAsberger syndrome is no longer in use as a separate diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision.

Table 2.

Diagnostic Tools for Attention-Deficit/Hyperactivity Disorder (ADHD)

Diagnostic tool (abbreviation)	Age range	Description
Vanderbilt ADHD Diagnostic Rating Scales	6-12 years	Parent and teacher questionnaires assessing core symptoms and impairment
Conners Rating Scales (Conners 3)	6-18 years	Comprehensive rating scales for parents, teachers, and self-report
Swanson, Nolan, and Pelham Questionnaire (SNAP-IV)	6-18 years	Parent and teacher rating scale for ADHD and oppositional defiant disorder symptoms
ADHD Rating Scale-5 (ADHD-RS-5)	5-17 years	Parent and teacher rating scale based on DSM-5 criteria
Adult ADHD Self-Report Scale (ASRS)	18 years or older	Self-report screening tool for adult ADHD symptoms
Conners Adult ADHD Rating Scales (CAARS)	18 years or older	Self- and observer-report scales for adult ADHD symptoms and impairment
Wender Utah Rating Scale (WURS)	18 years or older	Retrospective self-report of childhood ADHD symptoms in adults
Barkley Adult ADHD Rating Scale-IV (BAARS-IV)	18 years or older	Self- and other-report forms for current and childhood ADHD symptoms

Strategies to Improve Care and Outcomes for Neurodivergent PWH

The following strategies are supported by emerging evidence and expert consensus, as well as the lived experiences of neurodivergent PWH, and can be adapted for clinical settings across the lifespan.

Clinician Education and Reducing Bias

Clinicians must maintain a sense of curiosity with patients regarding their “operating system.” If a diagnosis of ASD or ADHD is suspect by either the patient or the clinician, an evaluation may be facilitated by the clinician and may involve a lengthy waitlist process. It may be helpful for patients who suspect they are neurodivergent to function as if they know they have a formal diagnosis even before one is obtained, in order to better support their own physical and mental health.

Collaboration should be fostered between HIV specialists, primary care, mental health, and neurodevelopmental clinicians to ensure holistic, coordinated care. Many HIV centers have an infrastructure in place that allows growth and improvements in neurodivergent care.

A 2022 study found that one adjustment described by people with autism as being most important in facilitating their access to medical care was “access to a clinician who understands autism.”⁴⁰ To better support patients who are neurodivergent, clinicians must seek continuing education opportunities on the presentation, diagnosis, and management of ADHD and ASD in children and adults, with an emphasis on reducing diagnostic overshadowing and implicit bias.

Neurodiversity-Affirming Clinical Environments

Neurodiversity-affirming clinical environments include a number of sensory-based supports:

• Modify clinic environments to reduce sensory overload (eg, provide quieter waiting areas, implement noise reduction, modulate voice tones; provide flexible lighting, minimize strong odors, and be aware of sensitivities to medicine taste and texture and sensititivity to temperature). Many of these recommendations overlap with trauma-informed clinic practices.

• Provide access or normalize the use of sensory tools such as noise-canceling headphones, fidget items, or weighted lap pads as appropriate.

• Ask each patient who is neurodivergent how to best support them, specifically in the sensory-processing realm. This is a simple, strategic way to reduce barriers to care and may include questions such as, “What are your sensory needs?” “What sensory challenges do you have?” “How can I help make your time in the health care setting easier?” Troubleshooting these needs in advance can often reduce barriers to care.³⁵ Offer the support of speech therapists or occupational therapists if sensory struggles cause challenges with pill-swallowing.

Neurodiversity-affirming clinical environments also include a number of executive function supports:

• Offer structured appointment reminders (eg, by text, email, or phone), visual schedules, written instructions, and checklists to support organization and follow-through. HIV clinics frequently have the staffing and infrastructure in place for these supports.

• Allow extra time during visits.

• Provide clear, stepwise explanations of care plans verbally and in print.

• Offer alternative methods of reaching the patient (eg, portal or secure text) as individuals with autism often struggle with phone calls.⁴¹

• Offer flexible appointment times, options for telehealth, and care navigation support to address executive functioning challenges and improve engagement.

