The medical certification of persons with HIV seropositivity will be considered as is the case for any other acute or chronic disease process: using medical information, clinical presentation and aeromedical concerns to determine the risk of subtle or sudden incapacitation during the validity period of the aviation license or permit held by the document holder or applicant.
In the case of HIV/AIDS, much is known about the natural course of the disease, the influence of treatment protocols, the side effect profiles of medications used, the potential for significant physical and psychological dysfunction arising from the disease and treatment, and the potential for periods of medical stability.
Transport Canada Civil Aviation Medicine will consider applicants with HIV seropositivity for all classes of aviation medicine certificates. Such issues as severity of disease, treatment protocols, side effects of treatment, potential for cognitive impairment and general prognosis will influence the aeromedical decision making with respect to licensing fitness and/or limitations and follow-up requirements.
Considerations
As a general principle, an applicant will be considered UNFIT for medical certification if there is evidence of:
- AIDS defining illnesses (Appendix A),
- unstable course of disease, or
- progression to CDC Stage 3 ,
Persons experiencing remission, resolution and/or stability of AIDS defining conditions may apply for consideration
All HIV seropositive applicants will need to provide the following supporting medical documentation for consideration;
- detailed medical report from attending infectious disease specialist
- CD4+- count
- Viral load
- Neuropsychological testing
- Serology for other infectious diseases
An applicant not on anti-retroviral therapy (ART) may be considered for medical certification if the CDC stage 1 or 2conditions are met:
- HIV infection Stage 1
- No AIDS defining condition
- CD4-+ T-Lymphocyte count > 350 cells/mL
Note: Current Canadian clinical guidelines suggest that CD4+ count of less than 350 cells/µL is an indication for initiation of anti-retroviral therapy.
An Applicant on ART may be considered for medical certification if:
- HIV viral load below level of detection,
- Any CD4+- count
- No aeromedically significant side effects from the medication.
If on anti-viral treatment (ART) applicants will need to submit additional medical reports documenting :
- dosage and type of medication.
- Medication side effect profile
- CBC, liver function tests, lipids
- Cardiac assessment (depending on cardiac risk profile)
Medical Certification
Medical Certification may be granted as FIT or FIT with Limitations, and may have specific validity period limitations, and will require specific and regular follow-up medical reports to maintain certification.
Follow-up
Follow-up reports requirements will be individualized but, as a minimum should include:
- Detailed report from attending physician/infectious disease specialist every six (6) months or sooner if condition changes radically
- Neuropsychological report or equivalent annually,
- Cardiovascular risk assessment (individualized schedule) if on ART
Note:
The Aviation Medical Review Board (AMRB) may provide recommendations on the risk assessment of individual applicants who present with more complex issues.
References:
| 1. | Revised Surveillance Case Definitions for HIV Infection Among Adults, Adolescents, and Children Aged <18 Months and for HIV Infection and AIDS Among Children Aged 18 Months to <13 Years—United States, 2008 MMWR Dec. 2008 Appendix A: AIDS Defining Conditions Appendix B: Comparison of the Revised World Health Organization and CDC Surveillance Case Definitions and Staging Systems for HIV Infection |
| 2. | Case Definitions for Communicable Diseases under National Surveillance - 2009 CCDR Volume 35s2, November 2009 |
| 3. | Canadian guidelines on sexually transmitted infections : Human immunodeficiency virus (HIV) infections 2006 (Reviewed 2008-Jan) Available from CMA Infobase |
| 4. | GUIDANCE MATERIAL TO SUPPORT THE PROPOSED CHANGES TO THE MEDICAL PROVISIONS CONTAINED IN ANNEX 1 — PERSONNEL LICENSING (Details of the proposed changes to the medical Standards and Recommended Practices contained in Annex 1 – Personnel Licensing can be found in ICAO State letter AN 5/22-08/33, dated 5 May 2008) |
| 5. | Manual of Civil Aviation Medicine - Preliminary Edition- 2008, International Civil Aviation Organization, Part III, Medical Assessment, Chapter 13, Human Immunodeficiency Virus. Doc 8984-ANS 895 Part III |
Appendix A AIDS DEFINING CONDITIONS (2008)
- Bacterial infections, multiple or recurrent*
- Candidiasis of bronchi, trachea, or lungs
- Candidiasis of esophagus†
- Cervical cancer, invasive§
- Coccidioidomycosis, disseminated or extrapulmonary
- Cryptococcosis, extrapulmonary
- Cryptosporidiosis, chronic intestinal (>1 month's duration)
- Cytomegalovirus disease (other than liver, spleen, or nodes), onset at age >1 month
- Cytomegalovirus retinitis (with loss of vision)†
- Encephalopathy, HIV related
- Herpes simplex: chronic ulcers (>1 month's duration) or bronchitis, pneumonitis, or esophagitis (onset at age >1 month)
- Histoplasmosis, disseminated or extrapulmonary
- Isosporiasis, chronic intestinal (>1 month's duration)
- Kaposi sarcoma†
- Lymphoid interstitial pneumonia or pulmonary lymphoid hyperplasia complex*†
- Lymphoma, Burkitt (or equivalent term)
- Lymphoma, immunoblastic (or equivalent term)
- Lymphoma, primary, of brain
- Mycobacterium avium complex or Mycobacterium kansasii, disseminated or extrapulmonary†
- Mycobacterium tuberculosis of any site, pulmonary,†§ disseminated,† or extrapulmonary†
- Mycobacterium, other species or unidentified species, disseminated† or extrapulmonary†
- Pneumocystis jirovecii pneumonia†
- Pneumonia, recurrent†§
- Progressive multifocal leukoencephalopathy
- Salmonella septicemia, recurrent
- Toxoplasmosis of brain, onset at age >1 month†
- Wasting syndrome attributed to HIV
* Only among children aged <13 years. (CDC. 1994 Revised classification system for human immunodeficiency virus infection in children less than 13 years of age. MMWR 1994;43[No. RR-12].)
† Condition that might be diagnosed presumptively.
§ Only among adults and adolescents aged >13 years. (CDC. 1993 Revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR 1992;41[No. RR-17].)