1. Adolescent/young sex workers in Managua: evaluation of a competitive voucher program disaggregated by age Anna C Gorter Zoyla E Segura Joel A Medina Julienne E McKay ICAS-Nicaragua www.icas.net Financed by the Dutch Embassy and NOVIB

2. Background Surprisingly little data used to demonstrate effectiveness of programs targeting populations at risk of STI/HIV are disaggregated by age and present results for younger age groups We analysed a competitive voucher program targeting populations most at risk of HIV

3. Introduction HIV prevalence remains low in Nicaragua Populations most at risk often receive inadequate STI/HIV care due to: –Costs of and distance to care –Marginalization, stigmatizing Need for special measures, however –Quality STI/HIV care is expensive –Limited resources should be targeted –Targeting possible through competitive vouchers

4. Demand Side Financing Competitive Vouchers Scheme Supply Side Financing Current System (Inputs) High Consumer empowerment Low Good Targeting Poor High Choice Low/No High Provider Competition Low/No Demand side financing compared to Supply side financing

5. Providing groups most at risk with quality STI/HIV care 1996: start competitive voucher program Regular distribution vouchers (2-3x/year) Contracting clinics on competitive basis Clinics trained in high efficacy treatment and ‘social’ protocols, closely monitored Voucher recipients obtain free counselling, treatment/care at clinic of their choice

6. Groups most at risk of HIV Clinics Voucher Agency ICAS Donor/ Government V O U C H E R V O U C H E R Clients & Partners V O U C H E R V O U C H E R V O U C H E R

7. Results 1996-2005 >25 clinics contracted and trained in public, private, NGO sector 160,000 field contacts with sex workers, glue-sniffers, transvestites, regular clients and MSM 60,000 vouchers distributed in 21 rounds 20,000 consultations 7,000 STIs and 9,000 RTIs cured 2,300 VCT (42 persons HIV positive:1.8%)

8. Results sex workers Managua 1996-2005 10,000 consultations, half to young sex workers, including young glue-sniffers Exogenous changes in frequency of voucher distribution rounds (see next slide), resulting from irregular financial flows, and with no changes in other possible explanators, allows to attribute observed STI reduction to program (published in AJPH 2006;96:7-9)

9. Reduction of syphilis and trichomonas in sex workers of Managua in 21 rounds of voucher distribution (1996-2005)

10. Characteristics different age groups of sex workers Median time worked (as SW) Never used STI/HIV care before Mean N vouchers distributed each round at SW sites SW all ages3 years18%1,100 SW >24 years5 years10%560 SW 20-24 years2 years17%360 SW 10-19 years1 ½ year34%120 Glue-sniffers 10-24 years 2 years39%60

11. Increase of condom use prevalence some STIs and HIV in age groups highest in youngest sex workers All SWs Managua SW >24 years SW 20-24 years SW 10-19 years Glue- sniffers 10-24 years Condom use 2002 and 2005 51%- 67% *** 52%- 72% *** 54%- 73% *** 55%- 76% ** 39%- 30% Prevalence gonorrhoea 2003 7%4%8% 9%26% Prevalence chlamydia 2003 13%6%18%18% 43%6% Prevalence HIV 2003 2.7% 1.6% 5.2%2.4% *P<0.05; **P<0.005; ***P<0.00001

12. Reduction syphilis all age-groups, most in glue-sniffing SW and other young SW

13. Reduction trichomonas all age-groups, most in young glue-sniffers

14. HIV prevalence sex workers Managua remained low, in marked contrast to other Central American countries HIV prevalence: 1991: 0.8% 1996: 1.5% 1997: 1.3% 1999: 2.0% 2000: 0.9% 2003: 2.7% Young sex workers in nightclub

15. Program successful in reaching young SW most at risk Young SWs have highest STI rates, but less access to STI/HIV care. Vouchers could reach them, effectively reducing STI rates and increasing condom use (except among glue sniffers). This is one of the first programs targeting SWs showing results for younger age groups: indicates much higher vulnerability compared to older peers

16. More information: www.icas.net anna@icas.net zoyla@icas.net