Drugs, HIV and gangs: the Pacific island paradise hit by a triple epidemic

Summary

Battle Lines – "Drugs, HIV and Gangs: The Pacific Island Paradise Hit by a Triple Epidemic"

Podcast: Battle Lines, The Telegraph
Date: February 25, 2026
Host: Arthur Scott Geddes
Guests: Sarah Newey (Telegraph correspondent), Dr. Jason Mitchell (Head of Fiji's HIV Task Force)

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Episode Overview

This episode of Battle Lines delves into Fiji’s escalating “triple epidemic” of drugs, HIV, and organized crime. Once seen as a tranquil Pacific paradise, Fiji now finds itself as both a stopover and destination on a booming drug superhighway—fueled by Mexican cartels, Chinese triads, and Australian biker gangs. The surge in methamphetamine use has sparked the world’s fastest-growing HIV epidemic, driven largely by unsafe injection practices and compounded by government inaction and persistent social stigma. On-the-ground correspondent Sarah Newey shares her recent reporting trip to Fiji, while Dr. Jason Mitchell provides insight from the frontlines of Fiji’s HIV response.

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Key Discussion Points and Insights

1. Pacific Drug Superhighway

[01:04–03:37]

• Fiji and its neighbors are the “Gateway to the Pacific” between meth-producing Latin America/Southeast Asia and lucrative markets in Australia/New Zealand.
• Drug traffickers use innovative routes (drones, narco-subs, yachts), and cartel profits soar due to Australia and New Zealand’s high street prices.
  • Quote: “A kilo of uncut cocaine in New York would cost about $50,000… in Auckland or Sydney, it would be $350,000. At the source in Peru or Ecuador… $1,500.” – Sarah Newey [03:17]
• Locals are often paid in product, creating a domestic market and quadrupling profits for dealers.

2. Fiji as a Shifting Drug Hub

[03:37–05:21]

• Drugs are now not just transiting but flooding local communities.
• Drug culture is visible—dealers operate openly, and law enforcement frequently fears to enter certain neighborhoods.
• Meth is the dominant drug; marijuana is longstanding, but the sheer scale of hard drug use is unprecedented.

3. Dangerous Drug Practices Driving HIV

[05:21–06:35]

• Injecting meth is the leading method; “Bluetoothing” (sharing blood after injection) and “Coda” (mixing drugs with blood then sharing) emerge due to needle scarcity.
• Unsafe, improvised methods cause the disease to “flourish” alongside the drug boom.

4. Voices from the Crisis

[06:35–11:47]

• Stories from the street:
  • Dealers explain the professionalization and profitability of the drug trade.
  • Users like Ben (forced into homelessness via family rejection) contract HIV, only discovering it after illness.
  • Mary and friends, all infected after sharing needles due to police crackdown on pharmacy syringe sales, demonstrate the tragic, common stories beyond statistics.
• Knowledge gaps: Many unaware that HIV is treatable, let alone survivable.
  • Quote: “Just the number of people who find out they’re HIV positive in the same year that they die… in 2024, more than half the people who died of AIDS only found out that year they had the virus.” – Sarah Newey [08:13]

5. Societal Impact and Public Perception

[10:18–11:47]

• Local newspapers report daily on the drug crisis, often emphasizing crime over health. Community anxiety rising, especially regarding youth involvement and possible threats to tourism—vital to Fiji’s GDP.
  • Quote: “If we don’t get on top of this, there will be no Fiji.” – Local health expert via Sarah Newey [11:24]

6. Law Enforcement and Government Response

[11:47–13:27]

• Authorities are making large drug seizures (notably 2.6 tonnes of cocaine), but face corruption—27 police arrested for drug offenses (Jan 2023–Oct 2025).
• Despite international collaboration (US, Australia, New Zealand), syndicates adapt faster than authorities.
• Drug prices on the street remain stable, suggesting seizures haven’t reduced supply.

7. Rural Spread and Regional Risk

[13:27–15:19]

• Stories circulate about remote villagers mistaking drug shipments for laundry powder, highlighting the reach and potential for new epidemics.
• Warnings that a “whack-a-mole” approach to enforcement could push problems across the Pacific, risking the whole region becoming a “semi-narco region.”

8. The HIV Explosion: Causes and Consequences

[15:19–19:00]

• Drug crisis and failing harm reduction (like needle exchange) have shifted HIV from a background problem to a national threat.
• Babies now being born with HIV—a sign of community-wide spread, not just confined to at-risk groups.
  • Data: New diagnoses:
    • 147 new cases (early 2020s)
    • 1,580 in 2024
    • 1,226 in first half of 2025
  • “Only 36% of people living with HIV in Fiji actually know that they have HIV.” – Sarah Newey [16:58]
• UNAIDS predicts up to 25,000 new cases annually by decade’s end without urgent intervention—a “tsunami that’s about to hit.”

