Conducting formative research during a pandemic threat to inform the development of an obesity prevention social and behaviour change communication strategy in Tonga.

ISSUE ADDRESSED: The global epidemic of obesity is overtaking many parts of the world with the Pacific Islands at particular risk. Tonga population surveys identify significant increases in overweight and obesity with Social and Behaviour Change Communication (SBCC) offering opportunities for curbing the rise in non-communicable diseases. Formative research was conducted during the Covid-19 pandemic to assess stakeholder and program beneficiary needs and wants toward an obesity prevention SBCC strategy in Tonga. METHODS: Semi-structured interviews with 17 key informants and 18 focus group discussions (N = 168) were conducted in Tongatapu. Data analysis was conducted on Nvivo 2020 qualitative software with desk research of secondary data supporting in-field findings. RESULTS: Potential barriers to behavioural compliance included social/cultural norms, poor attitudes; low motivation and capability; and vulnerabilities of gender and other social determinants. Opportunities included the Tongan collective mindset and the desire for greater social interaction and fun. Strong political will to affect change was apparent with the need to consider targeting to youth, social mobilisation of communities through empowering messaging, and an integrated range of activities. CONCLUSIONS: Co-design in the formative research process was able to be fostered via online communication processes to overcome the challenges of Covid-19 travel restrictions. The innovative approach provided a number of learnings including identification of national and regional priorities and improved efficiencies in SBCC planning, implementation and evaluation. SO WHAT?: Formative research adopting co-design approaches with stakeholders and program beneficiaries can provide optimal engagement and ownership in the SBCC strategy including insights into messaging approaches.

Sweetened beverage taxes and changes in beverage price, imports and manufacturing: interrupted time series analysis in a middle-income country.

BACKGROUND: The Pacific Island nation of Tonga (a middle-income country) introduced a sweetened beverage tax of T$0.50/L in 2013, with this increasing further in 2016 (to T$1.00/L), and in 2017 (T$1.50/L; US$0.02/oz). Given the potential importance of such types of fiscal intervention for preventing chronic disease, we aimed to evaluate the impact of these tax changes in Tonga. METHODS: Interrupted time series analysis was used to examine monthly import volumes and quarterly price and manufacturing 1 year after each tax change, compared with a counterfactual based on existing trends. Autocorrelation was adjusted for when present, and adjustments were made for changes in GDP per capita, visitor numbers, season and T$/US$ exchange rate. RESULTS: In the year after the 2013, 2016 and 2017 tax increases, the price of an indicator soft drink increased by 16.8% (95%CI: 6.3 to 29.6), 3.7% (- 0.6 to 8.3) and 17.6% (6.0 to 32.0) respectively. Imports of sweetened beverages decreased with changes of - 10.4% (- 23.6 to 9.0), - 30.3% (- 38.8 to - 20.5) and - 62.5% (- 73.1 to - 43.4) respectively. Juice imports changed by - 54.2% (- 93.2 to - 1.1), and sachet drinks by - 15.5% (- 67.8 to 88.3) after the 2017 tax increase. Tonga water bottling (T$) increased in value by 143% (69 to 334) after the 2016 tax increase and soft drink manufacturing increased by 20% (2 to 46, albeit 5% market share). CONCLUSIONS: Consistent with international evaluations of sugar-sweetened beverage taxes, the taxes in Tonga were associated with increased prices, decreased taxed beverages imports, and increased locally bottled water.

Effectiveness and Feasibility of Taxing Salt and Foods High in Sodium: A Systematic Review of the Evidence.

Diets high in salt are a leading risk for death and disability globally. Taxing unhealthy food is an effective means of influencing what people eat and improving population health. Although there is a growing body of evidence on taxing products high in sugar, and unhealthy foods more broadly, there is limited knowledge or experience of using fiscal measures to reduce salt consumption. We searched peer-reviewed databases [MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and the Cochrane Database of Systematic Reviews] and gray literature for studies published between January 2000 and October 2019. Studies were included if they provided information on the impact on salt consumption of: taxes on salt; taxes on foods high in salt, and taxes on unhealthy foods defined to include foods high in salt. Studies were excluded if their definition of unhealthy foods did not specify high salt or sodium. We found 18 relevant studies, including 15 studies reporting the effects of salt taxes through modeling (8), real-world evaluation (4), experimental design (2), or review of cost-effectiveness (1); 6 studies providing information relevant to country implementation of salt taxes; and 2 studies reporting stakeholder perceptions toward salt taxation. Although there is some evidence on the potential effectiveness and cost-effectiveness of salt taxation, especially from modeling studies, uptake of salt taxation is limited in practice. Some modeling studies suggested that food taxes can have unintended outcomes such as reduced consumption of healthy foods, or increased consumption of unhealthy, untaxed substitutes. In contrast, modeling studies that combined taxes for unhealthy foods with subsidies found that the benefits were increased. Modeling suggests that taxing all foods based on their salt content is likely to have more impact than taxing specific products high in salt given that salt is pervasive in the food chain. However, the limited experience we found suggests that policy-makers favor taxing specific products.

Getting it right when budgets are tight: Using optimal expansion pathways to prioritize responses to concentrated and mixed HIV epidemics.

