The last time the International AIDS conference was held in the United States -- in San Francisco in 1990 -- it was the dawn of what soon became a global pandemic. The number of people living with HIV rose from around 8 million that year to 34 million by the end of 2010.
As the conference, which is held every two years, returns to the U.S. Washington this weekend, health-policy wonks are now looking at a very different global AIDS picture. HIV rates have leveled off. New infections declined by almost 20 percent in the last 10 years.
Still, governments and advocates have a long way to go. Here are three big challenges that experts say remain in the fight against the AIDS pandemic:
1. More research into treatment and prevention, and more ways to deliver treatments
Treating people who have HIV with anti-retroviral drugs dramatically reduces the concentration of the virus in their blood. A 2011 clinical trial showed that relatively healthy people with HIV who received early treatment with the drugs were 96 percent less likely to pass on the virus to their uninfected partners.
“Treatment is a powerful prevention tool, and we can make a huge dent in the epidemic that way,” said Chris Collins, vice president and director of Public Policy for amfAR, the foundation for AIDS Research.
There are also new ways to prevent HIV infection pre-emptively. This week the FDA approved Truvada, a daily pill that the organization says could reduce the risk of infection by 42 percent among male partners and 75 percent in opposite-sex pairs.
However, many see Truvada as just one part of a whole package -- one that includes access to condoms and lubricants, risk reduction counseling and regular testing.
The problem is then getting these services to rural populations, especially in developing countries. Because many areas lack sufficient doctors to provide HIV treatments, some countries are experimenting with allowing local nurses and clinicians to administer treatments in place of doctors. And in the U.S., some clinics have even tried doctor visits for HIV patients in remote areas via webcam.
“One issue that continues to be problematic is the ability to have a clinic or a doctor or nurse practcioner to go to who is familiar with HIV,” said Victor Barnes, interim president of AIDS United. “There’s a more of a challenge in the African context because the delivery systems across the board are far less developed.”
2. Reaching gay people, sex workers and other marginalized populations
At least 75 countries criminalize same-sex behavior, according to the Global Forum on MSM & HIV, an advocacy organization, and these laws can prevent gay people from seeking information on or treatment for HIV. At the same time, men who have sex with men have a much higher rate of HIV infection than the general population in most countries, according to the World Bank.
“These barriers create fear for individuals who need to access information,” said Krista Lauer, a senior policy advisor with the Global Forum. “It’s difficult to access health-care providers if you’re worried about disclosing your sexual behavior for fear of criminal repercussions.”
Lauer also said aid workers should perform outreach outside the typical locations if they’re trying to target gay men for treatment services.
“You may need to have outreach at gay-friendly venues, or known safe environments where men who have sex with men are known to congregate,” she said.
3. Increasing funding for PEPFAR and other anti-AIDS programs
President Obama incensed some AIDS activists earlier this year when he proposed cutting $214 million from the budget of the President's Emergency Plan for AIDS Relief, a program that was started in 2003 under President Bush. Researchers have found that the program lowers the odds of mortality from AIDS by 20 percent in countries where the program is active.
There’s been a “retreat on support from developed nations, with the U.S. sadly leading the way, on global AIDS,” said Ged Kenslea, a spokesman for the AIDS Healthcare Foundation, in an e-mail.
Doctors Without Borders has also contested that current funding levels are inadequate. International anti-AIDS funding has not increased significantly since 2008, according to UNAIDS. Congo, for example, is only able to supply anti-retroviral drugs to 15 percent of the people who need them, Doctors Without Borders said, which means "patients are literally dying on our doorstep,” the AP reported.
Dr. Kevin DeCock, director of the Center for Global Health at the Center for Disease Control and Prevention speculates that two reasons for the AIDS funding gap could be “fatigue and forgetting” -- meaning that the general public is growing tired of throwing money at the disease, and that the devastation it caused in the late ‘90s is no longer as fresh in our minds.
“Many have forgotten or never have known about the extraordinary impact of AIDS in heavily affected settings, especially in sub-Saharan Africa where hospitals overflowed with dying patients, families were destroyed, and tuberculosis escalated,” he wrote on the One blog.