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Interview with Dr. Jason Mitchell, Head of Fiji’s HIV Task Force

HIV Response: Barriers and Challenges

[21:33–24:13]

• HIV epidemic shifted rapidly due to high-risk injecting, but government bureaucracy and slow manpower mobilization have delayed critical public health interventions, especially needle and syringe programs.
  • Quote: “We haven’t been able to introduce… needle and syringe programs. And as a result… the infections continue to spread very rapidly.” – Dr. Jason Mitchell [21:47]

Prevention & Harm Reduction Efforts

[24:13–26:19]

• Legislation exists, but practical deployment is hampered by process hurdles.
  • Fiji will introduce not an “exchange” but a “needle and syringe program” to lower access barriers.
  • PEP (post-exposure prophylaxis) was previously limited but is set for expansion beyond healthcare workers/sexual assault victims.

Stigma and Service Uptake

[26:19–29:17]

• Widespread stigma in healthcare, communities, and churches scares people away from testing/treatment.
  • Quote: “Anyone that is HIV positive now is automatically assumed to be a drug user, which is not the case. 50% of our HIV infections remain as sexual transmission.” – Dr. Jason Mitchell [26:50]
• Peer-to-peer outreach succeeds where official efforts fail—4,000 drug users reached in Suva in 12 weeks.

Traditional Beliefs vs. Medical Treatment

[29:17–31:05]

• Many Fijians rely on traditional healing and prayer. Some abandon treatment, only to return seriously ill.
  • Quote: “There is no herbal remedy or prayer… that has been documented to cure HIV. That much I know.” – Dr. Jason Mitchell [30:21]

Patient Surge & Overwhelmed Health System

[31:05–33:04]

• Clinics see unprecedented HIV-related admissions and deaths, including a worrisome increase in HIV-associated cancers and pediatric cases. Lack of medication for opportunistic infections compounds the crisis.

Projected Impact & Regional Threat

[33:06–34:39]

• Modeling shows the possibility of 25,000 HIV cases in Fiji by 2030 without scaled-up prevention and treatment.
  • “We have only found or diagnosed half [of people with HIV], and only half of those are actually on treatment.” – Dr. Jason Mitchell [33:50]
• Fiji’s status as an education and commercial “hub” means the epidemic could easily seed outbreaks across the Pacific. The economic fallout could devastate tourism, remittances, and the workforce.

Crisis Among Young People

[37:33–38:33]

• The youngest recent documented case is a 10-year-old—a result of underage intravenous drug use.
  • “Our younger populations are now engaged in intravenous drug use…” – Dr. Jason Mitchell [37:47]

What Keeps the Team Going

[38:33–40:04]

• Team members are emotionally invested, seeing their work as both a professional and personal commitment to Fiji’s survival.

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Notable Quotes & Memorable Moments

• “If we don’t get on top of this, there will be no Fiji.” – Local health expert via Sarah Newey [11:24]
• “The data is now showing us that our younger populations are now engaged in intravenous drug use. The youngest case we’ve had in the last two years is a 10-year-old.” – Dr. Jason Mitchell [37:46]
• “Anyone that is HIV positive now is automatically assumed to be a drug user, which is not the case. 50% of our HIV infections remain as sexual transmission.” – Dr. Jason Mitchell [26:50]
• “In 2024, more than half the people who died of AIDS only found out that year they had the virus.” – Sarah Newey [08:13]
• “A kilo of uncut cocaine in New York would cost about $50,000… in Auckland or Sydney, it would be $350,000. At the source in Peru or Ecuador… $1,500.” – Sarah Newey [03:17]
• “It creates fear about security in our country. And then of course, you pair it with a health issue… people get concerned about visiting our country… 40% of our GDP comes from tourism.” – Dr. Jason Mitchell [34:39]

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Important Timestamps

• 01:04–03:37 – Salient economics of the Pacific drug trade
• 03:46–05:21 – Ground-level observations in Fiji
• 05:21–06:35 – Injection practices and HIV transmission
• 06:41–11:47 – Personal stories and scale of crisis
• 13:39–14:22 – “White powder” washes ashore in rural Fiji
• 15:28–17:24 – HIV epidemic statistics and projections
• 21:33–24:35 – Dr. Mitchell on government interventions and challenges
• 26:36–29:17 – Stigma and peer outreach effectiveness
• 33:06–34:29 – Projections: 25,000 HIV cases by 2030
• 37:33–38:33 – Children, adolescents and intravenous drug use

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Tone & Language

The episode is investigative yet empathetic, blending on-the-ground reporting with expert public health insight and candid testimonials from affected Fijians. The tone is grave but determined, reflecting the emergency and the resilience of those responding.

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Summary

Fiji stands at the crossroads of a global “superhighway” for drugs, facing an unprecedented crisis where addiction, crime, and a spiraling HIV epidemic threaten its future. International traffickers, local corruption, and inadequate public health responses trap Fijians in a vicious cycle. Children as young as 10 now inject drugs; most new HIV cases are undiagnosed; stigma pervades households and hospitals alike.

While the challenges are daunting—slow-moving government processes, deeply rooted stigma, and explosive rates of infection—there are glimmers of hope: innovative harm-reduction plans, grassroots outreach, and public servants unwilling to give up. But as Dr. Jason Mitchell and Sarah Newey warn, unless these efforts scale up urgently, Fiji—and the greater Pacific—could face incalculable losses.

Transcript

[Sarah Newey]

The Telegraph.

[Dr. Jason Mitchell]

The data is now showing us that our younger populations are now engaged in intravenous drug use. The youngest case we've had in the last two years is a 10 year old. These cuts will make the world less healthy, less safe and less prosperous. Countries are continuing extremely risky research into bioweapons. It is a famine. The Gaza famine.

