Over half of the people living with HIV in the United States are age fifty and older. Dr. David Wohl talks about the importance of not only controlling the virus, but taking good care of your overall health and well-being. He says that while there are some additional challenges people living with HIV face, there are things people can do to improve their chances of living a long and healthy life. Dr. Wohl is a Professor of Medicine in the Division of Infectious Diseases. He co-directs HIV services for the North Carolina Department of Corrections, and co-directs the North Carolina AIDS Training and Education Center.
“How do I make sure you understand how precious you are? And that you’re worth not polluting your body. Everything that you put into your body—is it good or bad in your fight against HIV? If it doesn’t pass the test, let’s try to help you pass on it.”
– Dr. David Wohl
Topics Covered:
- Taking better care of yourself
- Risk for cancer & smoking
- Making better choices every day
- HIV and mental health
- Health monitoring
- A prescription for aging gracefully
Ron Falk, MD: Hello, and welcome to the Chair’s Corner from the Department of Medicine at the University of North Carolina. This is our series for patients where we talk about HIV. Today, we will discuss how to live a long life with HIV.
We welcome Dr. David Wohl, who is a Professor of Medicine in our Division of Infectious Diseases. He is the co-director of HIV Services for the North Carolina Department of Corrections and co-directs the North Carolina AIDS Training and Education Center. Dr. Wohl sees patients who have HIV and helps them live long and healthy lives. Welcome, Dr. Wohl.
David Wohl, MD: Thank you, Dr. Falk, for this opportunity to talk.
Taking better care of yourself
Falk: Dr. Wohl, you really are an expert in taking care of patients who have HIV and who are living long, productive, and healthy lives. What are the messages that you would want to tell people on how to do that?
Wohl: That’s a really good question, and it’s a good question for a number of reasons. One, is that over half of the people living with HIV in the United States right now are age fifty and above. That’s 1.2 million people who are infected in our country, so over 500,000 people are HIV positive and over fifty. Not only that, but some people older than fifty do acquire HIV, so not all those of those people are living a long time with HIV, some are acquiring it. It’s really important that we understand how we help people who are infected, control their virus but also not only survive with HIV but thrive with HIV. As we’ll talk about, there are some challenges for all of us as we age, but probably for people living with HIV, there are some additional challenges.
Falk: What are those?
Wohl: It’s really interesting, as you said, I’ve been very fascinated by this whole thing of aging with HIV, which is ironic, because back in the late 80’s, early 90’s, I got into HIV because I like taking care of young people. As I’ve gotten older, my patients have gotten older with me.
Falk: Scary thought, isn’t it?
Wohl: We’re aging together—I’m over fifty. I’m thinking about how do I prepare myself for my sixties, my seventies, my eighties and beyond, and I’m thinking about that with my patients. What’s very interesting is that some data show that having HIV infection may accelerate some of the processes that are associated with aging, but on the other hand, I have to honest with you that I have been very skeptical of that kind of research, because I have patients I’ve been caring for, for many years and more of them smoke, more of them are obese, more of them have diets that are suboptimal, and they don’t exercise. The drop in the bucket may be that they have this virus that’s controlled that may lead to some problems metabolically, but they have this preponderance of risk that we all face.
Falk: The general population.
Wohl: The general population. The bang for the buck for me has really been, “How do I get my patients to take better care of themselves?”—whether they had HIV or not.
Falk: There is this thought process or a word choice called, “restoration of health.” You have a disease, you are perhaps even cured from a disease or on medication so that you are free of the disease, but your health has not been restored. In other words, you are not able to go back to doing the things that you wanted to do beforehand. The real goal is restoration of health. Are you saying that it is very plausible that somebody whose HIV is controlled has restoration of health, at least as restored as it was before they got the disease and associated with all of the problems and foibles of the rest of us?
Wohl: Different people with HIV have different trajectories—they have different histories. Some people get infected, it’s caught early, and they really never suffer the kind of problems that are associated, that we think about with HIV or even AIDS. So, we find some people early on and there’s really not been much in the way of damage. There’s others, more typically, we find who have had the virus for a long time and it’s been doing some damage—their immune systems are weaker, and we have to restore not only their immunity and get it back towards normal, but sometimes their health.
