Guidance for medical examiners when assessing a patient for either a general topic or condition – Human Immunodeficiency Virus (HIV).
Effect of aviation on condition
- Access issues - specialist treatment and monitoring
Effect of condition on aviation
- Overt incapacitation:
- Risk of secondary CVD
- sudden death
- distracting chest pain
- Risk of secondary CVD
- Subtle incapacitation:
- Neurocognitive impairment
- Incapacitation secondary to AIDS defining illnesses.
Effect of treatment on aviation
HIV medications have significant side effects many of which are aero-medically significant e.g. gastrointestinal intolerability, medicine hyper-sensitivity, Stevens-Johnston syndrome, cytochrome P450 interactions, CNS effects, myopathy, neuropathy, bone marrow depression, nausea, diarrhoea, fatigue, headache, hepatitis, hepatic steatosis, lactic acidosis, pancreatitis, dilated cardiomyopathy, renal colic, nephrolithiasis, haematuria, abdominal pain, metabolic syndrome and lipodystrophy.
Approach to medical certification
Based on the condition
- Early diagnosis and treatment
- Condition stability
Based on treatment
- Acceptable, stable treatment without significant side effects
- Good response to treatment
- Absence of symptoms
- Stability of laboratory results
Risk assessment protocol - information required
Following an initial diagnosis of HIV sero-positivity:
a) HIV specialist review
- History of infection - please indicate if:
- infected via IV drug use
- infected via any route other than IV drug use
- Current and previous symptoms
- Stability of condition
- History of opportunistic infections or associated illnesses
- History of CD4+ T cell counts
- History of viral load measurements
- Medication history (including 'over the counter' medications and alternative medicines)
- Report concerning side effects of medications
- Laboratory testing to include:
- Hepatitis B and C, cytomegalovirus, toxoplasma, tuberculosis
- Full blood count, urea, creatinine and electrolytes, liver function tests, fasting glucose, lipids
b) Neurological review - can be undertaken by HIV specialist, or neurologist
- Assessment for neurological sequelae. Include assessment of primitive reflexes (because of their association with cognitive decline)
c) Neuropsychological review
- Baseline neuropsychological assessment
- Tests should include timed psychomotor tasks and memory tasks requiring attention, learning, active monitoring and retrieval of information
d) Psychiatric review (only if clinically indicated)
- Assessment for psychiatric sequelae related to HIV seropositivity and antiretroviral treatment
e) Cardiological review (only if indicated) Cardiological review is recommended if the following exist:
- Lipodystrophy or metabolic syndrome (dyslipidaemia — raised total cholesterol, low high density lipoprotein cholesterol and raised triglycerides or insulin resistance with hyperglycaemia)
- Cardiac risk factors are present, including:
- hypertension, evidence of left ventricular hypertrophy, smoking, raised lipids, diabetes, age over 40 years.
Regular follow up is required to monitor treatment efficacy, ART adherence, toxic side effects of medication or evidence of resistance.
Surveillance is to include:
- 3-monthly CD4 and viral load measurements
- 6-monthly neurological assessment (by HIV specialist or neurologist including consideration of the need for psychiatric evaluation)
- if taking ART: 6-monthly LFTs, FBC, lipids and fasting glucose
- annual cognitive function assessment
- result of annual flight test or controller sim check
- repeat neuropsychiatric assessment compared with baseline testing if there are any concerns about cognitive impairment
- further co-infection testing should be undertaken where clinically indicated and those with new positive tests will require specific review by CASA.
- If an applicant develops new symptoms and/or fails to achieve the nominal levels listed above they must be declared temporarily unfit with notification to CASA.
- Initial notification to CASA and grounding required on diagnosis
- Clearance by CASA required before exercising privileges
- Audit will be required with review at 12 months
- Class 1 may require multi-crew restriction
- An assessment will be made based on the requested information and the risk of clinical progression in the following 12 months
- During the initiation of therapy and when adjustments are made to the regimen used, applicants should be assessed as temporarily unfit. Further assessment should then be made for side effects that are likely to be disabling, and after treatment is stable for a period of months, before any decision on certification is made
- abacavir, didanosine, emtricitabine, lamivudine, tenofovir, zidovudine, atazanavir, fosamprenavir, lopinavir/ ritonavir, nelfinavir, saquinavir, nevirapine and efavirenz
- enfuvirtide, zalcitabine, indinavir and stavudine
Pilot and controller information
- HIV is an aero-medically significant medical condition. Pilots and controllers who have been diagnosed with HIV are required to ground themselves and notify this condition to their DAME and CASA AVMED
- Treatments are associated with significant side effects. You should also ground yourself if there is a change in your treatment and report to your DAME for review
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The clinical practice guidelines is provided by way of guidance only and subject to the clinical practice guidelines disclaimer.