[Advertisement Voice]

Arthur.

[Arthur Scott Geddes]

I'm Arthur Scott Geddes and this is Battle Lines Global Health security. It's Wednesday 25th February 2026. The war on drugs has created a huge HIV boom in Fiji. Four coups over the past 40 years have opened the door to powerful drug syndicates on the archipelago known as the Gateway to the Pacific. Chinese triads, Mexican cartels and even Australian biker gangs are fueling a booming methamphetamine trade and in its wake, the fastest growing HIV epidemic on Earth. Today I'm joined by Telegraph correspondent in Bangkok Sarah Nguy, who recently travelled to Fiji to report on the epidemic. Sarah, welcome to Battle Lines. So where are all these drugs coming from?

[Sarah Newey]

Lots of places. So the Pacific islands are in a very strategically placed location in between both Latin America and Southeast Asia, two major hotspots for the production of methamphetamine, but also cocaine, heroin, etc. And so increasingly the Pacific are becoming a stopover point and there's a really thriving criminal ecosystem. The UN has done a lot of reporting on this, saying that the trade is just getting bigger and bigger and these islands are finding themselves increasingly at the forefront. We're seeing things like drones being used, narco subs, also yachts. So really it's a major stop off point and the drugs are going to Australia and New Zealand. I think that's quite important to understand because the prices that drug cartels, et cetera, can get from Australia and New Zealand are just so much higher. You know, the distance makes the prices just shoot skyward.

[Arthur Scott Geddes]

How much higher are we talking?

[Sarah Newey]

So one academic was telling me that a kilo of uncut cocaine in New York would cost about 50,000.

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[Sarah Newey]

US dollars in Auckland or Sydney, it would be $350,000, bearing in mind that at the source in Peru or Ecuador for cocaine, that would be worth about $1,500. So there's just a huge market sense for getting your drugs across. And the Pacific islands are finding themselves as just a really popular hotspot on that stopover route.

[Arthur Scott Geddes]

So, Sarah, paint me a picture of what it is that you saw while you were out there, because this is obviously a very different image to what a lot of people would have of Fiji as this kind of tropical paradise.

[Sarah Newey]

Yeah, exactly. Well, Fiji has increasingly become not just a transit point on this route, but a destination for drugs. Since about 2018, the market has gradually been booming, but now, by the time we went, it was really booming last month, and it was striking how easy it was to see drugs both being used and being traded. We went out with some drug dealers one night who took us to lots of different locations around town, a real variety, from behind a block of flats to a local bus stop to a village on the outskirts of town where you got a sense of the challenges for law enforcement, too. When we were there, our guides, who were keeping anonymous, were telling us that police struggle to get into that community. They know that there's problems there, but it's too dangerous for them effectively to go. So we drove in and we paused, and as soon as we stopped the car, a guy in a red hoodie kind of walked over and opens his hands, and there are six little pouches of meth. So it's meth that is the big drug that's being being consumed in Fiji, not cocaine or heroin. Marijuana has long been used in the country, and drugs aren't new to Fiji. But just the scale of drug use and drug trade is really what's new. This overflow kind of emerged because drugs, cartels, et cetera, increasingly started to pay people not in cash, but in product, which gave local dealers and collaborators an opportunity to triple or quadruple their money by selling these products. On the. But to do that, they needed a local market. Right. And so it's kind of all spawned from there. In the last six years, something I

[Arthur Scott Geddes]

found uniquely disturbing about your piece was some of these ways that the drugs are being taken that seem just even more dangerous than what we're used to hearing about.

[Sarah Newey]

Yeah. So there's been a mixture of reporting on this. At the beginning of the epidemic, there was lots of talk of Bluetoothing, which is this idea that one person takes the meth, then they inject themselves with meth, and it's injecting drug use that's the prevalent method of consumption in Fiji. Then someone else draws blood from that original person and re injects themselves to get a secondary high, effectively to save money. But what we found when talking to people is that they were saying, yeah, that happened maybe among inexperienced drug users or at the beginning, but people found it didn't really work. However, that hasn't meant that unsafe drug practices haven't continued. Another one that we were hearing a lot about was called coda, or taking drugs on the rocks or raw. Coda is kind of the Fijian. Traditional Fijian term for sharing, and that involves. Involves somebody basically taking their blood and mixing the crystals. Because normally you would dilute the meth crystals in water and then inject it. But people are using their blood instead, and sometimes they're sharing blood. And there's also a real problem with access to needles. Needles and syringes have not been easily available in Fiji, which has resulted in a lot of sharing of needles. So we've had these unsafe drug practices which have allowed for disease to flourish alongside this boom in drug use.

[Arthur Scott Geddes]

So in these, you know, these red zones where drug use is rife, were there any people that you met that really stuck with you?

