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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.

鈥�How do I make sure you understand how precious you are? And that you鈥檙e worth not polluting your body. Everything that you put into your body鈥攊s it good or bad in your fight against HIV? If it doesn鈥檛 pass the test, let鈥檚 try to help you pass on it.鈥�

鈥� 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鈥檚 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 . 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鈥檚 a really good question, and it鈥檚 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鈥檚 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鈥檚 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鈥檒l 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鈥檚 really interesting, as you said, I鈥檝e been very fascinated by this whole thing of aging with HIV, which is ironic, because back in the late 80鈥檚, early 90鈥檚, I got into HIV because I like taking care of young people. As I鈥檝e gotten older, my patients have gotten older with me.

Falk: Scary thought, isn鈥檛 it?

Wohl: We鈥檙e aging together鈥擨鈥檓 over fifty. I鈥檓 thinking about how do I prepare myself for my sixties, my seventies, my eighties and beyond, and I鈥檓 thinking about that with my patients. What鈥檚 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鈥檝e 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鈥檛 exercise. The drop in the bucket may be that they have this virus that鈥檚 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, 鈥淗ow do I get my patients to take better care of themselves?鈥�鈥攚hether they had HIV or not.

Falk: There is this thought process or a word choice called, 鈥�restoration of health.鈥� 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鈥攖hey have different histories. Some people get infected, it鈥檚 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鈥檚 really not been much in the way of damage. There鈥檚 others, more typically, we find who have had the virus for a long time and it鈥檚 been doing some damage鈥攖heir 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鈥檙e taking care of with HIV really are pretty healthy, they really are鈥攆rom their HIV. Now, if they鈥檙e smokers, if they have emphysema, if they have cardiovascular disease because of hypercholesterolemia, other types of things, that鈥檚 what we鈥檙e dealing with. More and more we鈥檙e dealing with those things鈥攕o, absolutely.

I talk to my patients about one thing and then another thing鈥攐ne 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鈥攜our hypertension, your cardiovascular disease health, your kidney health鈥攁ll those things start to rise to the top.

Falk: Modifiable risk factors.

Wohl: Mostly modifiable risk factors鈥攚e can鈥檛 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鈥檚 a little bit like being an athlete. I don鈥檛 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, 鈥淟et鈥檚 just drive this car until it dies. Let鈥檚 not do an oil change every 3,000 miles. Let鈥檚 not change the air filters.鈥� You can run a car into the ground. You can buy a new car, but you can鈥檛 buy new kidneys that works as well as your own kidneys, you can鈥檛 buy new coronary arteries, you can鈥檛 buy new lungs, you can鈥檛 buy a new brain.

Really, what we鈥檙e 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鈥擨 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鈥檚 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, 鈥淭his doesn鈥檛 belong here,鈥� and attack an emerging cancer cell, and prevent that cancer cell from replicating and causing cancer. If your immune system is weakened, let鈥檚 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鈥檚 other things, like lung cancer, which is because of the smoking, really, by and large, in our population鈥攖hat鈥檚 again, another preventable. Probably people with HIV for the same 鈥減ack years,鈥� 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鈥檛 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鈥檛 walk into many buildings in the state of North Carolina鈥攈ospitals, 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鈥攁nd it really is an epidemic鈥攊t came almost out of nowhere, it鈥檚 claimed millions of lives all around the planet, a real public health emergency, on the order of what we鈥檝e seen with Ebola. One of the things that attracted me was how intertwined it is with the social fabric. There鈥檚 no accident that many of the people who I see living with HIV, where there are still billboards advertising menthol cigarettes and malt liquor鈥攚here these populations are targeted for certain products. They are designed to be bad for your health. There鈥檚 no other design for cigarettes than to be smoked and they do nothing health-wise beneficial, but everything deleterious to your health. It鈥檚 an addiction, it鈥檚 wrapped up in society, it鈥檚 wrapped up in messaging, advertising counts, movies, television, it looks 鈥渃ool,鈥濃�攚hatever.

