The HIV Epidemic in Fiji
Ideas and resources to strengthen response efforts
The island nation of Fiji is experiencing the world’s fastest-growing HIV outbreak. Driven in part by injection drug use, the outbreak is fueled by an influx of methamphetamines circulating on trans-Pacific trade routes. Fiji’s position as a transit stop has given rise to a booming domestic drug market. Domestic funding and foreign aid from Australia and New Zealand has unlocked around $15 million for response efforts. However, major gaps in social support, education, prevention, testing, and treatment persist, and cases continue to rise.
A December 2025 rapid assessment commissioned by WHO and UNDP highlights the urgent need for clean needle and syringe programs (NSPs), better access to HIV testing and treatment, and education campaigns. The purpose of my report is to offer additional practical ideas and resources that may be useful to government agencies and NGOs responding to the crisis. This report focuses in large part on strategies to address barriers to access, with additional recommendations for HIV prevention and electronic disease surveillance systems.
Access
Access barriers are social, financial, structural, or geographical obstacles that prevent individuals from receiving timely, high-quality health and support services. In Fiji, these barriers may include social stigma around HIV and drug use, punitive attitudes and laws regarding people who inject drugs, geographical accessibility of remote island communities, geographic mobility of seafarers, lack of education and awareness, and difficulties following up with transient population groups like prisoners.
Involving communities
Many of the most effective solutions to addressing the needs of vulnerable groups arise from the groups themselves. Community engagement builds upon local knowledge, strengths, and capacities, while empowering communities to make decisions in their own self-interest. There is solid evidence that community engagement has a positive impact on a range of health outcomes in public health settings. Therefore, it is a pragmatic choice to involve members of target populations in planning and delivering interventions. Externally imposed interventions that are not owned by participants have a lower likelihood of success, especially if they rely on behavioral change among participants. UNICEF’s guide titled Minimum quality standards and indicators in community engagement may be a helpful resource to guide community participation efforts.
Bundling services
Integrating HIV and substance use services can be an effective means to expand coverage and improve outcomes. This has been demonstrated at health facilities as well as in community outreach settings. The logic is straightforward: bundling multiple services into a single access point reduces the burden of navigating otherwise fragmented systems and increases the number of opportunities to reach patients. Given the high demand for needles and syringes, NSP distribution sites present an opportunity to reach PWID with HIV services who might not otherwise seek care. Additionally, integrated care could be tailored to meet the specific needs of target groups including seafarers and sex workers.
Peer outreach workers and influencers
A recent pilot program in Chicago demonstrated that outreach workers with lived substance use experiences were effective at linking PWID to primary care and infectious disease services. The program’s success is likely attributable in part to trusting relationships between PWID and outreach workers with a history of substance use. These peer workers serve as a cultural bridge between PWID and healthcare systems, where trust is often eroded by stigma and criminalization. Peer outreach models have also been effective at promoting PrEP initiation among female sex workers. Enlisting PWID and members of other high-HIV-incidence groups as paid outreach workers could be an effective way to expand access to HIV and substance use services.
Social media influencers wield the ability to reach large audiences in the information ecosystem and are often regarded as trustworthy by their followers. The power of influencers has proven to be an effective resource for promoting positive health-seeking behavior. Case studies from the U.S., South Africa, and Kenya demonstrate that social media campaigns have significantly increased HIV testing rates and reduced stigma. A study in Nigeria demonstrated increased HPV vaccine coverage after engaging influencers to amplify messaging. Since Fiji’s HIV epidemic disproportionately effects teens and young adults, social media influencers could be valuable partners in spreading awareness of the risks of HIV and drug use and promoting HIV and substance use services among hard-to-reach groups.
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Fiji’s tradition of Talanoa might offer another effective avenue to engage community members in inclusive, participatory dialogues.
Reaching PWID
In addition to community engagement, bundled services, peer outreach workers, and influencers, mobile clinics that provide health and substance use services in communities and hotspots may overcome barriers to access that exist in traditional health facilities, including stigma towards both drug use and HIV. This model is already active through MSP’s Moonlight program, and has been used in the Philippines and elsewhere. Funding, human resources, and supplies should be mobilized to expand the reach of mobile clinics, and to integrate HIV treatment initiation and substance use services.
Regulatory hurdles and public support
Despite their proven effectiveness, harm reduction interventions often face resistance and backlash from public officials, medical providers, and communities. Harm reduction interventions include clean needle and syringe exchange programs (NSPs) and opioid agonist therapy (OAT) to treat opioid dependence by tapering the use of harmful drugs. Although Fijian public health policy has cleared the way for NSPs, action has been delayed and no dedicated harm reduction services exist to date. This may be due to continued stigma and punitive attitudes; pharmacies in Fiji are reportedly reluctant to supply needles and syringes due to the fear of legal prosecution. Tackling stigma and garnering public support are therefore crucial for delivering effective and accessible services to PWID.