Communication Differences

In What I Mean When I Say I'm Autistic, Kotowicz stated that “Communicating across neurotypes is like communicating across cultures. One side shouldn't have to constantly adapt everything about how they communicate just to be understood.”⁴² Although communication challenges are common between neurotypical individuals, they can be markedly magnified between neurotypical and neurodivergent people, often creating miscommunication between clinicians and patients.⁴³ A neurodiversity-affirming model views this observation as a bidirectional breakdown in communication, rather than unilateral impairments in autism, and refrains from assigning blame. First characterized by Milton, a researcher and sociologist with autism, this concept is often termed the “double empathy” problem, ie, communication difficulties arise from mismatches in social communication styles, expectations, and what each neurotype finds salient or relevant.⁴⁴ A common example is that some autistic individuals take verbal communication very literally, which can result in nonautistic individuals taking offense. Communication between 2 autistic individuals tends to be more effective than interactions between people with different neurotypes. It is vital to remember that a neurotypical communication style is not more correct than a neuroatypical style. However, we have seen that verbal communication skills, processing speed, and atypical nonverbal communication skills can affect the clinical interaction and therefore health outcomes.⁴⁵ By asking questions preemptively, the clinician can help the patient access standards of care that may otherwise be unattainable. For example, autistic individuals frequently have hypo- or hyperreactivity to pain and differences in interoception (challenges with bodily awareness). The clinician can help set the patient at ease by asking them how they tend to react to various stimuli.⁴⁴

Prior to the upcoming medical interaction, a discussion of screening or testing methodologies, such as colonoscopies or mammograms, can help to dispel patient anxiety. A version of “social stories,” an evidence-based autism intervention developed by educator Carol Gray in the early 1990s,¹⁴ may be used to help set the stage for a planned medical intervention. Social stories provide scaffolding for the patient's expectations and experiences and reduce anxiety from the unexpected. For example, it might comprise a short, personalized verbal narrative that includes the patient's “to-do” list and what they can expect from the medical system. It might include photographs or verbal descriptions, and could be as simple as saying, “The nurse will come in to give you your shot. After this, you can go to the laboratory. Within a week, you will get a call to schedule your mammogram. Since you have never had a mammogram, I want to share the process with you, since it can be a bit surprising the first time.” The goal of this method is to improve reciprocal communication and provide scaffolding for the individual's next steps in an unfamiliar scenario with the goal of reducing anxiety. At the end of the visit, an overt wrap-up is advised, reiterating the plan and describing what is expected from the patient, as well as addressing the benefits to the patient.⁴⁵

A therapeutic communication approach known as “declarative language” can help preempt miscommunication or social friction when working with neurodivergent individuals. This approach supports patient comfort and autonomy by fostering a low-pressure, collaborative, nonshaming interaction style (Table 3). Declarative language was popularized in the speech-language pathology literature by Murphy in 2020; its core principles align with longstanding responsive and naturalistic approaches in communication-focused therapies. This approach is particularly helpful when working with neurodivergent individuals and others who experience differences in pragmatic language, processing speed, or social communication.

Table 3.

Directive (Interrogative/Imperative) vs Declarative Language in Neurodiversity-Affirming HIV Care

Communication style	Definition	Clinical examples	Potential impact on neurodivergent patients
Directive language (interrogative or imperative)	Questions or commands that require action or explanation and may imply urgency, expectation, or evaluation	“Why didn't you take your medication?” “Did you schedule the referral?” “You need to call today.” “Start this medication now.”	May increase anxiety, shame, or defensiveness Can heighten avoidance in patients with executive dysfunction May overwhelm individuals with slower processing speed Shifts tone toward compliance rather than collaboration Should be reserved for emergencies
Declarative language	Neutral observations, reflections, or shared information that invite engagement without demanding immediate response	“I'm noticing refills have been difficult.” “The colonoscopy preparation can feel overwhelming for some people.” “Your last mammogram was 3 years ago. The usual recommendation is to have a mammogram yearly.” “Your viral load had a bump.”	Reduces perceived pressure Supports autonomy Allows processing time Fosters psychologic safety Encourages collaborative problem-solving
Declarative language with structured scaffolding (using social stories and executive function supports)	Declarative framing or narrating combined with stepwise, predictable steps and support	“Today we will draw blood to understand how the virus is affecting your body and to make sure your medications are working well. The laboratory visit usually takes about 10 minutes. You can make a follow-up appointment on the way out at the desk. Laboratory results return in 2 days. Once I review them, I will send you a message in the portal. If anything feels confusing at any step, we will slow down and review it.”	Improves predictability Reduces procedural anxiety Supports executive function and autonomy Enhances follow-through and retention in care

Rather than directing behavior (imperative language) or requiring a response (interrogative language), declarative language centers on sharing observations, thoughts, and information in a neutral and supportive manner. The goal is not compliance or pressure, but shared understanding and psychologic safety. By reducing performance demands and allowing additional processing time, this approach promotes autonomy, encourages collaborative engagement, reduces shame, and creates space for self-initiated participation within the clinical encounter.