[Sarah Newey]

There are several people who have stuck with me. We met a lot of characters. One person who I think is worth thinking about is the drug dealer who we're calling Simon. He was interesting because he really explained how the trade is working and how much money people are making. So he was a reggae musician. He said he was selling drugs to put food on the table for his children and also to ensure people had high access to high quality. High quality stuff was his phrase. There are concerns that the drugs circulating are laced with all sorts of things. But he was kind of really driving home how much the market has exploded, the way it's become so professionalized. When he was sat there on the side of the street, was sitting on the curb, and he's just going through the prices and he's rattling off like that. That was really fascinating to me. Just kind of driving home how professional people are about this and you can see why it's circulated so widely. But people have their own patches that they sell in. They're selling at wholesale price to other dealers. They're having people running 2sh a night. The pushers who are selling the drugs are earning more than them, way more than the national minimum wage. But then on the other side, there was two drug users who then became infected with hiv who really stuck with me. The first was a guy called Ben, who just had an incredibly difficult family life. He was bisexual and his father and five brothers didn't approve of this. Fiji is really conservative and there's a lot of stigma. And they effectively attacked him and drove him out to the streets where he first started using drugs. Two years later, he found out when he was really sick that he had hiv. He described it as he'd been transferred to the ward in Fiji's major hospital, which was notorious as a place that people go to die. He got this from all these risky drug practices. He was telling us how many needles he was sharing, sharing blood, wasn't really thinking about it because he just saw drugs as an escape from this really difficult scenario. And it was a community on the streets. They were all doing it, and it felt like that was part of how you belonged. For him, certainly the great thing for Ben is that several years later, his viral load is undetectable. Having had HIV treatment, one figure that I really want people to understand is that just the number of people who find out they're HIV positive in the same year that they. They die. So in 2024, more than half the people who died of AIDS, they only found out that year that they had the virus. And this happened to the friends of someone who we're calling Mary. She was older, she was 55, and she lived on the streets as well. And at the time, the actually fueled some of this health outbreak because the initial response to drugs in Fiji was very criminal heavy, like criminalized drug use. And they cracked down on pharmacies, selling syringes and needles, which meant people couldn't get access to cleans, needles and syringes. So Mary was telling us how her and her friends at the time, HIV wasn't really spreading very widely in Fiji, so they didn't think about it that much. And clean needles and syringes had become a luxury, so they all shared their needles. A few years later, she tested positive for HIV and she phoned her friends, by which point the three of them. So there were four in the group, Three of them, they always also found out they had the disease, but it was too late. And they actually she buried all three of them last year. I think it just drove home to me how common this has become and how many of these stories aren't really reflected in the official data. There's a really amazing report that came out last year, a rapid assessment of HIV and injecting drug use in Fiji. And it found that lots of people just didn't even really realize that HIV is curable. So they thought, why? What's the point of getting a test if there's no cure? These sorts of issues around lack of knowledge are prevalent in Fiji and a big problem.

[Arthur Scott Geddes]

And what do Fijians make of this kind of explosion of drug use?

[Sarah Newey]

When I was there, it was striking to me that every single day when we went down, downstairs to breakfast at our hotel, the newspapers would have a different headline about drugs. Normally it was very much from the criminal perspective. So there were calls for. Someone was calling for death penalty for drug dealers. And there was lots of talk about the trade, about there'd been a really big drug seizure only a few weeks before, so still a lot of talk about that. And when we were talking to local people, everyone was saying that they've increasingly seen drug users. One of the experts that we interviewed was telling us a tale where she, on Christmas morning popped to the shops and outside she saw someone injecting drugs just outside the supermarket. I think people are quite worried, especially about the impact on tourism and the economy, but also on the future, because it's a lot of young, really young people who were also using drugs. It's kind of tied into other issues around broken families or support systems, people finding themselves on the streets and then maybe peer pressured or intrigued to try drugs. And we saw like young people on the streets. There was one health expert we went out with who was kind of in tears over thinking about what this all means for her grandchildren, but also the future of Fiji. Something that she said really stayed with me. She said, if we don't get on top of this, there will be no Fiji. Because the trajectory of the outbreak is not looking good in terms of HIV in particular. But obviously there are all sorts of other ramifications that come from mounting drug use in a community.

[Arthur Scott Geddes]

So they are trying to crack down on this.

[Dr. Jason Mitchell]

Right.

[Arthur Scott Geddes]

Maybe we'll hear a little bit more about that from Dr. Jason Mitchell later on. But what was your sense of how well The Fijian authorities were handling the

[Sarah Newey]

situation from a drugs perspective. I think that they are really trying to crack down and there have been some really high profile seizures of drugs recently, but there are also lots of challenges. There is a problem with corruption. 27 police officers were arrested between January 2023 and October 2025 and charged with drug related offenses. There were all sorts of issues in curbing drugs. And also what one expert was telling me was that, you know, these are often syndicates who have cut their teeth against US law enforcement, et cetera, in Latin America and know how to game a system, right? These, these aren't small time drug gangs. So it's a huge problem they're working across with the us, with Australia, with New Zealand. There's been a lot of collaboration and definitely they're trying to crack down, but it's just such a big issue. I mean, what was also striking to me in conversations was we're talking about the end market, right? Getting to Australia and New Zealand, they're increasingly recording ever greater seizures at their borders of drugs. But there's been no increase in the price of drugs on the street, which suggests they're just being flooded with more and more and maybe they're seizing more, but likely increasing quantities are reaching the country in the first place. So that's on the drug side, on the HIV side, as you say. Dr. Jason Mitchell is going to take us through some of that in a moment. But I do think it's quite clear that the outbreak, which is linked in part to drug use, has spiraled out of control. And it's at the point where the trajectory is likely to get worse before it gets better.

