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included in the 1993 AIDS surveillance case definition are shown in Table 1.
Along with the four-level WHO clinical staging system for HIV disease, the Centers for Disease Control
and Prevention (CDC) in the United States have also devised a classification system for HIV disease
progression. This was linked with AIDS case definition (which was as initially intended for
epidemiological use as a surveillance tool) and allows only for a unidirectional progression through the
categories from asymptomatic (Category A) to having an AIDS indicator condition (Category C). It is
ICAO Preliminary Unedited Version — November 2009 III-13-4
recognized now that some people can make a significant recovery from AIDS-defining illnesses and so
the development of these illnesses is not necessarily an indicator of long-term unfitness for aeromedical
certification. The WHO has recently modified the clinical staging system to recognize that antiretroviral
therapy can reverse disease progression and that subsequent HIV-related events and clinical staging
events can be used to guide decision making on when to switch to second-line ART.
Table 1. — AIDS-defining illnesses
Candidiasis of oesophagus, bronchi, trachea or lungs
Cervical cancer, invasive
Coccidioidomycosis, disseminated or extrapulmonary
Cryptococcosis, extrapulmonary
Cryptosporidiosis, chronic intestinal (greater than 1 month duration)
Cytomegalovirus disease (other than liver, spleen or nodes)
Cytomegalovirus retinitis (with loss of vision)
Encephalopathy (Dementia), HIV related
Herpes simplex: chronic ulcer(s) (greater than 1 month duration); or bronchitis, pneumonitis or
oesophagitis
Histoplasmosis, disseminated or extrapulmonary
Isosporiasis, chronic intestinal (greater than 1 month duration)
Kaposi’s sarcoma
Lymphoma, Burkitt’s (or equivalent term)
Lymphoma, immunoblastic (or equivalent term)
Lymphoma, primary, of brain
Mycobacterium avium complex or M. kansasii, disseminated or extrapulmonary
Mycobacterium tuberculosis, any site (pulmonary or extrapulmonary)
Mycobacterium, other species or unidentified species, disseminated or extrapulmonary
Pneumocystis carinii pneumonia
Pneumonia, recurrent
Progressive multifocal leukoencephalopathy
Salmonella septicaemia, recurrent
Toxoplasmosis of brain
Wasting syndrome due to HIV
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EVALUATION OF HIV AND DISEASE THAT MIGHT
GIVE RISE TO INCAPACITATING SYMPTOMS
Current health
General examination
Besides specific screening for progression of the disease and central nervous system (CNS) involvement
(described separately), HIV-positive applicants should be thoroughly screened to exclude any
disqualifying condition. HIV and/or antiretroviral medication may also affect heart, respiratory system,
liver, and metabolic functions and so the assessment should include haematological, cardiovascular, and
pulmonary evaluation, liver and kidney function, and metabolic tests. Opportunistic infections generally
occur with advanced or severe disease, and the physician should always pay attention to signs and
symptoms of Stage 3 or Stage 4 disease, such as oral or oesophageal candida, pneumocystis carinii
pneumonia, toxoplasmosis, cytomegaly, progressive multifocal leukoencephalopathy, tuberculosis, and
fungal infections. This especially applies for candida infections, which can be seen early in the course of
HIV infection, heralding the onset of clinical immunodeficiency.
The following specific tests are recommended:
a) Immunological status
Two laboratory tests are routinely used as surrogate markers of HIV disease progression to
determine indications for treatment and to monitor the efficacy of therapy. These are the CD4+ T
cell count and plasma HIV RNA (or viral load).
CD4+ T cell count.— The extent of immune system damage is indicated by the CD4+T cell
count, which is a measure for disease status and can enhance the assessment of the risk of
developing opportunistic infections and other sequelae of HIV infection when used together with
viral load determinations. CD4+ T cell counts are subject to substantial variability due to both
biological and laboratory methodologies and can vary up to 30 per cent on repeated measures in
the absence of a change in clinical status. Therefore it is important to monitor trends over time
and to repeat a test to confirm a value rather than take a decision on one specific determination.
Sudden changes in the count need to be confirmed by a second determination. The number of
CD4+ cells varies diurnally, being higher in the morning, increasing slightly with smoking and
decreasing acutely with stress and with intercurrent infection. A significant change between two
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Manual of Civil Aviation Medicine 2(92)
