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Anna Gorter Zoyla Segura Esteban Zuniga Roger Torrentes ICAS-Nicaragua Financed by NOVIB

Anna Gorter Zoyla Segura Esteban Zuniga Roger Torrentes ICAS-Nicaragua Financed by NOVIB. The Potential of Voucher Schemes for the Prevention and Treatment of STI’s amongst Clients of Sex Workers. NICARAGUA. First AIDS case reported: 1987 AIDS cases reported: 392

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Anna Gorter Zoyla Segura Esteban Zuniga Roger Torrentes ICAS-Nicaragua Financed by NOVIB

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

  2. NICARAGUA • First AIDS case reported: 1987 • AIDS cases reported: 392 • Prevalence HIV adults: 0.2% • Prevalence sex workers Managua: 1991 0.8% 1997 1.3% 1999 2.0% • 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. 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” What is a voucher 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. NGO's V O U C H E R V O U C H E R V O U C H E R Voucher V Agency O U C H E R V O U C H V E O R U C H E R Donor/ Government Vulnerable groups Clinics V O U C H E R V Clients & O U C H Partners 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 STI’s / year: trichomonas 5% gonorrhoea 5% syphilis 7% Poorest sex workers with highest STI rates made much more use of their vouchers Reduction of STI’s in SWfrom round 1 to round 13 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

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