While there is no playbook for persuading institutions and individuals of the benefits of harm reduction programs, interviews with professional harm reduction advocates in the United States offer a glimpse into the thinking behind effective messaging strategies. These experts emphasize the importance of aligning messages on harm reduction with the audience’s values and particular concerns. For American Christian audiences, some of the experts who were interviewed recommend aligning with Christian values around redemption. Similar messaging may be appropriate in majority-Christian Fiji. For policymakers, arguments around cost savings may be effective. Police officers may be receptive to arguments around alleviating the strain on jails; an increasing proportion of the Fijian prison population have histories of drug use, and drug use has been linked to gender-based violence. This report includes many more anecdotes from harm reduction advocates that may be helpful for tailoring messaging to specific target groups. Compelling harm reduction success story comes from Portugal, where new HIV infections dropped from 1,016 in 2021 to 16 in 2020 following the decriminalization of drug use and expansion of harm reduction programs, and Canada, where the decline in HIV transmission among PWID between the mid-90s mid-2000s has been attributed overwhelmingly to harm reduction interventions. Additionally, several organizations including the National Harm Reduction Coalition and Harm Reduction International publish reports and other resources to help harm reduction advocates make their case.
Service delivery channels
Ongoing HIV outreach services in Fiji, including the Moonlight Program’s mobile clinics, have expanded access to HIV screening. However, local regulations require that diagnosis and treatment initiation take place at health facilities. As a result, some individuals who screen positive are lost to follow-up before they are diagnosed and connected to care. Similar obstacles have been encountered in prison programs in Fiji. WHO guidelines recommend rapid initiation of antiretroviral therapy (ART), ideally on the day of diagnosis. Offering diagnosis and treatment initiation at mobile clinics could be an effective strategy to reduce pre-treatment loss to follow-up, prevent HIV transmission, and improve treatment outcomes. It is important that patients initiated in community outreach settings as well as health facility settings receive pre-treatment counseling and are not pressured to initiate ART, both of which may increase the risk of treatment discontinuation.
Prevention
While preventing new HIV infections among PWID is crucial, attention should also be directed upstream towards preventing the initiation of injection drug use and downstream towards protecting the sexual partners of PWID.
A 2017 review highlights a global trend towards interventions that seek to prevent the incidence of injecting initiation by focusing on the role of active PWID in exposing others to injecting. Some programs have engaged with PWID to equip them with strategies to resist initiation requests and to avoid exposing injection-naive individuals to injecting behavior. In Fiji, family members are often involved in initiation, so family-centered strategies may be appropriate. Since many Fijian drug users who inject methamphetamine did not inject the first time they used meth, preventing non-injection meth use may also decrease rates of injection initiation.
HIV can also spread between HIV-positive PWID and their sexual partners through unprotected sex. Global research suggests that condom use among PWID is often low, and PWID in Fiji have reported injecting methamphetamine to enhance sex. Sexual health education and condom distribution could therefore be integrated into programs for PWID to curb transmission of HIV and other STIs.
Electronic disease surveillance systems
Dr. Tuidraki noted that various organizations involved in the outbreak response use discordant data systems. With multiple organizations and government agencies operating on the ground in Fiji, centralized, electronic disease surveillance systems are crucial to coordinated response efforts. Such systems enable data sharing across organizations and health system levels, real-time dissemination of information for rapid decision-making, aggregation of data to identify geographical and demographic trends, and data standardization for better interoperability. Data centralization must be designed with privacy protections to avoid inappropriate use of health data to target PWID and PLHIV.
The WHO’s guidelines for Integrated Disease Surveillance and Response (IDSR) provides guidance on designing electronic surveillance systems at all levels of the health system, event-based surveillance via hotlines and media scanning, establishing management committees, and more. As much as possible, electronic IDSR tools should be built upon existing frameworks and systems to promote easy adaptability by implementers and smooth transitions. In Fiji, Tamanu has been adopted for HIV patient records, and this could be a good starting point. Alternatives such as DHIS2 include tools tailored to HIV surveillance and prevention.
Conclusions
Fiji’s rapidly growing HIV epidemic presents an urgent but addressable challenge. Strengthening the response will require coordinated action that expands access to services, reduces stigma, and promotes an enabling environment for the rollout of proven harm reduction interventions. The strategies outlined in this report — community engagement, integrated service delivery, peer outreach, targeted programs for key populations, pragmatic prevention efforts, and improved electronic reporting systems — offer practical opportunities to close existing gaps and build on the important work already underway in Fiji.
AI statement: no portion of this text was generated using artificial intelligence.
