Anna C Gorter Zoyla E Segura Joel A Medina Julienne E McKay ICAS-Nicaragua icas

1. Anna C Gorter Zoyla E Segura Joel A Medina Julienne E McKay ICAS-Nicaragua www.icas.net Adolescent/young sex workers in Managua: evaluation of a competitive voucher program disaggregated by age Financed by the Dutch Embassy and NOVIB

2. Background • Surprisingly little data used to demonstrate effectiveness of programs targeting populations at risk of STI/HIV are disaggregated by age and present results for younger age groups • We analysed a competitive voucher program targeting populations most at risk of HIV

3. Introduction • HIV prevalence remains low in Nicaragua • Populations most at risk often receive inadequate STI/HIV care due to: • Costs of and distance to care • Marginalization, stigmatizing • Need for special measures, however • Quality STI/HIV care is expensive • Limited resources should be targeted • Targeting possible through competitive vouchers

4. Demand side financing compared to Supply side financing Demand Side Financing Supply Side Financing Competitive Vouchers Scheme Current System (Inputs) High Consumer empowerment Low Good Targeting Poor High Choice Low/No High Provider Competition Low/No

5. Providing groups most at risk with quality STI/HIV care • 1996: start competitive voucher program • Regular distribution vouchers(2-3x/year) • Contracting clinics on competitive basis • Clinics trainedin high efficacy treatment and ‘social’ protocols, closely monitored • Voucher recipients obtain free counselling, treatment/care at clinic of their choice

6. Voucher NGO's V O U C H E R V O U C H E R V O U C H E R Agency ICAS V O U C H E R V O U C H V E O R U C H E R Donor/ Government Groups most at risk of HIV Clinics V O U C H E R V Clients & O U C H Partners E R

7. Results 1996-2005 • >25 clinics contracted and trained in public, private, NGO sector • 160,000 field contacts with sex workers, glue-sniffers, transvestites, regular clients and MSM • 60,000 vouchers distributed in 21 rounds • 20,000 consultations • 7,000 STIs and 9,000 RTIs cured • 2,300 VCT (42 persons HIV positive:1.8%)

8. Results sex workers Managua 1996-2005 • 10,000 consultations, half to young sex workers, including young glue-sniffers • Exogenous changes in frequency of voucher distribution rounds(see next slide), resulting from irregular financial flows, and with no changes in other possible explanators, allows to attribute observed STI reduction to program (published in AJPH 2006;96:7-9)

9. Reduction of syphilis and trichomonas in sex workers of Managua in 21 rounds of voucher distribution (1996-2005)

10. Characteristics different age groups of sex workers

11. All SWs Managua SW >24 years SW 20-24 years SW 10-19 years Glue-sniffers 10-24 years Condom use 2002 and 2005 51%-67% *** 52%-72% *** 54%-73% *** 55%-76% ** 39%-30% Prevalence gonorrhoea 2003 7% 4% 8% 9% 26% Prevalence chlamydia 2003 13% 6% 18% 43% 6% Prevalence HIV 2003 2.7% 2.7% 1.6% 5.2% 2.4% Increase of condom use prevalence some STIs and HIV in age groupshighest in youngest sex workers *P<0.05; **P<0.005; ***P<0.00001

12. Reduction syphilis all age-groups, most in glue-sniffing SW and other young SW

13. Reduction trichomonas all age-groups, most in young glue-sniffers

14. HIV prevalence: 1991: 0.8% 1996: 1.5% 1997: 1.3% 1999: 2.0% 2000: 0.9% 2003: 2.7% HIV prevalence sex workers Managua remained low, in marked contrast to other Central American countries Young sex workers in nightclub

15. Program successful in reaching young SW most at risk • Young SWs have highest STI rates, but less access to STI/HIV care. • Vouchers could reach them, effectively reducing STI rates and increasing condom use (except among glue sniffers). • This is one of the first programs targeting SWs showing results for younger age groups: indicates much higher vulnerabilitycompared to older peers

16. More information: www.icas.net anna@icas.net zoyla@icas.net