HIV seropositive pilots using antiviral medications are not considered eligible for any class of medical certificate under the "General Medical Condition" clauses of FAR 67.113, .213 and .312, paragraphs (b) and (c) per Federal Air Surgeon policy. However, as a result of the combined efforts of several previously disqualified pilots and aviation medicine specialists/advocates, including the physicians of Virtual Flight Surgeons and the ALPA Aeromedical Office, the Federal Air Surgeon has liberalized this previously restrictive policy. See the ALPA Aeromedical Office petition to the Federal Air Surgeon, March 28, 1997. Now, many HIV+ pilots using antiviral medication may hold FAA medical certificates under the Special Issuance provisions of FAR Part 67.401.
In 1997, the Federal Air Surgeon changed the FAA policy on grounding all pilots/controllers with AIDS (Acquired Immunodeficiency Syndrome) and those HIV positive pilots/controllers using anti-viral medications after considerable debate and review of the scientific literature. The main area of concern dictating past and current policy centers on the potential for neurocognitive impairment due to HIV, AIDS dementia or the medications used to treat the condition, any of which could compromise a individual's ability to safely operate in the aviation environment.
The new policy allows granting a Special Issuance Authorization to some previously disqualified pilots in these categories. Each case must be reviewed individually. The first pilot using medications for HIV/AIDS was certified by the Federal Air Surgeon in November 1997. Since then, more than a dozen other pilots have applied and been certified under the Special Issuance provisions of FAR Part 67.401. VFS physicians have represented the majority of these cases with the FAA.
In the past, HIV positive pilots have been allowed to fly with a standard medical certificate as long as they were asymptomatic and were not taking anti-viral medications (including protease inhibitors). Recent advances in the treatment of HIV leads many physicians to treat asymptomatic patients with medication early in the condition. The goal is to reduce the likelihood of progression to AIDS and to lengthen the disease free state. This early treatment is now the standard for medical care.
Until the November 1997 change in FAA policy, HIV+ pilots using antiviral medication could not legally fly. Professional pilots often faced the loss of employment, and subsequently, the loss of their medical insurance benefits. Without medical coverage, many expected their health status and longevity to decline. Certainly their quality of life would deteriorate. If they declined to take medication to allow continued flying, their medical condition could deteriorate rapidly or they could have subtle neurologic deficiencies affecting their flying.
Confronting this dilemma, some pilots chose to conceal their condition from the FAA and their AME in order to maintain their certification. This was not unlike the situation prior to the granting of Special Issuance medical certificates for pilots with heart disease, diabetes, substance abuse and other medical conditions where revealing the diagnosis or treatment meant certain, permanent medical disqualification.
One problem with concealment is that the FAA loses the ability to monitor these pilots for potentially safety compromising conditions. Most of the pilots' treating physicians do not have the aeromedical expertise to assess the potential risks to safe operation of aircraft. Therefore, pilots who have not reported their treatment for HIV fly in fear of being discovered by the FAA and may not reveal all pertinent medical issues with the treating physician.
Current FAA Policy on HIV Seropositivity
The new FAA policy is a significant step toward enhanced monitoring cooperatively with the pilot, the FAA Aeromedical Certification Division and the treating physician. The result will be both enhanced aviation safety and personal health. Not all HIV affected pilots will be granted Special Issuance medical certificates under the FAA protocol however.
Those pilots who are HIV positive or are currently asymptomatic following recovery from an AIDS-defining illness may be certified if they meet certain conditions. They must be taking FDA approved medications used in accordance with the "Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents " and tolerate these medications well. HIV viral load should be less than 1,000 copies/ml by PCR. CD4+ counts should be stable. Laboratory studies should be near normal and the pilot should be under the regular care of a physician experienced in treating HIV and AIDS.
In a 2003 policy change, the FAA now will allow pilots with a history of any AIDS defining illness (AIDS-DI) to hole a Special Issuance. A history of PCP as an initial presentation of HIV disease was first granted a Special Issuance by the Federal Air Surgeon in October 2000. Prophylactic medications for suppression of opportunistic infections are permissible. The certification criteria for an AIDS-DI are some what more stringent than for pilots who are only HIV-positive. (See chart below)
The pilot will also be required to undergo regular testing for neurocognitive function compared to other aviators. Cognitive testing by the CogScreen®-Aeromedical Edition is strongly preferred although a battery of alternate tests is acceptable if the CogScreen is not available. If the test results are satisfactory, the pilot may be granted a Special Issuance Authorization valid for a limited period (6 months to one year). Continued certification is contingent on stability of the condition and repeat testing. Neurocognitive testing is required annually for ATCs, First and Second Class certification, and every two years for Third Class certification.
The current FAA protocol for certification of HIV positive pilots remains flexible and requirements may be added or deleted from those listed below. Each case is considered individually. The current policy requires:
Viral Load (PCR) if CD4 >350
Viral Load (PCR) if 200<CD4<350
CD4 < 200
# > 6 months
# >6 months
## 6 months
## 6 months
Clinical cognitive assessment
* Viral load by PCR on two consecutive test at least one month apart
** Viral loads done at least quarterly
# AIDS defining illnesses resolved at least 6 months
## Stable CD4+ count (> 200, see above for viral load)
## Complete Blood Count (CBC)
## Liver Function Tests (LFTs)
## Renal Function Tests (Kidneys)
@ "Normal" neurocognitive function testing, CogScreen AE is preferred; Required annually for 1st and 2nd Class, every 2 years for 3rd Class
@@ If CMV retinitis is present, a full ophthalmologic exam with visual fields is required initially and every 6 months
Using FDA approved medications by Acceptable Protocol
Tolerate medications well without major side effects
Under the care of physician experienced in HIV treatment
No other disqualifying conditions or medication
Amnesty for Previous Concealment of Treatment
Those pilots who have previously concealed treatment for their condition may be allowed Special Issuance Authorizations after they have released complete information about their condition and treatment, if they meet the above criteria. HIV Seropositivity Protocol. Dr. Warren Silberman, Manager of the FAA Aeromedical Certification Division, released a statement concerning his policy on pilots who are interested revealing complete medical information on future Airman Medical Applications. VFS encourages all pilots to report significant medical information completely and honestly on all medical applications.
Initial Special Issuance Authorizations for HIV controlled with medication are granted by the the Aermedical Certification Division or the Regionalo Flight Surgeons' offices. Renewals of SIAs, if there has been no adverse changes in clinical status, are granted by the both the Regional Flight Surgeon's office and the Aeromedical Certification Division (AMCD) in Oklahoma City. This is usually a faster process if all appropriate information is included in the package and forwarded to the FAA in a timely basis.
VFS Waiver Assistance
VFS conservatively estimates that there are 100-200 pilots with HIV or AIDS currently flying without reporting their condition to the FAA or who are not taking medication as recommended by their physician. VFS encourages all pilots to seek the optimum medical treatment for whatever condition afflicts them. We also strongly encourage full disclosure and honest reporting to the FAA of treatment for medical conditions. We will assist pilots with questions regarding the optimum way to report treatment for medical conditions. Contact us through our Confidential Questionnaire. Members of the National Gay Pilots Association should contact their officers for discounted rates for VFS services.
VFS link to FAA Protocol for HIV Disease Evaluation