To be honest with you, most of the people we’re taking care of with HIV really are pretty healthy, they really are—from their HIV. Now, if they’re smokers, if they have emphysema, if they have cardiovascular disease because of hypercholesterolemia, other types of things, that’s what we’re dealing with. More and more we’re dealing with those things—so, absolutely.
I talk to my patients about one thing and then another thing—one is the restoration of health. We can build you back up, but I need you, as I push HIV down on the list of things that are a threat to you, to take care of the things that are rising to the top—your hypertension, your cardiovascular disease health, your kidney health—all those things start to rise to the top.
Falk: Modifiable risk factors.
Wohl: Mostly modifiable risk factors—we can’t help the genetic lottery. Some of us have high blood pressure, some of us have hypercholesterolemia, or just a tendency towards cancers, those are things that are harder, but we work on them and some of those are modifiable. Change the things we can change.
It’s a little bit like being an athlete. I don’t need you to be an Olympic athlete, but I need you to be motivated to take care of yourself if you want to survive, if you want to live. Our default is, “Let’s just drive this car until it dies. Let’s not do an oil change every 3,000 miles. Let’s not change the air filters.” You can run a car into the ground. You can buy a new car, but you can’t buy new kidneys that works as well as your own kidneys, you can’t buy new coronary arteries, you can’t buy new lungs, you can’t buy a new brain.
Really, what we’re talking about is health maintenance. For many people living with HIV, is very challenging due to poverty, due to lack of access to health care, due to mental health and substance abuse disorders, due to discrimination, due to all sorts of the things that society has really overlaid on top of HIV, that—I have to be honest with you, is one of the biggest challenges we face in that restoration of health.
Risk for cancer & smoking
Falk: You mentioned the issue of cancer, because that’s a reality that occurs in the general population as well. Are patients with HIV at particularly increased risk for cancers of one sort or the other?
Wohl: They are, and we think of our immune systems as fighting germs. Our immune system is developed to take away things that we can breathe in, or touch. Our immune system also patrols looking for cancer cells. Cancer cells look foreign than us, so the immune system often times will see that, and say, “This doesn’t belong here,” and attack an emerging cancer cell, and prevent that cancer cell from replicating and causing cancer. If your immune system is weakened, let’s say by the HIV virus, certain types of cancers could develop. Now, this generally happens when the immune system is pretty weakened from HIV which usually takes some time.
There’s other things, like lung cancer, which is because of the smoking, really, by and large, in our population—that’s again, another preventable. Probably people with HIV for the same “pack years,” the number of packs of cigarettes a day for how long, probably have increased risk, compared to somebody who smoked the same amount, who didn’t have HIV.
Falk: This is a question not just for patients with HIV, but for the general population who smoke: There is excellent data and lots of public information that smoking is just not good for your health. As a matter of fact, you can’t walk into many buildings in the state of North Carolina—hospitals, restaurants, public spaces, and smoke. Why do people keep doing it? What have you learned from the HIV population that would shed light on that issue?
Wohl: One of the things that also attracted me to HIV is how much the epidemic—and it really is an epidemic—it came almost out of nowhere, it’s claimed millions of lives all around the planet, a real public health emergency, on the order of what we’ve seen with Ebola. One of the things that attracted me was how intertwined it is with the social fabric. There’s no accident that many of the people who I see living with HIV, where there are still billboards advertising menthol cigarettes and malt liquor—where these populations are targeted for certain products. They are designed to be bad for your health. There’s no other design for cigarettes than to be smoked and they do nothing health-wise beneficial, but everything deleterious to your health. It’s an addiction, it’s wrapped up in society, it’s wrapped up in messaging, advertising counts, movies, television, it looks “cool,”—whatever.