[Arthur Scott Geddes]

You know, the impression you get from reading your story is that these islands are awash with drugs. There's quite a memorable anecdote in there about islanders discovering white powder. Could you tell that story?

[Sarah Newey]

Yes, it's a story that we heard from about four different people when we were there. And it's hard to say if it's a rumor or a fact, but the fact that so many people told us about it kind of speaks to just how prevalent it is, which was that the government has confirmed that there have been wash ups of drugs in remote islands. And people were saying that in one of these wash ups the locals just hadn't known what to make of this white powder and assumed it was washing powder. So they tried to wash their clothes with this white stuff that had rocked up on their shores. That's one of the concerns as well, that this is increasingly spreading. Not Just from the capital city in the main Fijian island, but to the maritime regions, both in terms of HIV and drug use. Obviously there's a lot less access to health services and law enforcement in those places.

[Arthur Scott Geddes]

You describe Fiji as being kind of situated on this drug superhighway, you know, with Australia off to one side and you've got these huge markets. Are the Fijian authorities working with America and Australia to kind of tackle the broader trade, or is it, you know, how are they. How are they dealing with being on this superhighway?

[Sarah Newey]

So, yes, Australia, New Zealand, the US have definitely been working with Fiji and we saw that quite prominently in this seizure of 2.6 tonnes of cocaine just in January. That was an operation that was a collaboration between multiple countries. So there's definitely work ongoing to combat this. One thing that really struck me, that Professor Jose Sousa Santos told me he's head of the security hub for the Pacific, is that this has also got to happen between collaboration between the Pacific nations, because it's not just Fiji that's on this trade. And if you start doing a whack a mole approach, where you just focus on one island and you don't do regional collaboration, then the whole of Pacific is at risk of becoming a semi narco region. He said that's the worst case scenario, but he's quite concerned that they're already heading that way.

[Arthur Scott Geddes]

So Fiji is kind of in the grip of two crises, really, that are kind of interlinked. You've got HIV and you've got the drugs. What's your sense of where all this is headed?

[Sarah Newey]

Well, I get no sense that drug use is necessarily going to change anytime soon. It feels quite embedded within society or sections of society. People are using drugs for all sorts of different reasons, but it's not just, you know, people on the streets, it's also becoming prevalent in universities, in elites, as a. As a sex drug. So I think it's going to be hard to put the genie back in the box as such, with drug use, really. The concerning ramifications as well, though, as you say, are on this HIV epidemic, which the trajectory is concerning and it's not solely linked to drug use, but these risky drug practices that we were talking about and the lack of needles has really accelerated or turned a background epidemic into something that's just at the forefront of society and it's not. And it's spreading now to all sorts of different groups. One thing that really struck me was that in the first half of 20, 25, 33 babies were born in HIV, an expert said this signals like a broader weakness in the healthcare system that shows that this is community spread as well. It's seeping out from a specific group of drug users or sex workers, and it's affecting people much more broadly. Yeah, the stats are just troubling on that front. Only four years ago, only 147 people were newly diagnosed in Fiji. That jumped to 1,580 in 2024. And in the first six months of 2025 alone, 1,226 cases were reported. But it's also so important to bear in mind that these are massive underestimates. People aren't necessarily getting tested. UNAIDS actually estimates that only 36% of people living in Fiji actually know that they have hiv. They've been. They've got a test and they've seen it's positive. So diagnosed cases are only the tip of the iceberg. Someone described it to me as a tsunami that's about to hit the country. And estimates suggests that they could have 25,000 cases a year by the end of the decade if they don't ramp up their response.

[Arthur Scott Geddes]

How has this exploded so quickly?

[Sarah Newey]

There are a few different factors at play here. Fiji had long had a background epidemic of hiv, but had mainly been contained within certain groups of people, especially gay and bisexual men and sex workers. And we're talking really low cases for a long time. There were all these warnings in the 1980s that the Pacific region was going to be battered by hiv, and. And largely because of a really strong response that never happened. But the way one expert from UNAIDS Renata was telling us was the country kind of became a bit complacent. International donor funding got diverted elsewhere where the situation was more acute, and lots of the infrastructure that existed to tackle HIV kind of dropped away in the last decade, which meant that there wasn't really a big education system or response system in place for when they've started seeing this shift into injecting drug use that cause a rampant epidemic. You started to see that more recently, but HIV has quite a long lag time from when symptoms might begin to emerge. So a lot of these infections happened like four or five years ago, and we're only just seeing the acute health symptoms now, and that's linked a lot to this boom in drug use. The pandemic accelerated it, but it had started before that, and it's just taken the government a while to catch up and respond to this shifting epidemic. But, yes, I think complacency contributed this boom in drugs contributed, the COVID pandemic contributed, stigma has contributed. And all of this has sort of created this toxic perfect storm that's triggered a massive explosion in hiv.

[Arthur Scott Geddes]

Thank you, Sarah. For anyone who's not read your piece, we'll include a link in the show notes. It's very worth checking out. And the photographs from Simon Townsley are extraordinary. After the break, we'll hear from some of your interview with Dr. Jason Mitchell. He's the Fijian doctor who is leading the response to the HIV outbreak.

