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Last month, 193 member states of the United Nations vowed to "accelerate the fight against HIV and to end the AIDS epidemic by 2030."

Bold words, but is the idea of eliminating the most deadly virus in history – with 78 million infected and 35 million deaths to date – within a generation actually feasible?

On paper, it is. But the barriers are many, and often dispiriting. It is also a question hanging over the 21st International AIDS Conference, which is being held in Durban, South Africa, this week.

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The first generation of AIDS, from 1981 to 1996, was a time of rapid spread of the virus, mass death and much despair.

Then, in 1996, came antiretroviral cocktails, drugs that could keep the virus from replicating, allowing people who were infected to live almost normal lives again.

Activists, clinicians and policy-makers alike were emboldened and determined to get the new drugs to where they were most needed: the developing world, and southern Africa in particular.

When, in 2003, the joint United Nations program on HIV/AIDS (UNAIDS) unveiled its "3 by 5" initiative – getting treatment to three million people by 2005 – it was widely viewed as a pipe dream. But after some battles with pharmaceutical companies (and, in many cases, co-operation), the goal was not only met but wildly surpassed.

Today, 17 million of the 36.7 million people infected with HIV-AIDS around the world are on treatment.

And "3 by 5" has morphed into a more audacious target for 2020 dubbed "90-90-90," meaning:

  • Ensuring that 90 per cent of the infected are tested and diagnosed; currently, that number is about 57 per cent;
  • Getting 90 per cent of those who are diagnosed onto treatment with antiretroviral drugs; that number is currently 46 per cent;
  • Aiming to have at least 90 per cent of those infected attain an undetectable level of virus in their bodies (essentially a functional cure); currently, those rates range from 40 to 80 per cent in various countries, but sits at only 38 per cent over all.

Scaling up treatment and embracing the philosophy known as "treatment as prevention" (because those who are treated are far less likely to infect others) resulted in a significant drop in infections, from a high of three million a year to just over two million annually.

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But progress has stalled.

Despite considerable spending and all manner of political and public health commitments, two million people each year are still infected, and that number has not budged for years.

Even in countries that have aggressively embraced 90-90-90, such as Botswana, the number of infections has held steady (though the number of deaths has dropped considerably).

There is a growing recognition that the 10-10-10, those who are hardest to reach, are fuelling the epidemic. That's why this year's conference, has a real focus on so-called vulnerable populations – sex workers, intravenous drug users, prisoners, transgender people, indigenous people, refugees and adolescent girls.

These groups, marginalized and often criminalized, are the least likely to get drug treatment and other care, and they often are missed by prevention efforts.

They are also a reminder that drug treatments, while essential, are not enough. There is renewed interest and recognition of the importance of old-school prevention methods such as condoms and education, and community programs that target very specific subgroups, often with peer outreach.

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More important, the stubborn spread of HIV-AIDS in these marginalized groups highlights that the global scourge is fuelled by hateful practices such as sexism, homophobia, transphobia and oppressive drug laws.

The plan to eliminate AIDS calls for the number of new infections to drop below 500,000 by 2020, and then to close to zero by 2030.

For that to have a fighting chance to happen, there has to be a commitment to human rights for everyone, and to tackling poverty and discrimination.

Getting 193 countries to sign on to that will be a lot harder than a vague pledge to end AIDS.

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