It’s very hard to take someone who has been smoking for decades and pull that away when it’s become a crutch. So many of my people who I take care of and have grown old with need crutches, unfortunately, whether it be smoking, whether it be alcohol, sometimes substances, and unfortunately many of them live very stressful lives. So, on the one hand I could wag my finger and say, “Stop smoking!” and “Go to a gym.” In reality, to walk in their shoes, you live in a double wide with an extension cord for power, you have a landlord who’s on your case, you have a partner who is not supportive, children who are in jail—there’s really so much going on that it’s really sometimes hard to put yourself first.
What I try to work on is, How do I build up your self-esteem? How do I make sure you understand how precious you are? And that you’re worth not polluting your body. Everything that you put into your body—is it good or bad in your fight against HIV? If it doesn’t pass the test, let’s try to help you pass on it.
Making better choices every day
Falk: You’ve just talked about living situation, the environment with respect to advertisement, social pressures, the individual’s home environment. How much can be done or how many times do patients actually extricate themselves or pull themselves out of adverse environments? You can imagine somebody who is living with people who are doing all sorts of drugs of one kind or the other. How do you get them to help themselves by moving out if they can, or trying to get the people around them to stop if they can? Drug addiction, just like smoking addiction, is a national crisis at this point. How can you help an HIV person who is otherwise doing well, not let that environment totally impinge on every day to day activity?
Wohl: Certainly, I’ve been impressed, even working with people coming out of prison who have HIV, and are living with HIV, how many people can be successful. It takes some resiliency and people who cope well with adversity can still live in a really toxic environment and do well whereas others don’t. That may be because of family support, or faith, but there is something that helps keep these people going and not let anyone get them down.
I’ve also heard some of my patients, and others say, “You know, in a weird way, HIV may have been the best thing that has happened to me. I got into care, I realized there was a problem, you all have been helping me—you have social workers, you have substance abuse counselors, mental health counselors, and they’ve helped me.”
Pretty much a lot of what we’re talking about is a failure of our mental health system. Many people self-medicate for their traumas, for their mood disorders, with substances that they buy off the street. We don’t really have clean, well-lit places that people can readily access to get mental health care. They can access those places to get a burger, but they can’t get mental health care as easily. I think we have to recognize that this is a failure of our dealing with psychiatric illnesses and mood disorders.
When we start to address that, and we start to get to the root causes of those things, and say, “You’re precious. You’re worth saving. Let’s remember, look at your baby pictures—look how great you were. You’re still great. Let’s work on that, let’s build on that. You should be around for your children, for your grandchildren. Let’s prepare you. Let’s grow old. I don’t care that there’s a virus latent somewhere in some cell—your virus is suppressed, you’re taking your medicines, let’s control the things we can control, but let’s partner in this together if you want to grow old. If you want to get gray hair, if you want to get social security, you want to do all those things, you’ve got to stay alive. I can help you with that, but you’ve got to do the other part.”
Falk: You’ve talked about going to a gym or doing exercise. What kind of exercise are you suggesting to folks?
Wohl: I’ve learned a lot about what to recommend to my patients by thinking about things for myself. There’s really good data that people from here and others who are much more expert on this know about, that indicate that you don’t have to sweat for an hour or an hour and a half five times a week. We’re learning more and more that short, intense exercise can make a big difference.
Even if you get an old exercise bike and you do twenty minutes of what we call interval training—simple as thirty seconds going light, twenty seconds a little harder, and ten seconds going all out—do a few of those up to twenty minutes, three times a week. Some of the data that we’re seeing in the sports medicine literature shows that that’s just as effective and more fun than doing an hour three times a week.
I’ve talked to many of my folks about things you can do even in your home—you don’t have to join an expensive gym. If your neighborhood is dangerous, you don’t have to go on a walk or jog at night. We’re talking about things you can do at home, probably pretty affordably—even doing squats, sit-ups, things like that, push-ups. You can do these things at home. I do them in hotel rooms sometimes when I’m traveling. You can do it too.
Let’s talk about food choices. You don’t have to buy an expensive book or sign up for an expensive program. We can make some reasonable food choices. There’s no recommended daily allowance for cookies and ice cream and candy—there’s a reason for that. They’re for special occasions. Special occasions aren’t days that end in the letter “Y”—if it’s a birthday, not Wednesday. If it’s an anniversary, or Christmas, I understand that, but not every day do you have to have a cookie or a scoop of ice cream or certainly soda. Little things count.