In practice, declarative language can look like narrating observations in a neutral fashion and then allowing silence for processing. These statements invite reflection without demanding explanation, justification, or immediate response. Declarative language removes implicit judgment and shifts the interaction toward collaboration and autonomy. Although there is some conceptual overlap with motivational interviewing, declarative language is particularly tailored to neurocomplex populations that may struggle with nonverbal cues or implied social expectations. It helps preempt miscommunication by making implicit expectations explicit and maintaining respect and autonomy. At its best, declarative language transforms the clinical encounter from directive to collaborative, supporting engagement, dignity, and shared meaning.

Addressing Intersectional and Structural Barriers

Culturally responsive care is an important goal when caring for any patient. The integration of trauma-informed and culturally responsive practices, and recognizing the compounded impact of racism, homophobia, transphobia, and ableism on individuals who are neurodivergent is crucial for all HIV centers. Clinician support and advocacy are essential to foster policies that expand insurance coverage for neurodevelopmental, therapeutic, and mental health services across the lifespan and promote integrated care models that bridge gaps between HIV, behavioral health, and neurodevelopmental care needs.

Leveraging Patient Strengths and Preferences

Strengths-Based Approaches.

Clinicians can identify and build upon the individual strengths of patients who are neurodivergent. For example, they might draw on the patient's attention to detail, adherence to routines, or self-advocacy skills to support their engagement in HIV prevention and treatment. This collaboration between clinician and patient is key to the success of any treatment plan and the ongoing therapeutic relationship.

Shared Decision-Making.

Clinicians can involve patients who are neurotypical and neurodivergent and their families in care planning, respecting autonomy and preferences and providing clear, accessible information about management options. Many individuals who are neurodivergent require extra processing time, particularly for tasks that rely on reaction speed or executive function. Meta-analytic data show that individuals with ASD consistently exhibit slower mean reaction times across a range of time-based tasks than neurotypical controls, suggesting a general slowing of information processing. In individuals with ADHD, and especially in those with cooccurring ASD, studies demonstrate increased mean reaction times and greater response time variability compared with neurotypical controls and groups with ASD alone. This is particularly highlighted under slow or less rewarding conditions,⁴⁷ which is likely due to minimal dopamine outflow.^2,4,5 People with ADHD or ASD and ADHD also show more pronounced impairment in sustained attention and response inhibition, which can manifest as slower and more variable decision-making. Decreased speed and increased variability in processing time are well-documented features in people with ASD or ADHD, and the effect is even more pronounced with the cooccurrence of these conditions.⁴⁷ This has important implications for assessment and intervention planning in these populations. Put simply, many people who are neurodivergent have a “slow cooker” brain, and not a “microwave” brain. They may need more processing time to make decisions. One useful strategy features low-pressure shared decision-making and utilizes the longitudinal clinician-patient relationship. For example, a nonurgent concept such as a screeningtest, referral, or procedure is introduced, without the expectation that the patient can or will schedule the test immediately. The patient is then informed that they can contemplate the intervention and that it will be readdressed at a later visit, or they can reach out virtually through a patient portal. Care is taken not to overwhelm the individual with nonurgent preventive care at any single visit and low-pressure shared decision-making is used to help optimize those needs over time.

Research and Quality Improvement

The care of neurodivergent PWH is an area that needs more data collection, outcomes tracking, and quality-improvement initiatives and studies that address the prevalence, health outcomes, and care needs of this group. “Nothing about us without us” is a slogan originating in sixteenth century Poland and popularized by disabilities advocates and the United Nations on its 2004 International Day of Disabled Persons, and is an excellent guiding principle.⁴⁸ All research and quality-improvement efforts should ensure the direct, meaningful participation of individuals who are neurodivergent.

Conclusion

Neurodivergence is an underrecognized factor influencing HIV acquisition risk, engagement in care, and treatment outcomes. Differences in cognition, sensory processing, communication, and executive function can affect communication, adherence, retention in care, and outcomes when care systems are not designed with these needs in mind. A neurodiversity-affirming approach reframes these challenges as modifiable features of care delivery rather than patient deficits. Recognizing neurodivergence as a difference rather than a deficit, and implementing neurodiversity-affirming, accessible, and inclusive care strategies, are essential components for reducing health disparities and improving outcomes. Many core strategies of high-quality HIV care, such as clear communication, flexibility, and patient-centered planning, align naturally with neurodivergent-inclusive practices when applied intentionally. Integrating the awareness of neurodivergent needs into HIV clinical training and care, research, and program design represents a practical and necessary step toward improving equity and outcomes across the HIV care continuum. Supporting neurocomplex PWH is crucial for achieving equitable, person-centered care for all neurotypes. Selected references for further reading on ASD are provided.^49,50