Philip Sayegh, David J. Moore, and Pariya Fazeli Wheeler
Since the first cluster of people with HIV was identified in 1981, significant biomedical advances, most notably the development of antiretroviral therapy (ART), have led to considerably increased life expectancy as well as a reduction in the morbidity and mortality associated with HIV/AIDS. As a result, HIV/AIDS is no longer considered a terminal illness, but rather a chronic illness, and many persons living with HIV/AIDS are beginning to enter or have already reached later life. In fact, Americans ages 50 years and older comprise approximately half of all individuals with HIV/AIDS and represent the most rapidly growing subpopulation of persons living with HIV/AIDS in the United States.
Despite significant advances in HIV/AIDS treatment and prognosis, older adults living with HIV (OALH) face a number of unique challenges and circumstances that can lead to exacerbated symptoms and poorer outcomes, despite demonstrating generally better ART adherence than their younger counterparts. These detrimental outcomes are due to both chronological aging and cohort effects as well as social and behavioral factors and long-term ART use. For instance, neurocognitive deficits and neuropsychiatric symptoms, including depression, anxiety, apathy, and fatigue, are often observed among OALH, which can result in feelings of loneliness, social isolation, and reduced social support. Taken together, these factors can lead to elevated levels of problems with everyday functioning (e.g., activities of daily living) among OALH. In addition, sociocultural factors such as race/ethnicity, ageism, sexism, homophobia, transphobia, geographic region, socioeconomic status and financial well-being, systemic barriers and disparities, and cultural values and beliefs play an influential role in determining outcomes.
Notwithstanding the challenges associated with living with HIV/AIDS in later life, many persons living with HIV/AIDS are aging successfully. HIV/AIDS survivor and community mobilization efforts, as well as integrated care models, have resulted in some significant improvements in overall HIV/AIDS patient care. In addition, interventions aimed at improving successful aging outcomes among OALH are being developed in an attempt to effectively reduce the psychological and physical morbidity associated with HIV disease.
Psychoanalyst Erik Erikson was the first professional to describe and use the concept of ego identity in his writings on what constitutes healthy personality development for every individual over the course of the life span. Basic to Erikson’s view, as well as those of many later identity writers, is the understanding that identity enables one to move with purpose and direction in life, and with a sense of inner sameness and continuity over time and place. Erikson considered identity to be psychosocial in nature, formed by the intersection of individual biological and psychological capacities in combination with the opportunities and supports offered by one’s social context. Identity normally becomes a central issue of concern during adolescence, when decisions about future vocational, ideological, and relational issues need to be addressed; however, these key identity concerns often demand further reflection and revision during different phases of adult life as well. Identity, thus, is not something that one resolves once and for all at the end of adolescence, but rather identity may continue to evolve and change over the course of adult life too.
Following Erikson’s initial writings, subsequent theorists have laid different emphases on the role of the individual and the role of society in the identity formation process. One very popular elaboration of Erikson’s own writings on identity that retains a psychosocial focus is the identity status model of James Marcia. While Erikson had described one’s identity resolution as lying somewhere on a continuum between identity achievement and role confusion (and optimally located nearer the achievement end of the spectrum), Marcia defined four very different means by which one may approach identity-defining decisions: identity achievement (commitment following exploration), moratorium (exploration in process), foreclosure (commitment without exploration), and diffusion (no commitment with little or no exploration). These four approaches (or identity statuses) have, over many decades, been the focus of over 1,000 theoretical and research studies that have examined identity status antecedents, behavioral consequences, associated personality characteristics, patterns of interpersonal relations, and developmental forms of movement over time. A further field of study has focused on the implications for intervention that each identity status holds. Current research seeks both to refine the identity statuses and explore their dimensions further through narrative analysis.