Lessons on HIV and AIDS: Oral thrush

Rarely, oral thrush in adults can be an early sign of another con­di­tion or ill­ness, such as HIV, can­cer, dia­betes or anaemia.

How­ever, if you have an oral thrush infec­tion, it doesn’t neces­sar­ily mean you have HIV, AIDS or any other con­di­tion. If your infec­tion is related to another con­di­tion, you’ll prob­ably have other more ser­i­ous symp­toms as well. So it’s import­ant to see your doctor.

When your doc­tor assesses your symp­toms, they may ask you about other infec­tions such as vaginal thrush or bal­an­itis. Bal­an­itis is inflam­ma­tion of the head of the penis (the glans), caused by a bac­terial or fungal infec­tion. It can be a sign of thrush.

Your doc­tor will also assess any other symp­toms you have, to check for any other con­di­tion or illness.

If you have oral thrush, your doc­tor will offer you treat­ment. If you’ve been at risk of HIV infec­tion but haven’t been dia­gnosed, your doc­tor may also offer you an HIV test.

If you’ve already been dia­gnosed with HIV, you should be under the care of a spe­cial­ist who will keep an eye on your immune status and arrange any treat­ment you need, such as anti­viral medi­cine to help your immune sys­tem. These spe­cial­ists are usu­ally based in HIV or GUM (genito-urinary medi­cine) clin­ics, although doc­tors are also involved in caring for people with HIV. We recom­mend you get your copy of Nutri­tion and HIV: A New Model for Treat­ment by Mary Romeyn M.D.

HIV (human immun­ode­fi­ciency virus) can develop into AIDS (acquired immun­ode­fi­ciency syn­drome). If you have AIDS, your immune sys­tem is severely weakened by HIV. You will there­fore find it harder to fight off ill­ness and infection.

Oral thrush is an infec­tion in your mouth. It’s one type of a fungal infec­tion called oral can­dida. The mem­branes in your mouth (oral mucosa) become infec­ted with a fungus, usu­ally Can­dida albic­ans. (Oral can­dida is also known as oral candidiasis.)

There are four com­mon types of oral can­dida; these types have dif­fer­ent signs. The four com­mon types are:

1. oral thrush — also known as pseudomem­bran­ous oral candidiasis,
2. acute atrophic oral can­didi­asis — also known as acute eryth­em­at­ous oral candidiasis,
3. den­ture sto­matitis — also known as chronic eryth­em­at­ous oral can­didi­asis and chronic atrophic oral can­didi­asis, and
4. chronic plaque-like oral can­didi­asis — also known as chronic hyper­plastic oral candidiasis.

These infec­tions are most com­monly found in babies, people who wear den­tures and eld­erly people. They are uncom­mon in other people, and can be a sign of another con­di­tion or ill­ness that’s not been diagnosed.

Oral can­dida infec­tions affect up to 48% of people with HIV and over 90% of people with AIDS.

If you have HIV and leave oral can­dida untreated, it can become a ser­i­ous prob­lem, last­ing for months or years.

As well as oral thrush, people with HIV can develop acute atrophic oral can­didi­asis, another type of oral can­dida (see above). Some­times this infec­tion can develop after you have oral thrush.

People with AIDS can also develop thrush infec­tions deeper within their bod­ies, for example, in their wind­pipe, throat or lungs.

How will oral thrush be treated if I have HIV or AIDS?

If you have HIV or AIDS, you will have a lowered immune sys­tem. This means that your body is less able to fight off ill­nesses and infec­tions. HIV attacks the infection-fighting cells in your immune sys­tem which, over time, weak­ens and becomes unable to defend your body against bac­teria, vir­uses and germs.

Oral thrush is one type of a fungal infec­tion called oral can­dida. If you have a lowered immune sys­tem, anti­fungal medi­cine is more effect­ive for treat­ing oral thrush than treat­ment applied to your skin (top­ical treatment).

If you’ve already been dia­gnosed with HIV or AIDS, you should be under the care of a spe­cial­ist who will keep an eye on your immune status. Your spe­cial­ist will also arrange any treat­ment you need, such as anti­viral medi­cine to help your immune sys­tem. These spe­cial­ists are usu­ally based in HIV or GUM (genito-urinary medi­cine) clin­ics, although doc­tors are also involved in caring for people with HIV.

