The Facts About HIV and Thrush

Fungal Infection Can Advance to an AIDS-Defining Disease

Candidiasis is a fungal infection caused by strains of Candida, a type of yeast. Commonly called thrush, the infection is characterized by thick, white patches on the tongue, as well as other parts of the mouth and throat. A sore throat and difficulty in swallowing can also accompany.

When candidiasis presents in the vagina, it is typically referred to as a yeast infection and is characterized by a thick, cottage cheese-like discharge from the vagina. Vaginal burning, itching, and soreness are commonly noted during outbreaks.

While less commonly seen, Candida infections can also occur on the skin; under the fingernails or toenails; on the rectum, anus, or penis; or within the esophagus or pharynx.

Candida plaque can be scraped off from the tongue, walls of the mouth, or walls of the vagina, revealing a sore, red, denuded patch underneath. The plaque is entirely odorless.

Candidiasis is not an uncommon condition and generally manifests when a person's immune response is low. The Candida yeast itself is present in most human beings, within the natural flora of the mouth and digestive tract, as well as on the skin. It is only when changes to these systems occur that Candida can actively thrive, usually manifesting with superficial infection.

However, when the immune system is severely compromised, as can happen with untreated HIV, Candida can become invasive and spread throughout the body, causing severe illness and possibly death.

Candidiasis in HIV Infection

Because an active HIV infection depletes an individual's immune response, candidiasis is commonly noted in people living with the virus. While it can present superficially even in those on ​antiretroviral therapy (ART), it is most frequently noted in people with severely compromised immune systems and often serves as a warning sign for the development of more serious HIV-related illnesses.

When an HIV infection is left untreated and a person's CD4 count dips beneath 200 cells/mL (one of the official classifications of AIDS), the risk of invasive candidiasis is profoundly increased. As a result, candidiasis of the esophagus, bronchi, trachea or lungs (but not the mouth) is today classified as an AIDS-defining condition.

The risk of candidiasis is not only linked to a person's immune status but to the level of viral activity as measured by the HIV viral load. Therefore, even in person's with more advanced HIV infection, the implementation of ART can provide benefits by way of disease avoidance—and not only of Candida infections but other opportunistic infections, as well.


Candidiasis can present in any number of ways: on mucosal tissues, on the skin, or invasively throughout the entire body. They are typically classified as follows:

Mucosal candidiasis

  • Oral candidiasis (oral thrush, oropharyngeal candidiasis)
  • Candidal vulvovaginitis (vaginal yeast infection)
  • Esophageal candidiasis (candidiasis of the esophagus)
  • Candidal balanitis (candidiasis of the penis, occurring almost exclusively in uncircumcised males)

Cutaneous (skin) candidiasis

Invasive candidiasis

  • Systemic candidiasis, involving a single organ
  • Disseminated candidiasis, involving multiple organs

Diagnosis of a Candida infection is typically done by microscopic examination and/or the culturing of yeast spores.

Treatment and Prevention

The most important first step to either treating or preventing candidiasis in people living with HIV is to reconstitute the person's immune function by ​starting ART. Treating the Candida infection alone does little to prevent recurrences should the immune response not be adequately restored.

The Candida infection itself is most commonly treated with antifungal drugs such as fluconazole, topical clotrimazole, topical nystatin, and topical ketoconazole. Oral candidiasis usually responds well to topical treatments, although oral drugs can also be prescribed. (For people living with HIV, oral medications are recommended, especially if they have AIDS.) Candidal esophagitis can be treated either orally or intravenously, depending on severity, often with the use of amphotericin B in more severe cases.

A newer class of antifungal called echinocandins are also being employed in the treatment of advanced candidiasis. Generally speaking, echinocandins offer lower toxicity and fewer drug-drug interactions, although they are more often prescribed to patients with intolerance to other antifungal drugs. All three types (anidulafungin, caspofungin, micafungin) are administered intravenously.

Systemic and disseminated candidiasis affecting the bones, central nervous system, eyes, kidneys, liver, muscles, or spleen are typically treated more aggressively, with oral and/or intravenous administration of antifungal drugs. Amphoterin B is another possible option.

Read more about causes and risk factors of thrush.

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  1. NIH. HIV-Related Candidiasis. AIDSInfo; published April 1, 1995; updated May 24, 2016.

  2. The Centers for Disease Control and Prevention. Candida infections of the mouth, throat, and esophagus.

  3. Buchacz K, Lau B, Jing Y, et al. Incidence of AIDS-Defining Opportunistic Infections in a Multicohort Analysis of HIV-infected Persons in the United States and Canada, 2000-2010. J Infect Dis. 2016;214(6):862-72. doi:10.1093/infdis/jiw085

  4. National Institutes of Health (NIH). Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents. AIDSInfo; Bethesda, Maryland.

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