Effectiveness of competitive voucher program providing

care to groups most at risk of HIV in Nicaragua

Anna C GorterZoyla E SeguraJoel A Medina

Julienne E McKay

ICAS-Nicaraguawww.icas.net

Financed by the Dutch Embassy and NOVIB

Background

• 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

Competitive voucher schemes

• Competitive voucher schemes can easily target limited resources to populations most at HIV-risk by distributing vouchers at prostitution sites or other sites where these groups congregate

• Competitive vouchers are a type of demand side financing

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 Managua 1996-2005

• We report results for 10,000 consultations provided to sex workers in Managua

• 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

Different socio-economic strata in sex workers

Type of prostitution site

Price paid for vaginal sex by type of site

Mean N of vouchers distributed in each round (‘96-’05)

Young female glue-sniffers

US$ 0.50-1 75

Poor sex workers at markets

US$ 1-3 335

Sex workers in bars and streets

US$ 4-10 490

Sex workers in red light area

US$ 10-15 200

All sex workers in Managua

- 1,100

Overview reduction syphilis and trichomonas and increase condom use among different

socio-economic strata sex workers  

All SWsManagua

Glue-sniffers

Poor SW at Markets

Bars/ Streets

Red Light area

Mean N of vouchers distributed 2-3 times per annum ‘96-‘05

1,100 75 335 490 200

Syphilis prevalence 1996 and 2005

9%-3%***

28%-7%***

17%-4%***

6%-1%**

1%-0.5%

Trichomonas prevalence 1996 and 2005

16%-8%***

39%-15%**

13%-6%*

15%-7%**

10%-8%

Condom use 2002 and 2005

51%-67%***

39%-32%

47%-69%***

55%-76%***

61%-79%**

*P<0.05; **P<0.005; ***P<0.00001

Reduction syphilis in all socio-economic strata (especially in the poorest)

0%

5%

10%

15%

20%

25%

30%

Base96

1996/7 1998 1999 2000 2001 2002 2003 2004 2005

Glue-sniffers Market Bars/streets Red Light

Reduction trichomonas in all socio-economic strata (especially poorest)

0%5%

10%15%20%

25%30%35%40%45%

Base96

1996/7 1998 1999 2000 2001 2002 2003 2004 2005

Glue-sniffers Markets Bars/streets Red Light

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

Reaching groups most at risk with STI/HIV care successful

• The voucher program:– attracted even most marginalized sex workers

(SW) to high efficacy STI/HIV care– reduced STI prevalence / increased condom use– contributed to maintaining low HIV prevalence

• SWs in lowest strata, with highest initial STI rates, recorded most significant declines

More information:

www.icas.net

anna@icas.net

zoyla@icas.net