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[Sarah Newey]

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[Dr. Jason Mitchell]

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[Arthur Scott Geddes]

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[Arthur Scott Geddes]

Welcome back. You're listening to Battlelines Global Health Security. Sarah Newey is speaking to Dr. Jason Mitchell, who is the head of Fiji's HIV task force.

[Sarah Newey]

Jason, thank you so much for joining Battlelines Global Health Security.

[Arthur Scott Geddes]

Thank you.

[Sarah Newey]

You're the HIV task force head in Fiji responding to this outbreak. Can we just start by how the situation got as bad as it is now? What's the overview and how do you explain the trajectory of what's been happening in Fiji.

[Dr. Jason Mitchell]

So I got involved with the HIV response well over a year now. And when I first joined the response, it was clear that something was actually happening on the ground and we weren't too sure what was causing the rapid rise in HIV infections. And so when we started looking at the data, it began to realize that the traditional sexual transmissions was leading to a lot of infections. And then there was this new group of people who were becoming infected with HIV very quickly. And this was intravenous drug users who were engaged in very high risk injecting practices that was leading to the rapid rise in HIV infections in the country. And that's continued for the best part of the last year. Ever since the creation of this task force, we haven't been able to introduce the very important public health measures known as the needle and syringe programs. And as a result of that, the infections continue to spread very rapidly in our population, mainly intravenous drug users. And of course, drug users are still sexually active. So the traditional mode of transmission continues to be an important form of transmission to those who don't belong to the group of people who inject drugs.

[Sarah Newey]

What have been the challenges that your team has faced when trying to respond to the situation you've just outlined? People have criticized it for being slow. What would be your explanation for that?

[Dr. Jason Mitchell]

I think one of the things that we have been grateful for and probably feel very lucky is that the government has made from our own budget here, the Fiji government has made $10 million available to the response. But at the same time, we're having to deal with a number of government processes which are essential to make sure funds are utilized in the right way. But they themselves have become a barrier to the rapid introduction of programs or for example, the mobilization of human resources to support some of the response work. One thing we do recognize is that we are taking human resources from other areas of health, so we can appreciate that there's a need for us to slowly trickle in the human resources for the response so that we don't have this sudden vacuum of human resources in other areas of health in the country. So I think we can totally understand the government's needs to have a slow trickling of human resources, but that has resulted in a very slow uptake of interventions on the ground. We recognize that there's a need to introduce a number of interventions. We need to do better at prevention, we need to do scale up of treatment and care programs, we need to do more testing out there in the community. We need to. All of this requires human resources you

[Sarah Newey]

mentioned the needle exchange program and also pre exposure prophylaxis and post exposure prophylaxis. When are you hoping that those interventions are going to be introduced and what have been the delays that mean that a year after declaring an outbreak and the knowledge that this was really spreading in drug users, it still hasn't been able to be enacted in Fiji.

[Dr. Jason Mitchell]

The needle and syringe program, while having the right policy support or legislative support, it is a new intervention to the country. So first of all, there's no capacity, so we needed to build that capacity in the country. We have been lucky to have a lot of resources made available to Fiji through DFAT or the Australian government. But one of the things that we are delayed on is the government processes to get the approvals through the various departments of government. In the meantime, we have set in motion the process of ordering all the resources that are required for the needle and syringe process program. So the needles, all the various arm reduction equipment that is needed to be part of the needle and syringe programs, those are currently ordered and they are making their way to Fiji. You know, if you know anything about the Pacific, you know, it takes a lot of time, but even if it were to arrive, there's still the government processes that we need to get through. Fiji has made a very bold decision not to have a needle exchange program. That's essential because the exchange component of a needle exchange program program creates a barrier for making needles and syringes accessible to our population of drug users. So we are simply introducing a needle and syringe program. There will be no pilots, no feasibility studies. It will simply be introduced and scaled up in terms of post exposure prophylaxis. This has been a very important intervention that is introduced into Fiji many years ago. When I first started in HIV almost 20 years ago, that exists here in the country currently. But what we need to do is to make that available to other population groups. Currently it's only available to healthcare workers and also those who have experienced sexual violence. We want to make PEP widely available to other population groups in our country.

[Sarah Newey]

How much does stigma play a role in Fiji in struggling to get people to come forward to test in access to treatment? What are you seeing on that side in terms of encouraging people to access services and also the kind of attitudes that exist within the country?

[Dr. Jason Mitchell]

Stigma, discrimination is a huge issue here. We have a lot of stigma not only within the health system itself. We have stigma in our workplaces, in schools, in our communities, in churches, in, you know, all segments of our life. Here in Fiji. So it makes it very difficult for us to mount an effective response because people are scared to come forward for tests in case somebody finds out they're HIV positive. I think a lot of the media around the HIV situation has not helped our cause. Certainly the linking of hiv, the HIV epidemic to drugs and the criminalities around drugs has not helped our case as well because it's anyone that is HIV positive now is automatically assumed to be a drug user, which is not the case. 50% of our HIV infections remain as sexual transmission. So you know, it's not correct to assume anyone that HIV positive is automatically a drug user. So, you know, the stigma, discrimination continues to be a battle that we need to address.

