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Vouching for health: HIV prevention for sex workers in Nicaragua

What methods of HIV prevention work best for countries in the early stages of the epidemic? How can sexual healthcare services be improved cost-effectively? Researchers from the Central American Institute of Health, Nicaragua and the UK Institute for Health Sector Development report on a healthcare voucher programme in Managua, Nicaragua.

The programme trains health clinic staff and provides vouchers for free sexual healthcare to commercial sex workers (CSWs) and their partners and clients. It is highly successful at reaching CSWs and clients and reducing sexual transmitted infections (STIs). A voucher programme can be a low-cost, efficient way of improving sexual healthcare services and reducing STIs, the study concludes.

Nicaragua is still at a relatively early stage of the AIDS epidemic. The total number of reported AIDS cases up to March 2000 was 242. The HIV prevalence among adults is estimated to be 0.19 percent. This in is stark contrast to the much higher figures reported from neighbouring countries. In the early stages of an HIV epidemic, prevention strategies directed at groups with a high incidence of STIs are very cost-effective.

CSWs were heavily involved in the design of the programme when it was established in 1995. The aim is to increase the uptake of sexual healthcare by the 1200 CSWs of Managua and their regular clients and sexual partners. In addition, it aims to improve the quality of sexual health services. Vouchers are exchanged for free sexual healthcare at a number of clinics, which are then reimbursed by the programme.

This study reports on the first four years of the project. Vouchers were distributed eight times during this period. Training for clinic staff aimed to improve both sensitivity and technical skills. The researchers found that:

Training greatly improves the attitude and sensitivity of clinic receptionists.
The technical capabilities of the clinics are also improved by training of clinical doctors.
40 percent of the vouchers distributed to CSWs are used.
CSWs who use the vouchers have a reduced incidence of STIs.
CSWs who work in the poorest areas have a higher prevalence of STIs. They also tend to use their vouchers more.
Male partners and clients use their vouchers less than CSWs. Despite this, the programme is efficient since the STI prevalence among these men is very high.

The implications of these findings for health planners designing HIV prevention programmes include:

A voucher programme can improve the quality of medical care at low cost and in a non-stigmatising manner.
It can attract otherwise hard-to-reach groups; vouchers can be distributed directly to groups at high risk.
Vouchers can be distributed at low cost by third parties with close contacts to specific population groups.
Sex workers can give vouchers to those men most likely to re-infect them.
Competitive pressure between health clinics holds down the prices for services and improves quality.
The programme can produce a reduction in prevalence and incidence of STIs.

Source(s):
'A voucher programme can efficiently target groups with high need for sexual health services: the case of Managua' by A. Gorter et al. (2000)

Funded by: UK Department for International Development; The Elton John Aids Foundation; The Novib Foundation, The Netherlands

id21 Research Highlight: 30 March 2001

Further Information:
Anna Gorter
Instituto Centroamericano de la Salud
Managua
Nicaragua

Contact the contributor: henkanna@worldonline.nl

Instituto Centroamericano de la Salud

Peter Sandiford
Institute for Health Sector Development
27 Old Street
London
EC1V 9HL
UK

Tel: +44 (0)20 7253 2222
Fax: +44 (0)20 7251 4404
Contact the contributor: peter@sandifords.net

Institute for Health Sector Development

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