HIV and mental health
Falk: Living with HIV, as you described, latent someplace in a cell in your body, still takes a toll. It’s hard to ignore the reality that you have to take a drug every single day and you could say, Yes, you’re taking your drug every single day but you’re healthy taking a drug every day. Nonetheless, that’s not easy to do. That’s not easy, especially for a young person. We see it in patients who have transplants who are on lifelong immunosuppression. Taking that drug every day is difficult—it leads to depression, it leads to anxiety. What are the mental health issues of patients with HIV? Are they the typical ones that other patients have, or are there HIV-associated mental health issues all by themselves?
Wohl: There’s a chicken and egg in some ways in which people who have mental health issues—which is, what we’re talking about is not a thin slice of pie in the general population—most of us do. Many of those folks sometimes make decisions that aren’t good for them. Sometimes they seek out acceptance in love, connection—some of these behaviors may put them at risk for things like HIV. So, on one level, we see people living with HIV acquire their virus. Maybe it’s a consequence of some of the things going on in their lives and what they were seeking to try to stave off some of the demons. I can’t fault anyone for that.
Others, after HIV was diagnosed, have suffered from stigma, either external stigma from how others treat them, or internalized. It’s very interesting that often people with HIV often times feel unclean or guilty. Recently, I’ve done some work with people who have survived Ebola, and we asked them the same questions we ask HIV-infected people. People with Ebola—these are survivors—very, very few ever say, “I feel unclean,” or “I deserve this,” or “This is a punishment from God.” They feel the stigma, but it’s all external stigma. Others are not treating me well, but I feel fine about myself. You don’t see that with HIV, and that’s, I think, because of our culture, because of some of the morality that’s been applied.
I think a step for all of us in the general population that can make a huge difference is to understand that there but for the grace of God, goes I that we should be tolerant, understanding, and that nobody asked to get HIV infected. There are many, many people who practice behaviors that could lead to HIV infection and are fortunate they did not get infected, it was just luck.
So, I think that we should not judge people, we should support them. This will help mental health significantly. We know that people who are stigmatized, who are discriminated against—HIV positive, HIV negative—whatever way you look at it, suffer higher levels of cortisone, adrenaline, and that these have deleterious consequences, starting in childhood. I think we have to really be careful about how punitive we act towards one another, and with HIV it’s really the poster child for this because of the way that people with HIV have been treated, even to this day.
It’s gotten better, and I credit people like Magic Johnson and others for really coming out, and I do encourage many of my patients who are able to come out and talk about this, to speak at their church, to speak at health fairs, to speak on podcasts like this. Those who do so are very brave, but we have to reverse the stigmatization.
We have to stop pointing fingers. We do it naturally because it makes us feel better about ourselves—“Oh, I could have gotten that, but I didn’t. I must be different from that person.” It’s a protective mechanism, I understand that, but it is really harmful and it lays on top of already existing mental health issues a further weight and burden.
Health monitoring
Falk: Health maintenance issues are common for the general population. We tell patients to get their blood pressure checked, get their serum cholesterol looked at, to get on a scale, and make sure that their weight is appropriate for their height—in other words, their body mass index. What other tips do you have to tell patients with HIV that they should think about, or ask their doctor about, for monitoring their overall state of health?
Wohl: One thing I will say about people living with HIV, as opposed to some others, really know science matters. They’ve benefitted from science and medical science. This has changed a disease that was uniformly fatal—it filled hospital wards with dying, young people. They’ve seen how that’s changed with science, with medicine. They know that there’s a lot of power in some of the things we do, that we can save lives and keep people healthy for decades. There’s no fake news about smoking—we know it’s reality, the science is irrefutable. We know that if we screen people for cancers, we can make a difference with the right cancers and the right screenings. No brainer—colonoscopy. I know it’s not fun taking the prep, I know it’s not fun, but I walk the walk, I did it myself—you can do it too. We can walk you through it and it can make a difference.
