Our pals across the pond, who tend to be less treatment trigger-happy than U.S. HIV docs, dropped a new bombshell at the British HIV Association’s April conference: They presented draft guidelines that advocate cutting d4T (Zerit) and solo Trizivir from starter combo options, calling d4T too toxic—causing lipoatrophy (fat loss), peripheral neuropathy and mitochondrial toxicity—and solo Trizivir too weak. The draft also reserves T-20 (Fuzeon) for salvage therapy and protease inhibitors for first line only if boosted with ritonavir (Norvir).

“This is a forward-looking agenda for HIV health care,” says guidelines committee member Graeme Moyle, MD, of London’s Chelsea and Westminster Hospital. For more than six months, some 20 docs monitored randomized controlled trials comparing starter combos. The Trizivir advice, for instance, follows the ACTG 5095 study showing that the easy doser failed more often than a combo including efavirenz (Sustiva). “The goal is to base the recommendations on evidence, [not] opinion,” Moyle says.

Another Brit innovation was being first to ditch the “hit early, hit hard” strategy, saving many HIVers years of side effects. But, notes Howard Grossman, MD, of New York’s Polari Medical Group, they also advocated postponing treatment until CD4s dipped below 200—a risky business.

Meanwhile, back in the colonies, response is mixed. Douglas Richman, MD, of the University of California at San Diego, thinks the guidelines make sense; Grossman agrees that d4T should be drop-kicked—but Antonio Urbina, MD, of St. Vincent’s Hospital in New York, says, “Until we better understand lipoatrophy, I’d ignore the [d4T] recommendation.” Grossman argues for keeping Trizivir in the line-up, for the convenience of one twice-daily pill: “For a patient with a pretty low viral load, I wouldn’t hesitate.” And Cal Cohen, MD, of New England’s Community Research Initiative, likes solo first-line Trizivir for HIVers who have trouble adhering.