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officer in discussion with the training captain. Tasks such as recall of six digits when changing
frequencies can be required of the affected pilot, delegation to the second pilot should not be
permitted, and conditional clearances (“after waypoint X, descend to flight level 120”) can test
longer term memory.
It is vital to involve the operator’s training department when assessing a pilot who is returning to
line flying after the diagnosis of HIV infection. Good communications should be established and
the airline’s medical adviser should ensure that he or she is very familiar with the simulator
environment and with the tasks required of pilots in routine checks. It is only if the medical
adviser is knowledgeable of simulator tests, and mutual trust is established between the medical
adviser and training department that the most benefit can be obtained from simulator checks.
Any performance that is regarded as significantly below average for that individual pilot should
be seen as a cause for concern, and should require further consideration.
g) Psychiatric evaluation
Although it is assumed to be uncommon that psychiatric symptoms are the first manifestations of
CNS involvement, the psychiatric examination should address the potentially serious
complications of infection with HIV. There is evidence that the average HIV infected person
experiences at least transient difficulties following notification of HIV seropositivity. A study (in
the pre-HAART era) among HIV-infected US military personnel in 1993 showed that 17 per cent
of the subjects had experienced serious suicidal ideation or behaviours after notification of
seropositivity. Ten percent had a major mood disorder and five per cent a psychoactive substance
disorder. The knowledge of being seropositive per se may be a reason for (temporary)
disqualification. The examiner should focus on signs of depression, other mood disorders and use
of psychoactive substance. A similar study of military personnel does not appear to have been
undertaken since the introduction of HAART, but there is evidence of a lower prevalence of
mood disorders amongst those attending HIV outpatient clinics compared to the pre-HAART era.
Psychiatric symptoms may also be associated with medication, e.g. efavirenz, and evaluation
should be made after commencing this treatment and before considering a return to certification.
Consideration should be given to psychiatric evaluation, particularly at the first assessment after
seroconversion, with subsequent review associated with clinical indication and the introduction of
efavirenz in any HAART regimen.
h) Cardiological evaluation
ICAO Preliminary Unedited Version — November 2009 III-13-9
Lipodystrophy and a metabolic syndrome may arise as an interaction between HIV disease and/or
immune recovery and antiretroviral medication. This may manifest as dyslipidaemia with raised
total cholesterol, low HDL cholesterol and raised triglycerides or insulin resistance with
hyperglycaemia. Cardiological review may be required in the presence of these or other
significant cardiac risk factors, e.g. hypertension, smoking, raised lipids, diabetes, age and
evidence of left ventricular hypertrophy. Some antiretroviral medicines are more likely to cause
these side effects, and expert consultation with a view to changing ART regimen is indicated.
i) Medication
The clinical effectiveness and tolerability of antiretroviral therapy has improved markedly over
the last few years. Most regimens are patient-friendly with low pill burden and few dietary
restrictions. Since 1996, there have been dramatic falls in the incidence of new AIDS cases and
AIDS associated deaths in the developed world. Many (highly active) antiretroviral therapy
regimens (HAART or ART) result in near-complete suppression of HIV-1 replication. For HIV-2
the picture is not quite so clear, as it is far less prevalent and there is limited clinical experience.
Both the nucleoside reverse transcriptase inhibitors (NRTI) and protease inhibitors (PI) classes of
antiretroviral medicines are active but neither efavirenz nor nevirapine, which are non-nucleoside
reverse transcriptase inhibitors (NNRTI), are active against HIV-2.
HAART does not cure HIV infection, so once started life-long therapy is always necessary.
Although complete eradication of the infection cannot be achieved, sustained inhibition of viral
replication results in partial and often substantial reconstitution of the immune system in most
patients, greatly reducing the risk of clinical disease progression.
Combination ART usually starts with 2 NRTI together with a NNRTI as the first-line therapy.
The PI class is usually reserved for second-line therapy. Some medicines are so similar or have
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Manual of Civil Aviation Medicine 2(95)
