HIV


White patches in the mouth, sometimes painful, often painless, are most commonly symptoms of thrush, and less commonly symptoms of oral hairy leukoplakia.
Thrush-Thrush is a common infection of the mouth caused by the fungus Candida albicans. Candida albicans is found in the mouths of most people; thrush occurs only when the fungus begins growing out of control. Symptoms include white or grayish-white patches that look a little like cottage cheese along the gums, along the inside of the cheeks, or on the tongue. Thrush can be unnoticeable, or it can cause pain severe enough to interfere with chewing or swallowing. Thrush does not cause fever, malaise, fatigue, tooth loss, or headache. Since most people have the fungus in their mouths, thrush is not considered contagious.
What appear to be patches of thrush can also simply be food particles in the mouth. The distinction is easily made by rinsing the mouth to remove food particles. Thrush cannot be removed without direct scraping, and scraping will leave an inflamed spot where the white patch was. A physician can usually verify the diagnosis by simply inspecting the mouth. Microscopic examination of the patch to identify the fungus can be done but is usually not necessary.
Thrush can result from taking antibiotics, which inhibit the bacteria in the mouth that seem to control the growth of Candida albicans. People with HIV infection are therefore more prone to thrush when taking trimethoprim-sulfamethoxazole, tetracycline, ampicillin, amoxicillin, erythromycin, ciprofloxacin, or other antibiotics.
Thrush is commonly viewed more as a nuisance than as a serious problem. Symptoms are often trivial, and even when severe, they are easily corrected with medication. Thrush becomes more serious when it extends to the back of the throat to the esophagus: the pain from
swallowing might cause people to stop eating, and the treatment given may be somewhat different than for thrush that is restricted to the mouth. The diagnosis of thrush in the esophagus can be made only with an endoscope, which is a tube put through the mouth by a medical specialist (gastroenterologist), or with an x-ray called a barium swallow. In many cases, these diagnostic procedures are unnecessary: the existence of thrush in the mouth, accompanied by painful swallowing, is enough to make the diagnosis.
About 80 to 90 percent of people with HIV infection eventually develop thrush; it is often the first condition indicating that the immune system is weakening. The CD4 count is usually around 100 to 400. Thrush is not an AIDS-defining diagnosis, but it does imply that AIDS is likely to occur within two or three years, unless treatment slows the progression of HIV infection. Thrush occurring in the esophagus, however, is an AIDS-defining diagnosis.
Common treatments for thrush include gargling with and then swallowing nystatin solution; sucking clotrimazole troches; or taking such pills as ketoconazole (Nizoral) or fluconazole (Diflucan). All of these are prescription drugs. If any of the drugs fails, another will usually work. Thrush is generally controlled after one or two weeks of treatment.
Occasionally people do not do well with any of these treatments, either because the diagnosis was wrong to begin with or because the infection has extended to the esophagus. In the latter cases, treatment with such drugs as amphotericin B, given intravenously, may be required for a few days.
In people with HIV infection, thrush tends to recur once treatment is discontinued. As a result, it is common practice to give these drugs for a long time, initially to control the infection and then to prevent its recurrence. Or people keep on hand the drugs prescribed for their original infection and use them intermittently whenever symptoms recur.
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When you feel bad, go ahead and feel that way. Tell yourself, as Dean does, “I’m just tired of this. I don’t see how I can do it any more.” Cry, stare into space, refuse to talk, stay in bed, write your terrible feelings in a private journal—go off by yourself and do whatever expresses the bad feelings. “I don’t believe in this crap of, ‘You’ve got to be happy all the time,’ ” says Steven. “I’m not taped together as well as I thought I was, or more likely, the tape was old. Anyway, sometimes I fall apart and just feel awful.”
In short, give your feelings their due. This is not giving in. It is acknowledging the reality and size of the problems you face. Somehow, such acknowledgment is easier than trying to control how you feel, or going from crisis to crisis and never feeling anything. These feelings, once acknowledged, don’t last as long as you might think. They seem to wear themselves out and disappear. “After I’ve been feeling hopeless for a while,” says Dean, “the feeling lightens up, and I feel that I’ve really got a long road ahead of me. I’ve seen too many people give up. I feel like I’d just like to keep going.”
