Manual of Civil Aviation Medicine 2(99)

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months, and that clinical condition, including general, neurological and, if indicated, psychiatric
examinations should be carried out every six months. A neuropsychological evaluation may be
considered every twelve months. Regular evaluation of cockpit performance may be considered in lieu of
this or to enhance assessment in asymptomatic, stable applicants with very low risk of progression.
Further co-infection testing will be required where clinically indicated and those with new positive tests
may require specialist evaluation prior to further certificatory assessment.
Clearly not every individual with HIV infection will be fit for certification. However, some applicants
may be fit and remain so for a prolonged period, and it is to assist in the identification of such individuals
that the information in this chapter is written. The assessment of HIV-positive applicants requires
specialist expertise and careful consideration of all the points mentioned in this chapter and applicants
need to be advised at the outset that continued certification will require ongoing medical scrutiny and
prolonged follow-up.
ASYMPTOMATIC HIV POSITIVE CASES
AND TRAVEL VACCINATION
Vaccinations can temporarily increase the viral load for approximately four weeks. As a rule,
immune-compromised people should not receive vaccines based on live-attenuated organisms, such as
measles and yellow fever. However, risk is not increased in true asymptomatic and immuno-competent
cases, confirmed by a sufficient CD4+ T cell level (> 350/ μL), and these cases will have a normal
response of the immunological system to these vaccinations.
— — — — — — — —

ICAO Preliminary Unedited Version — November 2009 III-13A-1
APPENDIX
SUGGESTED PROTOCOL FOR ASSESSMENT OF HIV DISEASE
(based on recommendations from a Contracting State)
1. Following an initial diagnosis of HIV seropositivity
Assess temporarily unfit, pending submission of reports.
a) HIV specialist review
• History of infection
• 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 & 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);
ICAO Preliminary Unedited Version — November 2009 III-13A-2
• Cardiac risk factors are present, including:
– hypertension, evidence of left ventricular hypertrophy, smoking, raised lipids,
diabetes, age over 40 years.
2. Aeromedical Certificatory Assessment
Applicants whose condition is stable, asymptomatic, with an acceptable CD4+ count, viral load
and acceptable co-infection serology can be considered for a Class 1 or 2 medical assessment if their risk
of disease progression is sufficiently low (determined using data from the CASCADE Collaboration1 for
those not on ART, and from the EuroSIDA Study Group2 for those who are). Solo operations may need to
be excluded. Those applicants with a history of an AIDS defining opportunistic infection or associated
illness will require careful consideration.
a) Table 1 — Applicants not established on combination antiretroviral therapy (cART)
Age (yr)
Minimum CD4+ count
20 – 39 350
40 – 59 400
60 + 500
The data in this table is provided as a quick guide and applicants may be considered for
certification on an individual basis utilizing the data from the CASCADE Collaboration1.
　
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