BACKGROUND: Prioritizing investments across health interventions is complicated by the nonlinear relationship between intervention coverage and epidemiological outcomes. It can be difficult for countries to know which interventions to prioritize for greatest epidemiological impact, particularly when budgets are uncertain. METHODS: We examined four case studies of HIV epidemics in diverse settings, each with different characteristics. These case studies were based on public data available for Belarus, Peru, Togo, and Myanmar. The Optima HIV model and software package was used to estimate the optimal distribution of resources across interventions associated with a range of budget envelopes. We constructed "investment staircases", a useful tool for understanding investment priorities. These were used to estimate the best attainable cost-effectiveness of the response at each investment level. FINDINGS: We find that when budgets are very limited, the optimal HIV response consists of a smaller number of 'core' interventions. As budgets increase, those core interventions should first be scaled up, and then new interventions introduced. We estimate that the cost-effectiveness of HIV programming decreases as investment levels increase, but that the overall cost-effectiveness remains below GDP per capita. SIGNIFICANCE: It is important for HIV programming to respond effectively to the overall level of funding availability. The analytic tools presented here can help to guide program planners understand the most cost-effective HIV responses and plan for an uncertain future.

Relapse to opioid use in opioid-dependent individuals released from compulsory drug detention centres compared with those from voluntary methadone treatment centres in Malaysia: a two-arm, prospective observational study.

BACKGROUND: Detention of people who use drugs into compulsory drug detention centres (CDDCs) is common throughout East and Southeast Asia. Evidence-based pharmacological therapies for treating substance use disorders, such as opioid agonist treatments with methadone, are generally unavailable in these settings. We used a unique opportunity where CDDCs coexisted with voluntary drug treatment centres (VTCs) providing methadone in Malaysia to compare the timing and occurrence of opioid relapse (measured using urine drug testing) in individuals transitioning from CDDCs versus methadone maintenance in VTCs. METHODS: We did a parallel, two-arm, prospective observational study of opioid-dependent individuals aged 18 years and older who were treated in Malaysia in the Klang Valley in two settings: CDDCs and VTCs. We used sequential sampling to recruit individuals. Assessed individuals in CDDCs were required to participate in services such as counselling sessions and manual labour. Assessed individuals in VTCs could voluntarily access many of the components available in CDDCs, in addition to methadone therapy. We undertook urinary drug tests and behavioural interviews to assess individuals at baseline and at 1, 3, 6, 9, and 12 months post-release. The primary outcome was time to opioid relapse post-release in the community confirmed by urinary drug testing in individuals who had undergone baseline interviewing and at least one urine drug test (our analytic sample). Relapse rates between the groups were compared using time-to-event methods. This study is registered at ClinicalTrials.gov (NCT02698098). FINDINGS: Between July 17, 2012, and August 21, 2014, we screened 168 CDDC attendees and 113 VTC inpatients; of these, 89 from CDDCs and 95 from VTCs were included in our analytic sample. The baseline characteristics of the two groups were similar. In unadjusted analyses, CDDC participants had significantly more rapid relapse to opioid use post-release compared with VTC participants (median time to relapse 31 days [IQR 26-32] vs 352 days [256-unestimable], log rank test, p<0·0001). VTC participants had an 84% (95% CI 75-90) decreased risk of opioid relapse after adjustment for control variables and inverse propensity of treatment weights. Time-varying effect modelling revealed the largest hazard ratio reduction, at 91% (95% CI 83-96), occurs during the first 50 days in the community. INTERPRETATION: Opioid-dependent individuals in CDDCs are significantly more likely to relapse to opioid use after release, and sooner, than those treated with evidence-based treatments such as methadone, suggesting that CDDCs have no role in the treatment of opioid-use disorders. FUNDING: The World Bank Group, Doris Duke Charitable Foundation, National Institute on Drug Abuse, Australian National Health & Medical Research Council, National Institute of Mental Health, and the University of Malaya-Malaysian Ministry of Higher Education High Impact Research Grant.

Scaling up of HIV treatment for men who have sex with men in Bangkok: a modelling and costing study.

BACKGROUND: Despite the high prevalence of HIV in men who have sex with men (MSM) in Bangkok, little investment in HIV prevention for MSM has been made. HIV testing and treatment coverage remains low. Through a pragmatic programme-planning approach, we assess possible service linkage and provision of HIV testing and antiretroviral treatment (ART) to MSM in Bangkok, and the most cost-effective scale-up strategy. METHODS: We obtained epidemiological and service capacity data from the Thai National Health Security Office database for 2011. We surveyed 13 representative medical facilities for detailed operational costs of HIV-related services for sexually active MSM (defined as having sex with men in the past 12 months) in metropolitan Bangkok. We estimated the costs of various ART scale-up scenarios, accounting for geographical accessibility across Bangkok. We used an HIV transmission population-based model to assess the cost-effectiveness of the scenarios. FINDINGS: For present HIV testing (23% [95% CI 17-36] of MSM at high risk in 2011) and ART provision (20% of treatment-eligible MSM at high risk on ART in 2011) to be sustained, a US$73·8 million ($51·0 million to $97·0 million) investment during the next decade would be needed, which would link an extra 43,000 (27,900-58,000) MSM at high risk to HIV testing and 5100 (3500-6700) to ART, achieving an ART coverage of 44% for MSM at high risk in 2022. An additional $55·3 million investment would link an extra 46,700 (30,300-63,200) MSM to HIV testing and 12,600 (8800-16,600) to ART, achieving universal ART coverage of this population by 2022. This increased investment is achievable within present infrastructure capacity. Consequently, an estimated 5100 (3600-6700) HIV-related deaths and 3700 (2600-4900) new infections could be averted in MSM by 2022, corresponding to a 53% reduction in deaths and a 35% reduction in infections from 2012 levels. The expansion would cost an estimated $10,809 (9071-13,274) for each HIV-related death, $14,783 (12,389-17,960) per new infection averted, and $351 (290-424) per disability-adjusted life-year averted. INTERPRETATION: Spare capacity in Bangkok's medical facilities can be used to expand ART access for MSM with large epidemiological benefits. The expansion needs increased funding directed to MSM services, but given the epidemiological trends, is probably cost effective. Our modelling approach and outcomes are likely to be applicable to other settings. FUNDING: World Bank Group and Australian National Health and Medical Research Council.