1. The Potential of Voucher Schemes for the Prevention and Treatment of STI’s amongst Clients of Sex Workers Anna Gorter Zoyla Segura Esteban Zuniga Roger Torrentes ICAS-Nicaragua Financed by NOVIB

2. NICARAGUA First AIDS case reported: 1987 AIDS cases reported: 392 Prevalence HIV adults: 0.2% Prevalence sex workers Managua: 19910.8% 19971.3% 19992.0% Highest among young sex workers

3. What is a Voucher Program A program in which health service providers are reimbursed for the number of patients attended Services best performing are selected Provision of services can be targeted to special (vulnerable) populations It puts the patient central and gives the power of choice to the consumer

4. What is a voucher A document which can be exchanged for defined goods or medical services as a token of payment OR “Tied cash As opposed to liquid cash” Example of voucher

5. The Voucher Program in Managua Started in 1995 The vulnerable groups it reaches are: –Female sex workers (including glue-sniffers) –Transvestite sex workers –Clients/partners of these groups (since 1999 sex workers redeeming their voucher receive one or two vouchers for their partner/clients) –Men who have sex with men (since 2001) Prevention and treatment of STIs Prevention development AIDS epidemic

6. Vulnerable groups Clinics Voucher Agency 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. Methods City-wide map of sites with prostitution Interviews with vulnerable groups Competitive tender/contracting of clinics Training of all staff in clinics Voucher distribution biannually (rounds) Medical attention with “best practice” treatment protocols Monitoring quality clinics, only best clinics contracted for subsequent rounds

8. Services Offered Consultation and follow-up Tests for syphilis, trichomonas,candida, gardnerella and cervical cancer Physical examination of condilomata, herpes, chancroid and other STIs Counseling safe sex, condoms Single dose of Azithromycine Additional treatment if necessary Voluntary counseling and HIV testing Gonorrhoea testing was performed during the first 4 years to measure impact of the program

9. Prostitution in Managua (1,300,000 inhabitants) 50-60 sites with prostitution 1,150 sex workers (SW) 40 transvestite sex workers Turnover sex workers is high Medium working time SW is 2 years Estimate regular clients is 5 to 10,000 Medium time clients visit SW is 3 years Medium number visits per months is 4

10. Overall results Between 8 to 10 clinics are contracted (public, private and NGO clinics) In 7 years (13 rounds ) > 20,000 vouchers distributed > 7,000 medical consultations > 3,000 STI’s detected and treated

11. Reduction of STI’s in SW from round 1 to round 13 Reduction STI’s / year: –trichomonas 5% –gonorrhoea 5% –syphilis 7% Poorest sex workers with highest STI rates made much more use of their vouchers Poor SW in market

12. Reduction STI’s in sex workers who used a voucher 3 times or more

13. Results Clients 3473 vouchers distributed through SW 682 vouchers used (20%) Highest redemption at sites with lowest prices and nightclubs (highest prices) Medium age is 25 (12 to 89 years) 60% had never visited a sexual health service before (because of perceived low technical quality of existing providers) Clients once diagnosed with an STI are more prepared to use a condom

14. STI’s amongst clients 49% one or more STI’s Of STI’s: –77% non-ulcerative –23% ulcerative Most frequent were: –chlamydia, gonorrhoea, syphilis, chancroid Number of STI’s per client

15. Conclusions Those in highest need, self-select Especially true in clients: men with high levels of STI’s used their voucher Therefore reduces costs Also it uses existing infra-structure and improves quality Voucher schemes should be considered as a new effective way to attract clients of SW’s, treat their STI’s and promote safer sexual behaviour

16. More information: www.icas.net bonos@ibw.com.ni agorter@ibw.com.ni