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On the Borderline: Identifying and Managing Personality Disorders in the HIV Clinic

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Released: October 07, 2026

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A major strength of HIV care is continuity. As HIV care providers, consistently caring for the same people long-term can help us identify and treat certain patterns of behavior that suggest a personality disorder. Keep reading to find out how I do this in my practice and what you can do to integrate mental health care and HIV care in yours.

Glenn J. Treisman
Glenn J. Treisman, MD, PhD
Personality Disorders in the HIV Clinic

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Case Scenario
A 29-year-old woman living with HIV presents at your HIV clinic and asks you to “bridge” her alprazolam prescription after it ran out early, as she can no longer reach her prescribing clinician. This individual is known at your clinic for repeated conflict, including alternating between praising and attacking staff, frequent urgent calls, and occasionally appearing intoxicated at visits. She is also known for frequent emergency department visits for lost/stolen medications. Her chart shows a prior diagnosis of borderline personality disorder.

Personality disorder is a condition in which the person's innate style of interacting with the world is so extreme that it prevents them from succeeding, rather than helping them succeed. The simplest characterization of the Cluster B personality disorders is that people who have them have an excessive endowment of emotions. Their emotions are running their life.

What to Look For
There are no formal screening tools for personality disorders, but a major strength of HIV care is continuity. Strong continuity of care in HIV management means that HIV care providers can notice and pick up on certain patterns of behavior that suggest a Cluster B personality disorder, such as:

  • Repeated conflict when interacting with various staff members
  • Dislike being told “no” as an answer to something they desire
  • Goals that are not necessarily in line with your treatment goal

In my practice, if a personality disorder is suspected, I first take a careful history from the patient and ask them about what kinds of things get them in trouble. This is integral to the process, because you need to know their story. While taking the patient's history, you should look for patterns of behavior that are problematic and disordered.

I believe the number 1 thing that tells you someone has a Cluster B personality disorder is intensely unstable interpersonal relationships. They may tell you this, or you might be able to observe it from their interactions with people in your clinic. The key is how they interact with others.

Ideally, the integration of mental health care and HIV care would involve dedicated mental health care professionals in the HIV clinic. However, if there are no mental health care professionals in the clinic and you cannot get a consultant, you can learn to do it yourself.

The most efficient way to learn how to treat personality disorders is to find somebody who knows how to do it and learn their process. It is best done as a tutorial, like learning to draw blood: it is a lot easier to pick up if someone shows you firsthand what it looks like. I find that if HCPs observe the process a couple of times, or even just once, it is often enough to get them going.

Treating Cluster B Personality Disorders in HIV Care
The treatment for borderline personality disorder is dialectical behavior therapy, which is meant to help people manage their intense emotions, accept reality, and eventually change unhelpful or harmful behaviors.

With dialectical behavior therapy, I help the patient create a pathway that starts with where they are and shows them where they need to get to. Usually, I find that patients are pretty receptive to the idea that they have an overwhelming emotional endowment. They know they have more intense emotions than average, and they trust that you are going to help them learn to manage those big feelings.

Redirecting Goals to Support HIV Care
Up to nearly 80% of people with borderline personality disorder will also struggle with substance use disorder. For example, consider the patient in our case study, who is requesting alprazolam. It is possible that she truly needs a bridge, but based on her history, this is an established pattern of behavior. For individuals like her, the best thing you can do is try to be practical about how you are going to help them.

Ideally, the patient in the case study would discontinue alprazolam if they have no indication for it. However, she cannot stop it cold turkey, because that can be life‑threatening. To taper her off, I would give her enough for today and tell her to return tomorrow, at which time I would give her enough for tomorrow. Then, we would work together to gradually taper down over the next couple of months.

People with Cluster B personality disorders are going to be persistent in trying to get their desires met. Sometimes, I even see individuals who try to bargain with us, like attempting to trade antiretroviral therapy adherence for substances. You can help them move to a different, healthier goal by explaining to them why the goal they are focused on is pathological. You can help them see how important it is that they learn to manage their behavior by going over the losses in their life or by showing them the ways that destructive patterns can harm them.

In the context of HIV care, if it turns out they have no indication for alprazolam, I would tell them, "You have no indication for alprazolam. You have an indication for antiretrovirals. Your life will be longer with antiretrovirals and shorter with alprazolam. My job is not to shorten your life. My job is to help you live longer and better.”

Finally, I always try to avoid making patients feel like their personality is completely detrimental, or that they are inherently “bad” or “difficult” people because of it. I always say to patients, "If I could take your condition away, it might make an easier life for you, but it would not necessarily make for a better you. Rather, I am going to help you learn how to manage your intense feelings, so they do not manage you."

Your Thoughts
What systems do you have in place to identify and care for people with borderline personality disorder? What advice or strategies from this commentary are most applicable to your practice? Leave a comment to join the discussion!

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