Falk: Presumably mammograms…
Wohl: Mammograms, breast checks, pap smears for women—I think those are simple, they’re easy. More and more we talk a lot about smoking. There’s even some things we can do. Talking to our pulmonary colleagues, if we get some low radiation CAT scans we can find lung cancer in those who have had substantial history of smoking and are over age 55, and prevent some of those.
So, we have a toolbox that’s pretty limited, there’s not a lot that we’re talking about, but it can have a pretty big impact, especially if you already have a higher risk for some of these things. It’s all part of the package of taking care of yourself. I know you’ve got to take care of others, at some point you have to pivot and take care of yourselves. That’s how we live long.
Falk: And if you develop pressure-like chest pain that radiates down your arm and goes up to your jaw, you need to go see an emergency room or cardiologist sooner rather than later.
Wohl: Absolutely, and we try hard to prevent people from getting to that point. One of the big things we work on is kidney health, which is near and dear to your heart. People with HIV suffer high rates of kidney disease, often because of confluence of diabetes, hypertension, and HIV. HIV has effects on the kidney. So, we know that if we treat your HIV effectively, again the majority of our patients do great with their medications, ninety percent plus of people in our clinic—their virus is so low it’s like a needle in a haystack, just like Magic Johnson. That’s very common-that’s the rule, not the exception. We do everything we can to turn the dial back on risks so we can keep you off of dialysis, keep you from going to the emergency room with pain radiating from your chest down to your arm, preventing strokes. We know how to do this.
A prescription for aging gracefully
Falk: If you were going to give a patient a prescription of behaviors that would help them age gracefully, what would they be?
Wohl: One, is that I think we have to be kinder to ourselves. I think our default has been, “Go, go, go.” We don’t think about things in the moment. We are swayed each way by the forces that come across us—our children, our parents, work, lack of work, money—all these things, we’re just at their mercy. I think we need to try to get a little more control over our lives, be mindful of the choices we’re making.
That really would be if I were to sum up on one prescription: Think about the choices you are making, and weigh them. We do so many things impulsively. I know that looks like it would be yummy to eat. Could you skip it today? There will be another time you could eat it, but let’s not eat that today. It’s not going to be good for me. I’m trying to shed the pounds, my doctor told me my blood pressure and weight are totally correlated—when I lose ten pounds, my blood pressure goes down ten points. Let me make some good decisions for my life, understanding that I am worth something. I am worth a lot. I am precious.
If people understand how precious they are, they take care of themselves better. We have patients who miss an appointment, or two or three, and they say, “Well, no one called me.” I say, “If someone owed you a lot of money, would you not call them to say, ‘Hey, you owe me money. When are you going to pay me?” The clinic is just like that. If we don’t call you, we’re not giving you something you really need, something that’s precious to you. Call and say, “Hey, I need to get an appointment. I haven’t been seen in six months.”
Take care of yourself, just as you would something you really adore or love. You are like that little precious baby that you hold in your arms and that you love—that’s you.
Eat well. I’m not talking about some strict vegan diet—reasonable choices. Don’t go to excess.
Try to move around—simple things. I am anti-escalator. If I was king, there would be no escalators. You don’t need an escalator. If it’s over three or four floors, unless you have some disabilities, you should walk. Don’t stand when you can walk. Don’t sit when you can stand—simple things. We’re made to move. I always say to my patients, “You don’t want to be in a position where you can’t get out of a chair. You need to keep your legs strong, you need to be able to move.”
If you want to thrive and grow old gracefully—whether you’re HIV positive or HIV negative—make mindful choices.
Falk: That’s just a wonderful, wonderful prescription. Thank you, Dr. Wohl, for a really inspiring conversation.
Wohl: Thank you.
Falk: Thanks so much to our listeners for tuning in. In our next episode, we’ll be joined by Dr. Ada Adimora, where we’ll talk about risks and challenges facing minorities and women related to HIV prevention and treatment. If you enjoy this series, you can subscribe to the Chair’s Corner on iTunes or like the UNC Department of Medicine on FaceBook.
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