Drugs: Antiretrovirals have become cheaper

The 19th international Aids conference opens this evening

Elton John and the executive director of UNAids, Michel Sidibé, join forces on the first day of the world's largest Aids assembly, saying: "We mark the rapidly approaching reality of a world with zero new HIV infections, zero Aids-related deaths, and zero discrimination due to stigma. In short, an Aids-free generation."

When more than 20,000 people, including Bill Gates, Whoopi Goldberg, Bill Clinton and Laura Bush, gather in Washington this week for the 19th International Aids Conference, they will discuss new ways to tackle what has been one of the world's deadliest epidemics for more than three decades.

Sir Elton and Mr Sidibé believe there is good reason to be hopeful. More than eight million people worldwide now have access to HIV treatment – more than 50 per cent of those who need it – and over the past decade, new infections among young people have dropped by 20 per cent. While "serious challenges remain in the Aids response", the pair added: "Through daily acts of creativity, compassion and courage, we can begin to end the epidemic."

As the conference kicks off, The Independent on Sunday investigates some of the obstacles still facing the world in the battle against Aids.

1. Targeting the gay and bisexual community

The epidemic continues to grow in one population in all countries: men who have sex with men. Some countries, including the US, Spain, Chile, Thailand, Malaysia, South Africa and some African and Caribbean nations, record HIV prevalence in this group at 15 per cent or higher. Worldwide, gay black men are 15 times more likely to become infected with HIV than the rest of the population; in the UK they are 111 times more likely. Gay men remain most at risk of contracting HIV in the UK with one in 20 testing positive, compared with one in 900 of the population as a whole. Campaigners have called for an increase in targeted face-to-face work with the most at-risk men.

2. Reducing mother-to-child transmission

Every minute around the world, a young woman acquires an HIV infection, but the burden falls disproportionately in sub-Saharan Africa, where women make up 60 per cent of people with the virus. Because of advances in the UK's antenatal programme, only one in 1,000 babies contract the virus from their mothers. Of the estimated 1.5 million women living with HIV in low- and middle-income countries, over 40 per cent do not receive effective antiretroviral drugs.

3. Reaching drug users

Injection-driven HIV infections are among the fastest-growing in the world, with one in 10 new HIV infections occurring in injecting drug users. The UK has one of the lowest HIV rates for this group (2.5 per cent of HIV-positive people) because of harm-reduction programmes such as needle exchange. In countries with no or few such initiatives, such as Russia, nearly half of all people living with the virus contract it from injecting drugs.

4. Getting more people tested

HIV testing has advanced to the stage where diagnosis can be made in 30 minutes with a finger prick or with a swab of saliva. The weakest level of reported testing exists for men who have sex with men. Less than 10 per cent of countries have 80 per cent coverage for this demographic. The first self-testing kit in the US has just been approved, and campaigners are now pushing for kits to be legalised in Britain. More than half of the HIV population in the UK is still being diagnosed later than it should be, with one in four infected people unaware they have the disease.

5. Increasing drug coverage

More people are receiving treatment today than ever before, but access to antiretroviral drugs remains one of the most pressing issues. More than eight million people living with HIV in low-and middle-income countries are receiving treatment, up from 6.6 million in 2010. Yet while world coverage rates rest at about 54 per cent, there are massive geographical variations. Treatment coverage is lowest in Asia, Eastern Europe, Central Asia and North Africa and especially the Middle East, where only 13 per cent of those in need receive care.

6. Finding a cure

Scientists have promised a future vaccine or cure for HIV for decades, but with 34 million people living with the virus, and 2.5 million new infections last year, experts have coined a new phrase, "treatment by prevention", highlighting the importance of an immediate response and uninterrupted treatment following diagnosis. The US has just approved Truvada, the first HIV prevention pill, which can be used by those at high risk of infection, and anyone who might engage in sexual activity with infected partners. Studies show the drug reduced the risk of contracting HIV by up to 73 per cent.

7. Helping the over-fifties

Because of effective HIV treatment, more people than ever are living to an older age with HIV. An estimated three million over-fifties live with HIV in sub-Saharan Africa, more than 14 per cent of those living with the virus. There are now more than 14,000 people aged over 50 living with HIV in the UK, which is more than 20 per cent of everyone with HIV. But living longer can also mean coping with a range of additional problems, from poor health to social isolation and a lack of savings.

8. Overcoming stigma

HIV continues to be one of the most stigmatised medical conditions. Twenty per cent of HIV-positive people surveyed in Rwanda and 25 per cent of their peers in Colombia have experienced physical violence because of their status. In Pakistan, 26 per cent of people say they have been excluded from family activities, and more than 10 per cent of people in Belarus, Burma and Paraguay have been denied healthcare.

9. Changing the law

In more than 60 countries around the world, exposing another person to HIV or passing on the disease through sex is a criminal act, despite arguments that such punitive laws deter people from getting tested or treated and increase the risk of the disease spreading. The US has one of the worst records around criminalisation of HIV transmission. There and elsewhere, people have been given 20 years in prison for spitting or doing other things that won't transmit HIV.

10. Reducing cost of drugs

A year's supply of first-line antiretroviral drugs plummeted in cost from $10,000 in 2000 to less than $100 in 2011. However, costs can vary greatly between countries and even within a country. If countries in Latin America and the Caribbean were all able to access the most affordable generic drugs in the region, between 1.2 and 3.8 times more people could receive treatment.