The feelings will certainly come back again—Steven says he now knows when he is likely to feel bad and sets aside time for the feelings: “I plan for falling apart,” he says. But when the feelings do come back, you will have them in better perspective. That is, you will know that the feelings are both real and temporary. For good reasons, you feel bad; and after a while, for reasons just as good, you will feel better.
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HIV: ON LIVING-TAKING CONTROL: GIVE YOUR FEELINGS THEIR DUEWhen you feel bad, go ahead and feel that way. Tell yourself, as Dean does, “I’m just tired of this. I don’t see how I can do it any more.” Cry, stare into space, refuse to talk, stay in bed, write your terrible feelings in a private journal—go off by yourself and do whatever expresses the bad feelings. “I don’t believe in this crap of, ‘You’ve got to be happy all the time,’ ” says Steven. “I’m not taped together as well as I thought I was, or more likely, the tape was old. Anyway, sometimes I fall apart and just feel awful.”     In short, give your feelings their due. This is not giving in. It is acknowledging the reality and size of the problems you face. Somehow, such acknowledgment is easier than trying to control how you feel, or going from crisis to crisis and never feeling anything. These feelings, once acknowledged, don’t last as long as you might think. They seem to wear themselves out and disappear. “After I’ve been feeling hopeless for a while,” says Dean, “the feeling lightens up, and I feel that I’ve really got a long road ahead of me. I’ve seen too many people give up. I feel like I’d just like to keep going.”     The feelings will certainly come back again—Steven says he now knows when he is likely to feel bad and sets aside time for the feelings: “I plan for falling apart,” he says. But when the feelings do come back, you will have them in better perspective. That is, you will know that the feelings are both real and temporary. For good reasons, you feel bad; and after a while, for reasons just as good, you will feel better.*239\191\2*

Once, when Dean Lombard was in the hospital, he “roomed for a while with a man who was in the advanced stages of AIDS. “I was glad to get out of that room,” Dean said. “As long as I was there, I needed to confront the possibility that what happened to him would happen to me. But confronting that possibility seemed necessary, to deal with this disease as positively as I am.”
Confronting the possibilities means, for Dean and others like him, understanding and admitting that the fact of HIV infection cannot be annulled. Steven said, “I have to deal with this whether I want to or not.” It is now a part of life. So are the possibilities of fatigue, disability, dependency, illness, clinic appointments, and hospitalizations. And so are the emotional reactions to all this. “HIV makes me face things I didn’t think I’d have to face,” Helen said. Confronting the facts and possibilities and reactions is often the only way through them.
Confronting everything all at once, however, is overwhelming and unnecessary. Face what you are ready to face, and only when you are ready. When you are tired of thinking or feeling, stop and rest. Do not push yourself because you or someone else thinks you ought to be facing things. Face a little at a time.
In fact, confronting the facts means facing not only sickness but also health. If, within some amount of time, fatigue, death, or dependency are possibilities, so are strength, life, and confidence. People remind themselves that no one knows with certainty how the disease progresses in every individual.
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HIV: ON LIVING-TAKING CONTROL: CONFRONT THE POSSIBILITIES A LITTLE AT A TIMEOnce, when Dean Lombard was in the hospital, he “roomed for a while with a man who was in the advanced stages of AIDS. “I was glad to get out of that room,” Dean said. “As long as I was there, I needed to confront the possibility that what happened to him would happen to me. But confronting that possibility seemed necessary, to deal with this disease as positively as I am.”     Confronting the possibilities means, for Dean and others like him, understanding and admitting that the fact of HIV infection cannot be annulled. Steven said, “I have to deal with this whether I want to or not.” It is now a part of life. So are the possibilities of fatigue, disability, dependency, illness, clinic appointments, and hospitalizations. And so are the emotional reactions to all this. “HIV makes me face things I didn’t think I’d have to face,” Helen said. Confronting the facts and possibilities and reactions is often the only way through them.     Confronting everything all at once, however, is overwhelming and unnecessary. Face what you are ready to face, and only when you are ready. When you are tired of thinking or feeling, stop and rest. Do not push yourself because you or someone else thinks you ought to be facing things. Face a little at a time.     In fact, confronting the facts means facing not only sickness but also health. If, within some amount of time, fatigue, death, or dependency are possibilities, so are strength, life, and confidence. People remind themselves that no one knows with certainty how the disease progresses in every individual.*244\191\2*