A voucher scheme to reach young sex workers (including young glue-sniffing girls), to treat STI’s and to prevent HIV transmission Zoyla Segura Anna Gorter Esteban Zuniga Roger Torrentes ICAS-Nicaragua Financed by NOVIB

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

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

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

The Voucher Program in Managua Started in 1995 The vulnerable groups it reaches are: –Female sex workers, including glue-sniffing girls –Glue-sniffing boys –Transvestite sex workers –Clients/partners of these groups (since 1999) –Men who have sex with men (since 2001) Prevention and treatment of STIs Prevention development AIDS epidemic

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

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

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

Prostitution in Managua (1,300,000 inhabitants) sites with prostitution 1,150 female sex workers –24% younger than 20 years –of the young SW ¼ is addicted to glue Turnover sex workers is high with a medium working time of: –Overall 2 years (range 1 week-30 years) –Adult women 3 years –Young sex workers 1 year

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 Of vouchers distributed to sex workers 40% is used 2,840 different sex workers attended (690 younger than 20)

Young and glue-sniffing sex workers Glue-sniffing SW’s marketYoung SW’s in nightclub

Young SW’s have more STIs then adult SW’s

Prevalence in young sex workers decreased

Prevalence in gluesniffers decreased

Conclusions Young SW, including glue-sniffers can be reached effectively Girls most in need make more use of their voucher STI rates reduced considerably Voucher schemes should be considered as highly effective in attracting young SW’s with high levels of STIs, treat their STI’s and promote safer sexual behavior

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