December 1, 2009 is World AIDS Day -- the first in the era of "hope and change". So it is a particularly good time to ponder how well "risk reduction" measures for AIDS control -- the most emphasised approaches to preventing new HIV cases -- produce change and generate hope.

Let’s start with the lack of change.

Dr Anthony Fauci of the National Institute for Health wrote in April in the Washington Post that "the annual number of new HIV infections in the United States -- about 56,000 -- has remained fairly constant for more than a decade." For emphasis, he repeated, "That's right, 56,000 people are infected in this country every year."

This amounts to a major, if tacit, admission that risk reduction methodologies (ie, condoms, treatment, needle exchange, methadone, etc) have not been very effective in curtailing new HIV infections. They don’t seem to be making a dent in the rates of other STDs either, to judge from the CDC’s most recent (November 2009) annual report on STD trends. High rates of common STDs persist unabated or are even rising. Between 2007 and 2008, there was an 18 percent increase in syphilis cases. In a separate report last year, the CDC revealed that one in four teenage girls (aged 14-19) had an STD.

Yet the response to these crises is always to redouble efforts to implement the failed philosophy of risk reduction -- even if it is presented as a commitment to science over ideology. But it is a philosophy which places no premium on hope and no confidence in the human capacity to change.

It is not yet permissible to point out the failures of risk reduction strategies with respect to the concentrated HIV epidemics in the West. But in recent years it has become acceptable to do so (in both scientific literature and the popular press) when discussing generalised epidemics such as those found in southern and eastern Africa.

The lack of impact on HIV incidence in Africa from years of multi-million dollar Western investments in condom promotion was too glaring and too consistent to keep ignoring -- even though UNAIDS brazenly attempted to do just that. When researchers at the University of California at San Francisco – who had been commissioned by UNAIDS! -- found that condoms have not been responsible for turning around any of the severe African epidemics, UNAIDS tried to alter these important findings and ultimately refused to publish them.

Success in reducing HIV rates from a handful of African countries is most attributable to changes in behaviour, particularly reductions in sexual partners. But this is a blueprint most architects of AIDS prevention policy have been reluctant to incorporate sufficiently into their programs. Yet, sadly, HIV rates are now rising in Uganda following the Western installation of risk reduction measures. Uganda had initially emphasised behaviour change and produced the most spectacular success story in the world.

The drug-abuse driven HIV epidemic presently afflicting Russia has Western AIDS experts and media outlets clamouring for needle exchange and methadone programs, despite an evidence-base that is mixed at best. Yet other reasons for caution abound. The drug buprenorphine, which like methadone is used as a "substitute" for injecting heroin has quickly become the preferred drug in the former Soviet republic of Georgia, and had led to an 80 percent increase in the number of drug addicts there.

Studies continents apart have indicated that a majority of addicts who seek out drug rehabilitation services say they want to be free of drugs entirely. Yet policy makers dismiss that longing as unrealistic and persist in emphasising methadone or needles ad infinitum. What should we make of this inclination to undervalue a "client’s" desire for more than merely languishing safely in the slavery of addiction?

This is not to say there is a guaranteed non-technical method for restoring any given person to sobriety. But it is an apt commentary on the discipline of public health, which has become too timid to challenge cultural dogma on matters of lifestyle and too enamoured with the esteem that comes from supposed technical know-how.

But technical fixes do little to relieve existential crises. And this is what Russia faces today, with massive alcohol consumption, staggering mortality rates, and a shrinking population.

At a deeper level, what all these risk reduction measures have in common is a deflating absence of hope. And hope for the future is what is needed most -- hope to be healed of past traumas; hope to live free of disease, discord and inner turmoil.

Fostering real hope is difficult, because it means first recognizing and then aspiring to a preferable alternate behaviour, a standard even.  But this is precisely what our culture tends to deny, relativise, or deride. This is why risk reduction, harm reduction and safe sex are the only politically safe ways to engage the issue. To foster hope, the public health establishment needs to be courageous and break free from the bonds of culture and from the deadening despair of relativism.

True, the government should not necessarily be in the business of dispensing hope, but there is no call for authorities to replace it with the (all too often empty) promise of “safety”.  

I once heard a colleague in Africa put it like this: "Ideals are like the stars. We may not reach them, but we set our course by them." The motto of risk reduction, however, is: "No need to shoot for the stars. Stay safely in the abyss." The virtually exclusive focus on risk reduction measures amounts to the quiet institutionalisation of hopelessness.

Is this really the best we can do for our fellow human beings?  Or is it time for a change?