1. Risk factors for syphilis within a female sex worker population in Managua, analysing data from a voucher programme Anna Gorter Zoyla Segura Esteban Zuñiga Roger Torrentes ICAS-Nicaragua Financed by NOVIB

2. Nicaragua 5.2 million Managua 1 million

3. NICARAGUA Early stage of the epidemic First AIDS case reported: 1987 AIDS cases reported: 392 Prevalence HIV adults: 0.2% Prevalence sex workers: 2%

4. Why a special program for groups with high STI rates Early in the epidemic interventions in such groups are highly cost effective In Managua these groups have NO or limited access to STI services due to: –Costs, distance, time –Stigmatising –Low human and technical quality Need for client-friendly STI services of high technical quality

5. Limited resources High quality STI services are expensive Limited resources should target those at highest risk One feature of vouchers is that they can target those at highest risk Analysis provides epidemiological profiles We examined data from our voucher program, to determine risk factors attributing to higher syphilis rates in female sex workers of Managua

6. What is a Voucher Program An alternative for the existing model of a centralised system, deciding which health services will be delivered It is financed from the demand side (users) as opposed to financing from the supply side (providers/clinics) Clinics compete for demand from users It puts the user central

7. Supply Side Financing Funding Agency Health Care Provider Users Exemption Mechanism/Contract/Norms and Standards

8. Demand Side Financing Funding Agency Health Care Provider Independent Purchaser/ voucher agency users contracts norms

9. 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)"

10. Example of a Voucher

11. Some characteristics of vouchers Power of choice with the consumerPower of choice with the consumer Improves the quality of servicesImproves the quality of services Reduces costsReduces costs Uses existing infra-structureUses existing infra-structure Can target those at highest riskCan target those at highest risk Those at highest risk, self-selectThose at highest risk, self-select

12. The Voucher Program in Managua Started in 1995 The vulnerable groups it reaches are: –Sex workers (including female and male glue-sniffers) –Transvestite sex workers –MSM with high rates of partner change –Clients and partners of these groups Prevention and treatment of STIs

13. Methods City-wide map of prostitution sites Interviews with vulnerable groups STI treatment protocols Competitive tender/clinics contracted Clinic staff trained Vouchers distributed at 6 month intervals (rounds) Medical attention Technical and human quality monitored

14. 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

15. Services Offered Consultation and follow-up Treatment protocol: - tests for syphilis, trichomoniasis, candidiasis, gardnerella and cervical cancer - physical examination of condilomata, herpes, chancroid and other STIs

16. ….. services - counselling on safe sex and prevention of STIs, condoms - presumptive treatment with single dose of Azithromycin (1 gram) - additional treatment if necessary Voluntary counseling and HIV testing Gonorrhoea testing was performed during the first 4 years to measure impact of the program

17. Prostitution in Managua 50-60 prostitution sites 1,150 female sex workers (FSW) Of FSW about 100 are glue- sniffing girls and women About 200 male glue-sniffers About 40 transvestites

18. Young pregnant glue-sniffing girl

19. Female Sex Workers Medium age is 25 (11 to over 60) 24% is younger than 20 years Turnover is very high with an overall medium working time of 2 years 1/3 worked one year or less –Adult women 3 years –Young sex workers 1 year Medium years of education is 6 One fourth <4 years of schooling

20. Young SWs in night-club

21. Overall results Between 8 to 10 clinics contracted (public, private and NGO clinics) In 7 years > 18,000 vouchers distributed > 7,000 consultations provided > 2,700 STIs detected and treated

22. Results in FSWs Each round 40% of FSWs used voucher > 3,000 different FSWs participated 5% reduction per year for prevalence of gonorrhoea (first 4 years) 6% reduction per year for prevalence of syphilis (over the full 7 years)

23. Prevalence syphilis per price for vaginal sex P<0.000005 for trend

24. Prevalence syphilis for age of sex worker P<0.0001 for trend

25. Prevalence syphilis for level of education P<0.000001 for trend

26. Prevalence of HIV In 1999 the overall prevalence of HIV in FSWs was 2%: Young FSW had double the HIV rate of adult FSW: - Young FSWs:3.1% - Adult FSWs:1.6%

27. Results syphilis FSWs Overall prevalence active syphilis was 4.7% 229 cases (5.6% first round - 3.3% last round) In FSW who used voucher more then once syphilis reduced from 7.5% to 3.5% 75% of cases were at sites with lowest prices for vaginal sex (represents just 1/3 of all FSWs) Illiterate, young FSWs at sites with lowest prices had highest rate: 15%

28. ….results syphilis Women with medium schooling and at sites with lowest prices had higher prevalence than illiterate women at best paying sites (6.7% against 2.4%) Only women with highest education succeeded in low levels of syphilis at poor paying sites (2%) and had no syphilis at sites with best prices

29. Conclusion STI programs should target FSWs working for lowest prices Safe sex education should be directed towards FSWs with little or no education and especially the youngest

30. Instituto CentroAmericano de la Salud (ICAS) www.icas.net zoyla@icas.net Gracias por su atención