It鈥檚 very hard to take someone who has been smoking for decades and pull that away when it鈥檚 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, 鈥淪top smoking!鈥� and 鈥淕o to a gym.鈥� In reality, to walk in their shoes, you live in a double wide with an extension cord for power, you have a landlord who鈥檚 on your case, you have a partner who is not supportive, children who are in jail鈥攖here鈥檚 really so much going on that it鈥檚 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鈥檙e worth not polluting your body. Everything that you put into your body鈥攊s it good or bad in your fight against HIV? If it doesn鈥檛 pass the test, let鈥檚 try to help you pass on it.

Making better choices every day

Falk: You鈥檝e just talked about living situation, the environment with respect to advertisement, social pressures, the individual鈥檚 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鈥檝e 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鈥檛. 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鈥檝e also heard some of my patients, and others say, 鈥�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鈥攜ou have social workers, you have substance abuse counselors, mental health counselors, and they鈥檝e helped me.鈥�

Pretty much a lot of what we鈥檙e 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鈥檛 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鈥檛 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, 鈥淵ou鈥檙e precious. You鈥檙e worth saving. Let鈥檚 remember, look at your baby pictures鈥攍ook how great you were. You鈥檙e still great. Let鈥檚 work on that, let鈥檚 build on that. You should be around for your children, for your grandchildren. Let鈥檚 prepare you. Let鈥檚 grow old. I don鈥檛 care that there鈥檚 a virus latent somewhere in some cell鈥攜our virus is suppressed, you鈥檙e taking your medicines, let鈥檚 control the things we can control, but let鈥檚 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鈥檝e got to stay alive. I can help you with that, but you鈥檝e got to do the other part.鈥�

Falk: You鈥檝e talked about going to a gym or doing exercise. What kind of exercise are you suggesting to folks?

Wohl: I鈥檝e learned a lot about what to recommend to my patients by thinking about things for myself. There鈥檚 really good data that people from here and others who are much more expert on this know about, that indicate that you don鈥檛 have to sweat for an hour or an hour and a half five times a week. We鈥檙e 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鈥攕imple as thirty seconds going light, twenty seconds a little harder, and ten seconds going all out鈥攄o a few of those up to twenty minutes, three times a week. Some of the data that we鈥檙e seeing in the sports medicine literature shows that that鈥檚 just as effective and more fun than doing an hour three times a week.

I鈥檝e talked to many of my folks about things you can do even in your home鈥攜ou don鈥檛 have to join an expensive gym. If your neighborhood is dangerous, you don鈥檛 have to go on a walk or jog at night. We鈥檙e talking about things you can do at home, probably pretty affordably鈥攅ven 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鈥檓 traveling. You can do it too.

Let鈥檚 talk about food choices. You don鈥檛 have to buy an expensive book or sign up for an expensive program. We can make some reasonable food choices. There鈥檚 no recommended daily allowance for cookies and ice cream and candy鈥攖here鈥檚 a reason for that. They鈥檙e for special occasions. Special occasions aren鈥檛 days that end in the letter 鈥淵鈥濃�攊f it鈥檚 a birthday, not Wednesday. If it鈥檚 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鈥檚 hard to ignore the reality that you have to take a drug every single day and you could say, Yes, you鈥檙e taking your drug every single day but you鈥檙e healthy taking a drug every day. Nonetheless, that鈥檚 not easy to do. That鈥檚 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鈥攊t 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鈥檚 a chicken and egg in some ways in which people who have mental health issues鈥攚hich is, what we鈥檙e talking about is not a thin slice of pie in the general population鈥攎ost of us do. Many of those folks sometimes make decisions that aren鈥檛 good for them. Sometimes they seek out acceptance in love, connection鈥攕ome 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鈥檚 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鈥檛 fault anyone for that.

