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

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 Contract/Norms and Standards Exemption Mechanism/ Health Care Provider Funding Agency Health Care Provider Users

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

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 consumer • Improves the quality of services • Reduces costs • Uses existing infra-structure • Can target those at highest risk • Those 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. 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

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