adolescent/young sex workers in managua: evaluation of a competitive voucher program disaggregated...
TRANSCRIPT
Adolescent/young sex workers in Managua: evaluation of a competitive voucher program
disaggregated by age
Anna C GorterZoyla E SeguraJoel A Medina
Julienne E McKay
ICAS-Nicaraguawww.icas.net
Financed by the Dutch Embassy and NOVIB
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
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
Demand Side Financing
Competitive Vouchers Scheme
Supply Side Financing
Current System(Inputs)
High Consumer empowerment Low
Good Targeting Poor
High Choice Low/No
High Provider Competition Low/No
Demand side financing compared to
Supply side financing
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 trained in high efficacy treatment and
‘social’ protocols, closely monitored
• Voucher recipients obtain free counselling, treatment/care at clinic of their choice
Groups most at risk of HIVClinics
VoucherAgency ICAS
Donor/ Government
NGO's
VOUCHER
VOUCHER
VOUCHER
VOUCHER
VOUCHER
Clients & Partners
VOUCHER
VOUCHER
VOUCHER
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%)
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)
Reduction of syphilis and trichomonas in sex workers of Managua in 21 rounds of
voucher distribution (1996-2005)
0%2%4%6%8%
10%12%14%16%18%20%
Jun-96
Dec-96
Jun-97
Dec-97
Jun-98
Dec-98
Jun-99
Dec-99
Jun-00
Dec-00
Jun-01
Dec-01
Jun-02
Dec-02
Jun-03
Dec-03
Jun-04
Dec-04
Syphilis Trichomonas Voucher distribution round
Characteristics different age groups of sex workers
Median time worked
(as SW)
Never used STI/HIV care before
Mean N vouchers distributed each round at SW sites
SW all ages 3 years 18% 1,100
SW >24 years 5 years 10% 560
SW 20-24 years 2 years 17% 360
SW 10-19 years 1 ½ year 34% 120
Glue-sniffers 10-24 years
2 years 39% 60
Increase of condom use prevalence some STIs and HIV in age groups
highest in youngest sex workers
All SWsManagua
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%
*P<0.05; **P<0.005; ***P<0.00001
Reduction syphilis all age-groups, most in glue-sniffing SW and other young SW
0%
5%
10%
15%
20%
25%
30%
35%
Base96
1996/7 1998 1999 2000 2001 2002 2003 2004 2005
Glue-sniffers 10-24 years SW 10-19 years
SW 20-24 years SW>24 years
Reduction trichomonas all age-groups, most in young glue-sniffers
0%
10%
20%
30%
40%
50%
Base96
1996/7 1998 1999 2000 2001 2002 2003 2004 2005
Glue-sniffers 10-24 years SW 10-19 years
SW 20-24 years SW>24 years
HIV prevalence sex workers Managua remained low, in marked contrast to
other Central American countries
HIV prevalence:• 1991: 0.8%• 1996: 1.5%• 1997: 1.3%• 1999: 2.0%• 2000: 0.9%• 2003: 2.7%
Young sex workers in nightclub
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 vulnerability compared to older peers