Others, after HIV was diagnosed, have suffered from stigma, either external stigma from how others treat them, or internalized. It鈥檚 very interesting that often people with HIV often times feel unclean or guilty. Recently, I鈥檝e done some work with people who have survived Ebola, and we asked them the same questions we ask HIV-infected people. People with Ebola鈥攖hese are survivors鈥攙ery, very few ever say, 鈥�I feel unclean,鈥� or 鈥�I deserve this,鈥� or 鈥淭his is a punishment from God.鈥� They feel the stigma, but it鈥檚 all external stigma. Others are not treating me well, but I feel fine about myself. You don鈥檛 see that with HIV, and that鈥檚, I think, because of our culture, because of some of the morality that鈥檚 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鈥擧IV positive, HIV negative鈥攚hatever 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鈥檚 really the poster child for this because of the way that people with HIV have been treated, even to this day.

It鈥檚 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鈥�鈥淥h, I could have gotten that, but I didn鈥檛. I must be different from that person.鈥� It鈥檚 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鈥攊n 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鈥檝e benefitted from science and medical science. This has changed a disease that was uniformly fatal鈥攊t filled hospital wards with dying, young people. They鈥檝e seen how that鈥檚 changed with science, with medicine. They know that there鈥檚 a lot of power in some of the things we do, that we can save lives and keep people healthy for decades. There鈥檚 no fake news about smoking鈥攚e know it鈥檚 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鈥攃olonoscopy. I know it鈥檚 not fun taking the prep, I know it鈥檚 not fun, but I walk the walk, I did it myself鈥攜ou can do it too. We can walk you through it and it can make a difference.

Falk: Presumably mammograms鈥�

Wohl: Mammograms, breast checks, pap smears for women鈥擨 think those are simple, they鈥檙e easy. More and more we talk a lot about smoking. There鈥檚 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鈥檚 pretty limited, there鈥檚 not a lot that we鈥檙e talking about, but it can have a pretty big impact, especially if you already have a higher risk for some of these things. It鈥檚 all part of the package of taking care of yourself. I know you鈥檝e got to take care of others, at some point you have to pivot and take care of yourselves. That鈥檚 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鈥攖heir virus is so low it鈥檚 like a needle in a haystack, just like Magic Johnson. That鈥檚 very common-that鈥檚 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, 鈥淕o, go, go.鈥� We don鈥檛 think about things in the moment. We are swayed each way by the forces that come across us鈥攐ur children, our parents, work, lack of work, money鈥攁ll these things, we鈥檙e 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鈥檙e 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鈥檚 not eat that today. It鈥檚 not going to be good for me. I鈥檓 trying to shed the pounds, my doctor told me my blood pressure and weight are totally correlated鈥攚hen 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, 鈥淲ell, no one called me.鈥� I say, 鈥淚f someone owed you a lot of money, would you not call them to say, 鈥楬ey, you owe me money. When are you going to pay me?鈥� The clinic is just like that. If we don鈥檛 call you, we鈥檙e not giving you something you really need, something that鈥檚 precious to you. Call and say, 鈥淗ey, I need to get an appointment. I haven鈥檛 been seen in six months.鈥�

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鈥攖hat鈥檚 you.

Eat well. I鈥檓 not talking about some strict vegan diet鈥攔easonable choices. Don鈥檛 go to excess.

Try to move around鈥攕imple things. I am anti-escalator. If I was king, there would be no escalators. You don鈥檛 need an escalator. If it鈥檚 over three or four floors, unless you have some disabilities, you should walk. Don鈥檛 stand when you can walk. Don鈥檛 sit when you can stand鈥攕imple things. We鈥檙e made to move. I always say to my patients, 鈥淵ou don鈥檛 want to be in a position where you can鈥檛 get out of a chair. You need to keep your legs strong, you need to be able to move.鈥�

If you want to thrive and grow old gracefully鈥攚hether you鈥檙e HIV positive or HIV negative鈥�make mindful choices.

Falk: That鈥檚 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鈥檒l be joined by Dr. Ada Adimora, where we鈥檒l talk about risks and challenges facing minorities and women related to HIV prevention and treatment. If you enjoy this series, you can or .

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