Sexually transmitted infections (STI), including HIV, disproportionately affect incarcerated populations. In 2010, over 90% of the inmates living with HIV in U.S. prisons were men and the prevalence of STIs such as chlamydia, gonorrhea, and syphilis, continues to be much higher among male inmates as compared to the U.S. population at large.
"This presents a significant public health problem in the U.S. which disproportionately affects African American males who, compared with whites, face eight to 18 times the incidence of common STIs," said Joy Scheidell, MPH, a research coordinator at the New York University Langone (NYULMC) Department of Population Health.
Compounding the already high-rate of STIs in the U.S. African American male population is the fact they are incarcerated at nearly six-times the rate of white males. These statistics outline a clear need to identify and address modifiable risk factors that drive high infection rates among men involved in the criminal justice system.
Prior research suggests that Borderline Personality Disorder (BPD) lends itself to increased sexual risk-taking, and may therefore be a significant factor in STI/HIV transmission. BPD, which is characterized by a persistent pattern of instability in interpersonal relationships, self-image and impulse control, is prevalent among 1.8% of the general population.
However, most studies on BPD in incarcerated populations have focused on women and have found up to 55% of incarcerated women have the disorder. Studies on the prevalence of BPD among incarcerated men are limited, but suggest the prevalence is near 20%.
A study from the Department of Population Health at NYULMC and New York University's Center for Drug Use and HIV Research (CDUHR), led by Scheidell, is the first to examine the association between borderline personality disorder (BPD) and the risk for HIV and other STIs in an adult male criminal justice population.
The study used a modified version of the Borderline Evaluation of Severity over Time (BEST) assessment to measure the presence or absence of five BPD indicators that address emotional lability and relationship dysfunction, namely the fear of abandonment, major shifts in opinions about others, severe mood swings, going to extremes to keep someone from leaving and temper outbursts.
Using select baseline data from Project DISRUPT, a cohort study of African American men being released from prison in North Carolina who were in heterosexual relationships at prison entry, researchers assessed the STI/HIV risk of 189 individuals in the six months before their incarceration, as well as their BPD symptoms--specifically emotional liability and relationship dysfunction. Participants qualified for the study if they were male; African American; had been in prison three years or less; were scheduled to be released within two months; HIV-negative at prison intake; not incarcerated for rape, kidnapping, or murder; and in a heterosexual, committed partnership at the time of prison entry.
"At the aggregate level, we found participants in the top 25% of the scale measuring BPD symptom severity were substantially younger than those in the remaining 75%," said Scheidell. "Furthermore, those who fell within the top quartile exhibited twice the rate of depressive symptoms, and reported far more instances of elevated stress."
"With regards to BPD as it relates to STI/HIV risk, we found certain BPD symptoms to be particularly strong correlates," said co-author Maria Khan, PhD, an associate director at CDUHR, and associate professor in the Department of Population Health Population Health at NYULMC. "With each unit increase in fear of abandonment came an almost 60% increase in the likelihood the participant engaged in sex with partners who sell sex."
Additionally, participants falling in the top 25% range of BPD symptom severity had over twice the odds of multiple and concurrent partnerships, as well as sex with non-monogamous partners. Increasing severity of "major shifts in opinions about others" was associated with increased odds of multiple partnerships, sex with partners who sell sex, and sex with non-monogamous partners, in addition to previous STI infection. Increasing severity of mood swings was associated with multiple partnerships, concurrent partnerships, and sex with non-monogamous partners.
A key feature of BPD is impulsivity, which is predictive of later psychopathology and negative health outcomes for those with the disorder.
"Finding symptoms of BPD that may be indicative of impulsivity to be most associated with STI/HIV risk has reinforced the idea that interventions seeking to reduce comorbidities associated with psychiatric illness may need to focus on that aspect of the disorder," said Dr. Khan.
Based on their findings, the researchers advocate for proper assessment and diagnosis as being the key to treatments for BPD.
"The period of incarceration has long been seen as a critical time for addressing public health concerns," said Scheidell. "Strengthening correctional programs that address mental illness, including BPD, along with STI/HIV risk mitigation, are critical for protecting the health of men involved in the criminal justice system. In turn, this may have positive effects on the health of their relationships and in turn their partners."
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