[Sarah Newey]

And what is working in terms of making sure you're accessing key vulnerable populations with services like treatment?

[Dr. Jason Mitchell]

I think it's important for us to highlight not only do we not have people coming forward for testing or people utilizing the prevention interventions that do exist in Fiji, we have a huge issue of anyone that is diagnosed with hiv. A lot of them are not actually linked to care and if they're not linked together, they are therefore not benefiting from the treatment that's freely available through the Fiji government. It's been the case since the very beginning of the epidemic. It's not something that is unique to hiv. It is an issue we face across all health areas. Compliance on medication is really poor, retention in care is really poor across all health sectors and HIV is not unique in any way. I think the stigma and discrimination associated with HIV doesn't contributes a lot to why people don't come forward for treatment and care and also why people don't remain in care. So that's an issue that we need to address. What we really want to celebrate and what we know really works for us is the involvement of communities in our response. So the involvement of communities throughout prevention, in diagnostics and treatment and care will be the interventions that we introduce that will bring us the most successful educators who are contributing to our response. They have reached out to just over 4,000 drug users here in the Subo area in a space of 12 weeks. This is something that the health workers, former health workers, would never be able to achieve. The ability of peers to reach out to peers is the way to go.

[Sarah Newey]

I just want to go back to something that you said there, which is this high drop off rate of people not accessing treatment. Why do you think that is? When I was in Fiji, I had some people saying that they were praying instead or using traditional Fijian treatments. Is that something that you've heard? And what other issues are contributing to so many people not having access to this life saving care? Do people even realize it's available?

[Dr. Jason Mitchell]

One of the things that our population, and certainly Fiji is not unique in this regard, it's the case in most of the Pacific, is our reliance on our traditional forms of healing, which also includes our faith systems. So people believing in the power of prayer to help heal people of illnesses. When I was a clinician many years ago, it was some of the challenges that we face and it hasn't gone away in this recent years. So it's something that we have to grapple with. And the one thing that we do give messages that we give to our patients is that we're not saying no to those interventions, but we're asking people to stay on their treatment. We always advise them that we don't know how. Some of our herbal medicines, for example, will interact with the medications that we are giving you, but we will not stop you from taking any of them. But we do provide them that information. Some people remain on our treatments, others will drop out. Some of them will not even tell us they're dropping out. They just simply drop out and don't return to our services. And oftentimes they come back much later when they are quite sick. There is no herbal remedy or no prayer or faith based healing that has been documented to cure hiv. That much I know and that much the scientific community is sure of. So we are asking people to, to continue to do their prayers, to continue to believe in their massages and herbal medicines. But they cannot do that alone without the interventions of modern medicine.

[Sarah Newey]

What impact is it having on Fijian society? And how are you seeing it manifest in health clinics, on the streets or in the communities?

[Dr. Jason Mitchell]

All our clinicians are speaking of the large number of HIV positive people who are presenting with opportunistic infections. Some of them have aids, which is the late stage of HIV infections. Many of them are succumbing from opportunistic infections and death rates are higher than they've ever been before. We certainly experiencing large groups of people who are living with HIV who are admitted in hospital for long periods of time. Unfortunately, one of the challenges we face here in Fiji is the absence of strong data around what we are seeing on the ground. So we don't have a good sense of how many admissions we're seeing in hospitals and how many of them are associated with HIV or opportunistic infections. But any clinician you speak to here in Fiji will tell you how overwhelmed they are with the infections that are presenting in the hospitals. And a lot of that is complicated by the absence of medications to provide for treatment around opportunistic care. We know that there's an increase in cancers that are related to hiv. We know those are on the increase, but we don't have a sense of the numbers right now. What we are reacting to here in our unit is the large number of people who are now being diagnosed with hiv. We are reacting to the large number of children who are becoming infected through their parents, through the process of pregnancy. We are reacting to the large number of children who are being admitted to hospital very sick as a result of opportunistic infections that are associated with hiv. We are reacting to the large number of people who are dying from hiv. We are reacting, of course, to the number of children who die every month as a result of hiv. This is higher than we've ever seen before. It is quite alarming what we are seeing through the numbers that are coming into our office as we wrap up the data analysis for 2025.

[Sarah Newey]

What's the trajectory of the outbreak look like?

[Dr. Jason Mitchell]

We projected in December 2024, through mathematical modeling that if we didn't introduce a needle and syringe program or prep or scale up the use of regular, consistent use of condoms into our population, by 2030, expect to have 25,000 HIV infections in Fiji. It has been estimated by UNAIDS that we have an estimated number of people living with HIV of 8,900. That's the higher limit of that number. We expect that to be an underestimation of the reality on the ground, but that's where we sit right now. We should be able to identify at least 8,900 people living with HIV in Fiji, of which we have only found or diagnosed half of them, and only half of them have been identified by healthcare workers. And even half of those are actually on treatment. So, you know, we can expect this epidemic to continue to grow exponentially the way that it has been in the last two or three years unless we have these high impact prevention interventions introduced into the country and unless we get on top of our treatment program. Treatment is not only beneficial to the individual's health, but it is a form of secondary prevention. So anyone that's on treatment and if they're viral is suppressed. Suppressed viral load means that somebody cannot transmit HIV to someone else either through sexual transmission, certainly not through intravenous drug use.