So, if you’ve been dia­gnosed with HIV or AIDS and have oral thrush, your doc­tor or spe­cial­ist will pre­scribe an anti­fungal medi­cine for you. If you’re under your doctor’s care, in some cases, they may seek spe­cial­ist advice before recom­mend­ing treat­ment or they may refer you to a specialist.

What medi­cine will be prescribed?

The anti­fungal medi­cines used to treat oral thrush include fluc­onazole and itraconazole. (Brand names for fluc­onazole include Diflu­can. Some medi­cines with this brand name are used to treat other forms of thrush, such as vaginal thrush in women or bal­an­itis in men.)

If you have HIV, your doc­tor will usu­ally pre­scribe fluc­onazole because it’s less likely than itrconazole to cause side effects. It’s also less likely to inter­act with other medi­cines that you may be tak­ing. Your doc­tor will prob­ably pre­scribe liquid medi­cine (sus­pen­sion), although cap­sules are also avail­able. We recom­mend you get your copy of Nutri­tion and HIV: A New Model for Treat­ment by Mary Romeyn M.D.

If you’ve become res­ist­ant to fluc­onazole, your doc­tor will seek spe­cial­ist advice before pre­scrib­ing itraconazole. Becom­ing res­ist­ant means that a medi­cine no longer works effect­ively, because the bac­teria or vir­uses caus­ing an infec­tion have become immune to the medicine.

Your doc­tor or spe­cial­ist will only pre­scribe other anti­fungal medi­cines if you’ve already shown ser­i­ous res­ist­ance to fluc­onazole and itraconazole.

Your doc­tor or spe­cial­ist may also con­sider whether you need anti­viral medi­cines to help your immune sys­tem, as well as treat­ing your oral thrush.

How do I take fluconazole?

You will need to take fluc­onazole for 7–14 days, depend­ing on how you respond to the treat­ment. Your doc­tor will tell you what dose to take and for how long. After around seven days, your doc­tor will review how you’re respond­ing to the treatment.

You can take fluc­onazole as liquid medi­cine (sus­pen­sion) or cap­sules. Liquid medi­cine is usu­ally best because you can swirl it round your mouth before you swal­low it. Remember:

• If you wear den­tures, take them out before you take your medicine.
• Don’t rinse your mouth out after you swal­low your medicine.
• Don’t eat or drink for 30 minutes after tak­ing your medicine.

If your kid­neys aren’t work­ing prop­erly (renal impair­ment), your doc­tor may need to adjust the dose of fluc­onazole that you take.

The most com­mon side effects of fluc­onazole are:

• nausea,
• diarrhoea,
• stom­ach pains,
• flat­u­lence,
• a head­ache, or
• a rash.

Most people don’t have any side effects.

Some medi­cines can inter­act with fluc­onazole which means that your treat­ment might be less effect­ive. You should tell your doc­tor if you’re taking:

• war­farin,
• medi­cines that con­trol dia­betes (sulphonylureas),
• medi­cines that lower the response of your immune sys­tem (immun­osup­press­ants), or
• nevirapine.

Will I be referred to a specialist?

If you have HIV or AIDS and your infec­tion has not cleared up when your treat­ment has fin­ished, you need to see a doc­tor again. Your doc­tor may pre­scribe fur­ther treat­ment or refer you to a specialist.

Your doc­tor may also seek spe­cial­ist advice or refer you to a spe­cial­ist if you have HIV or AIDS and:

• you’re no longer see­ing a spe­cial­ist or have not been see­ing one regularly,
• you keep get­ting oral thrush or other oral can­dida infections,
• your doc­tor knows you’re res­ist­ant to fluconazole,
• you’re already tak­ing another anti­fungal medi­cine to pre­vent infec­tion — you may have become res­ist­ant to it, or
• you’re under 18.

Rein­fec­tion rates are high in people whose immune sys­tems are severely lowered. Repeated infec­tions affect 30–50% of people, usu­ally return­ing within 14 days of stop­ping treatment.