Why a tropical paradise has the world's fastest growing HIV epidemic
Just three years ago the archipelago reported 245 new cases. But by 2024, the government said that figure had jumped 550 per cent to 1,583, earning Fiji a grim new title: after decades of minimal spread, the tropical paradise now has the world's fastest growing HIV epidemic.
'By the time we realised what was happening, boom, the explosive numbers came in,' said Dr Tuidraki, acting country director at Medical Services Pacific (MSP), which runs sexual health clinics in Fiji. 'Honestly, I think we became complacent… now we're left racing to just catch up.'
The sudden spiral is linked to a boom in methamphetamines.
The archipelago, home to some 900,000 people across hundreds of islands, has for years been a transit point on the 'Pacific drug highway'. But since 2020 domestic consumption has surged, as the pandemic disrupted illicit trade routes.
'The big impact here was Covid,' said Eamonn Murphy, the Asia-Pacific region director of UNAIDS. 'Drug supply used to transit through Fiji, it wasn't really a domestic market. But during Covid, the drug trade got stuck there. That's when increasing use of injecting drugs met a background epidemic that had been neglected.'
Experts have since reported children as young as 10 taking meth, while drug-related deaths – both from addiction and suspected gang activities – are rising. Meanwhile, HIV is being widely transmitted through needle sharing, chemsex and 'bluetoothing'.
This third factor refers to a group of people pooling money to buy meth, before one person uses a syringe to inject the drug. Once they're high, another person draws their blood and injects themselves, chasing a secondary rush from the traces of meth in their bloodstream.
'We're gathering from patients that this is now common, and this is part of what's fuelling [the outbreak],' said Dr Tuidraki. 'But because of HIV's long incubation, we're only just seeing the rippling effects of Covid disruption now.'
And the ripples are 'startling'. In the MSP clinic in the capital Suva, Dr Tuidraki has seen a steady flow of new HIV patients in the last 18 months – and unlike the past, many are very young. Too often, they seek care only when their condition is severe, and too often they drop off the radar and stop taking antiretroviral drugs.
'Trends have really changed from what we were seeing before,' Dr Tuidraki said. 'Patients are getting sicker more quickly – perhaps because of the mode of the transmission. The viral load is so high when people share drugs and needles.
'We're also seeing a much younger generation – before, most of the cases [were aged] 29 and above. But it's changed to the point that in our 10 to 19 year-olds, that's where we're having a lot of new cases.'
Dr Tuidraki's observations are reflected in UNAIDS data published last month.
Of new cases in 2024, 60 per cent of cases are among young people aged 10 to 29. Some 48 per cent were linked to injecting drug use – narrowly overtaking sexual transmission, the cause of 43 per cent of known infections, as the main source of spread.
Meanwhile UNAIDS estimates that only a third of roughly 6,000 people living with HIV are aware of their status, pointing to widespread undetected transmission. What's more, just 24 per cent of those affected are currently receiving treatment; without the antivirals, they will almost certainly die.
'This shows there's a hell of a lot of work that needs to be done to get on top of the outbreak, and it needs a different response to the past,' Mr Murphy said.
'[The country] never needed a drug-related response before… but if Fiji doesn't challenge community perceptions around drug use and how to respond to injecting drug use, this epidemic is going to blow up even more.'
Shame and stigma
Yet, even before the current wave of cases, stigma and stereotypes complicated both treatment and prevention efforts in the island nation.
'Fiji is a close knit, faith-based society where privacy is difficult and people fear being judged,' said Mark Shaheel Lal, who founded the awareness group Living Positive Fiji after testing positive for HIV.
He's one of a small group of people living with the virus who have been willing to speak openly about their diagnosis and experience.
'It was a huge shock [to test positive]. But I had a few friends who had passed away from Aids, sadly, because they didn't begin treatment because of the stigma and shame and fear of going to the clinics to get the meds.
'So I felt I had a responsibility to actually come out and help other people living with HIV,' Mr Lal said. 'Conversations about same sex relationships, sex work and sexual health in general remains a taboo here – and this silence keeps HIV hidden, and makes prevention and support so much harder. If Fiji wants to reverse the trend, we must break the silence.'
The government has taken some steps to tackle HIV – including designating the situation as a national outbreak in January.
This allowed for the mobilisation of more resources, including $10 million Fijian (£3m) of new funding, the creation of a dedicated HIV unit in the ministry of health, expanded testing and an awareness campaign. Australia and New Zealand have also pledged support.
But experts have called for drug harm reduction policies, including a needle exchange programme, and warned that a public health response to the meth crisis is needed alongside policing.
They say Fiji should also expand sexual education in schools, ensure the wider availability of pre pre-exposure prophylaxis drugs, and introduce a peer counselling programme in clinics, to offer extra support to those who test positive.
'I'm supportive of the ministry [of health], but there's not been enough implementation yet – there's still a lot of talk,' said Dr Tuidraki. 'The outbreak was declared in January, it's now July. At the end of the day we're trying, but we're not moving with the speed the crisis requires.'
She added that better training for health workers must also be prioritised within efforts to curb transmission, as too many have 'judgemental' mindsets and are 'not well informed on preventative measures'.
'This has been feedback from patients as one of the reasons they stop going in for treatment,' said Dr Tuidraki. 'HIV is too often associated with death, with something that's disgusting… I've been surprised that this is even true among healthcare workers.'
Whether or not Fiji successfully tackles these challenges and reigns in HIV will have ramifications not just for the archipelago, but its neighbours across the region.
'Our big concern with Fiji is both the domestic epidemic, but it's also the gateway to the Pacific,' said Mr Murphy. 'Back in 2001, everyone was expecting an explosion in the Pacific because the background STI [sexually transmitted disease] rates were very high.
'It didn't happen then. But now, it's very much a reality looming.'
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