[Sarah Newey]

So what could be the impact of this on Fiji more broadly? And is there a risk of HIV spreading across the Pacific. Fiji is often referred to as the gateway of the Pacific. What's the impact on neighbouring countries?

[Dr. Jason Mitchell]

Fiji is both a gateway and also a hub of the Pacific. We say it's a hub because a lot of our students from around the Pacific come to Fiji to school. So they're in Fiji for long periods of time and they're of course at risk of any kind of infection that we have here in the country, including hiv. A large number of our civil servants from across the Pacific come to Fiji either for meetings or en route to other destinations for work related matters. So Fiji is definitely a hub. Many other countries are concerned about this and they have started activities with their students that are coming to Fiji. They're focusing a lot on awareness raising rather than building capacity on the use of prevention interventions that would reduce their risk of hiv, which is essential. Fiji is actually concerned about how the possibility that an overwhelming epidemic of HIV in the country will have a multiplying effect across, not just in health, but across other sectors. There's concern that our tourism industry will become impacted by this as tourists are often paying attention to what is happening in countries that they might be planning a holiday to. Certainly the issues around drugs is highly publicized, so it creates fear about security in our country. And then of course, you pair it with a health issue, then people get concerned about visiting our country in case they get sick and they end up in the hospital. And how safe are our hospitals? And it's just a multiplying effect. You know, 40% of our GDP comes from tourism. Our various ministries are already raising concern, a reduction in our tourist numbers. Given that HIV is one of those infections that leads to other infections, there's a possibility that it could have an impact on our very young population. As the years move along, our populations who are becoming infected with HIV become younger and younger. So there's always a fear that because people are not enrolled in care and then therefore not receiving treatment, there's always this possibility that it will impact the productivity of our country. Fiji relies a lot on industries that require healthy people to provide support to. Of course, many of our neighboring countries develop. Neighboring countries. Australia and New Zealand rely on our workforce through various schemes where our citizens go over to Australia and New Zealand to provide support to industries there that need human resources. So, you know, if people stop going to, to Australia and New Zealand, therefore it has an impact on our economy because we rely so much on remittances of people who are working overseas, sending money home to family members that stay behind so in the next couple of months, we're hoping to look into the greater impact that HIV might have on the country as a whole. We haven't done that exercise yet, but I think it's important for us to at least do some projections and some modeling to see how hiv, if unattended to, will have a greater impact on the country.

[Sarah Newey]

You've referred a few times to the nature of how young people are who are contracting hiv. You know, it really is the future generation. But just tell us a bit about what clinicians are seeing and just how young are our patients and how is that happening?

[Dr. Jason Mitchell]

The youngest case we've had in the last two years since I've been involved in this work is a 10 year old. Traditionally, anyone that would have been infected with HIV in our adolescents or very young population would have been infected through sexual transmission. But the data is now showing us that our younger populations are now engaged in intravenous drug use. And as you know, we don't have an effective harm reduction program here in the country. So it means anyone that is being engaged in drug use that involves injecting will most likely be sharing needles and syringes and that's leading to infections. Our young people are, of course, just as exposed to this as the older population of people in the country. So younger people are now becoming infected with HIV through intravenous drug use.

[Sarah Newey]

Some people have said to me that this is a really depressing situation. And how do you all keep going? How are you feeling about this outbreak and the future of Fiji and what drives you to do this work?

[Dr. Jason Mitchell]

A lot of the team members that have joined the unit have come from the HIV sector. We have been working with people living with HIV for many, many years. A lot of people living with HIV are close colleagues, they are friends of ours. We work very, very closely with our communities. You know, like I said, they're part of our work. They are with us in the trenches, so to speak. We see them every day, both as patients, as we're colleagues. So for us, this is very close to home for a lot of us. And we feel like we are there to provide support not only to this group of people that we work with on a regular basis, but to the country as a whole. And so I think a lot of us are energized by that need for us to do as much as we can for the benefit of not only those who are currently in our care, but also those who we want to prevent from becoming infected with hiv. So I think most of us are just passionate about what we do. A lot of us feel like if we weren't doing it, there would be no one else to pick this up. So I think there's a great sense of responsibility in the members of my team, not only in the Ministry of Health, but more broadly amongst our NGO partners, our CSO partners, community members, people who are affected and infected with HIV and other blood borne viruses.

[Arthur Scott Geddes]

That was Sarah newey talking to Dr. Jason Mitchell, the head of Fiji's HIV task force. That's all we've got time for on Battlelines Global Health Security. We'll be back on Friday. Goodbye. Battle Lines is an original podcast from the Telegraph created by David Knowles and hosted by me, Arthur Scott Geddes and Venetia Rainey. If you appreciated this podcast, please consider following Battle Lines on your preferred podcast app and if you have a moment, leave a review as it helps others find the show. To stay on top of all our news, subscribe to the Telegraph, sign up to our Global Health newsletter or listen to our sister podcast Ukraine the Latest. You can also get in touch directly by emailing battlelinestelegraph.co.uk or contact us on X. You can find our handles in the show. Notes the producer is Sophie o'. Sullivan. The Executive Producer is Louisa Wells. The Telegraph's Global Health Security team is supported by the Bill and Melinda Gates Foundation.

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