Guidance on aeromedical certification for HIV positive applicants

UK CAA Guidance on Aeromedical Certification for HIV Positive Applicants

Following diagnosis or on declaration of HIV infection, the pilot should be declared unfit or certificate issue deferred until reports have been obtained from the reviews described in (a) to (e) below.  These can be used to assess functional fitness and the prospective incapacitation risk.

 

(a)    HIV Specialist Review
An accredited specialist in Genitourinary/HIV medicine should undertake this review. The report submitted should include: 
   • a history of infection, 
   • current symptoms, 
   • stability of the condition, 
   • history of AIDS defining opportunistic infections or associated illnesses, 
   • CD4+ T cell counts and viral load measurements, 
   • Medication and start dates (describing side-effects if any), 
   • Results of co-infection testing (including Hep B/C, CMV, Toxoplasmosis and, in at risk cases, tuberculosis) 
   • FBC, U&Es, LFTs, fasting glucose and lipids.

 

(b) Neurology Review
Assessment should be undertaken to look for neurological sequelae either of HIV positivity or therapy by an HIV specialist or consultant neurologist.

 (c) Neuropsychological Review
The pilot should undertake a baseline neuropsychological assessment.  The tests should assess timed psychomotor tasks and memory tasks which require attention, learning and active monitoring or retrieval of information.  These baseline tests may be used as a future comparator.
 

(d) Psychiatry Review (if clinically indicated)
Assessment should be undertaken by a consultant psychiatrist with particular attention paid to the psychiatric symptoms and signs related to HIV seropositivity and or Anti Retroviral Therapy (ART).  There is evidence in the immediate post diagnosis phase of a higher risk of developing a depressive illness.  Some medication may also have side-effects such as mood changes and/or depressive illness.  An initial assessment of these conditions can be made by the treating HIV specialist with a further assessment by a psychiatrist if indicated.

           

(e) Cardiology Review (if clinically indicated)
Lipodystrophy and metabolic syndrome may arise as an interaction between HIV disease and or immune recovery and ART.  This may manifest as a dyslipidaemia with raised total cholesterol, low HDL cholesterol and raised Triglycerides or insulin resistance and hyperglycaemia.  Cardiology review is required in the presence of significant cardiac risk factors eg:
   • Hypertension
   • Family history
   • Smoking
   • Raised Lipids
   • Diabetes
   • Age
   • Evidence of Left Ventricular Hypertrophy


Aeromedical Certification Assessment
Pilots whose condition is stable, asymptomatic, with an acceptable CD4+ count and viral load (assessed using data from CASCADE Collaboration/EuroSIDA), with acceptable co-infection serology and therefore an acceptable risk of disease progression may be considered for a Class 1 with an Operational Multi-pilot Limitation.  These applicants should be referred to the AMS.  Class 2 applicants who are similarly well and have an acceptable risk of disease progression can be considered in consultation with the AMS.


Medication
As a guide the following are generally acceptable medications providing the applicant has no ongoing side-effects and their FBC, LFTs, lipids and fasting glucose are acceptable:

• Abacavir, Didanosine, Emtricitabine, Lamivudine, Tenofovir, Zidovudine, Atazabavur, Fosamprenavir, Lopinavir, Ritonavir, Nelfinavir, Saquinavir, Nevirapine, Efavirenz, Darunavir.
• Other medication will be considered on an individual basis assuming they are appropriately licensed and there is sufficient data on their safety available.

Certificate holders should be declared unfit whilst initiating, modifying or discontinuing ART and may be reassessed after a period of 2 months, although in some cases it may be at least 6 months before recertification, by means of a report from their treating HIV specialist, to include recent
CD4+ counts and viral loads and confirmation of an absence of ongoing side-effects from medication or symptoms related to HIV seropositivity.


Follow Up

3 MonthlyViral loads and CD4+ count (can be submitted as part of a 6 monthly report from HIV specialist to include neurology review, if applicant remains stable with no symptoms related to infection or treatment)

 

6 MonthlyReport with neurology review - see (b) above

If on ART, blood results should include LFTs and FBC

 

12 MonthlyIf on ART, blood results should include lipids and fasting glucose
Cognitive Function Assessments (can be Licence Proficiency Check or Medical Flight Test with a Flight Examiner where risk of disease progression is low).  Impaired performance will require further neuropsychological assessment to be compared with baseline testing and any deficits will require that the pilot is declared unfit.


Further co-infection testing will be required as clinically indicated, and those with positive tests need to be referred to the AMS in the case of Class 1 certificate holders or assessed in consultation with the AMS in the case of Class 2 certificate holders.

New symptoms or results outside acceptable limits are likely to lead to an unfit assessment and should be referred to/assessed in consultation with the AMS in accordance with the class of certificate held.