Educational Pamphlet for SW
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Voucher distribution

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Training workshop

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It is now generally recognised that guaranteed access to health services tailored to the needs of vulnerable groups most at risk of Sexually transmitted Infections (STI) and HIV-AIDS is beneficial to society by preventing the spread of HIV among the general population.

Vulnerable groups such as sex workers have historically been stigmatised because they have been associated with the transmission of STI-HIV-AIDS. This makes the uptake of health services for this group even more important, including access to appropriate information and sexual and reproductive health care.

Since 1995 ICAS has run a competitive voucher program. ICAS promotes the human rights of vulnerable groups through the voucher scheme, peer education, lobbying and advocacy. This is one of the world’s first voucher schemes for health services and has proven to be highly successful in reaching vulnerable groups with priority health services.

The voucher scheme began as a research program providing free-of-charge prevention and treatment services for STIs in Managua. The target groups are:

• Sex workers (SW)
• Glue-sniffing young people
• Transvestite sex workers and
• Their partners and regular clients

Following the success of the strategy in tackling the spread of HIV/AIDS in Nicaragua, the voucher scheme was converted to an ongoing program in 2000. At this time further vulnerable groups were added:

• Men who have Sex with Men (MSM)
• Military
• Prisoners
• Mobile populations (for example; truck drivers).

The program was scaled up to other prioritised areas of Nicaragua, particularly to the Pacific Coast, borders with Honduras and Costa Rica, the sea-ports of Corinto and San Juan del Sur, and cities along the Pan-American Road (Somotillo, Chinandega, Leon and Rivas). The voucher program now includes Voluntary Counselling and Testing for HIV and follow-up and care of People Living With HIV/AIDS, including pregnant women.

The program is now in its twelfth year and is currently being implemented at Nicaragua's southern border in Peñas Blancas and Rivas, reaching mobile populations and sex workers.

The program has received funding from the Dutch and English Government, US-AID (through the NGO-network NicaSalud), the Dutch NGO NOVIB (member of OXFAM International), the Elton John AIDS Foundation and currently from the Global Fund to fight AIDS, Tuberculosis and Malaria through the Mexican National Public Health Institute (INSP).

Promotional fair

The strategy to distribute vouchers directly at sites where vulnerable populations work or congregate has been proven to be highly cost-effective.

The strategy has received wide international recognition. The Nicaraguan experience has set an example for many other countries, and has been praised in publications from UNAIDS, WHO, The World Bank and others. A list of publications on the voucher schemes developed in Nicaragua is available at this link. Publications Vouchers 2010.pdf

For further information please contact Dr. Zoyla Segura Guevara coordinator of the Program for the prevention and treatment of STI-HIV-AIDS.

Handing out tokens

The most recent publications in English on the Program for the prevention and treatment of STI-HIV-AIDS are shown below.

• Gorter AC, Segura ZE, Medina JA, Rodriguez OG, Medina GM, Peralta WJ and Rovin K, Providing STI/HIV/AIDS services to glue-sniffing young people in Nicaragua: needs, relevance and feasibility, Abstract at the XVII International Conference on AIDS, 3-8 August 2008, Mexico City.
• Kimberly Rovin, The Situation of Drug-Addicted HIV+ Street Children in Managua, Nicaragua, Central American Institute of Health Internship, Spring 2008.
• Gorter AC, Segura ZE, Medina JA, McKay JE. Effectiveness and impact of a long running competitive voucher program providing quality STI/HIV care to groups most at risk of HIV in Nicaragua. Poster XVI International Conference on AIDS, Toronto, Canada, 13-18 August 2006.
• Gorter AC, Segura ZE, Medina JA, McKay JE. Adolescent and young sex workers in Managua, Nicaragua compared to their older peers: STI/HIV prevalence and evaluation of the effectiveness of a competitive voucher program disaggregated by age. Poster XVI International Conference on AIDS, Toronto, Canada, 13-18 August 2006.
• McKay J, Campbell D, Gorter AC, Segura Z. Can targeted STI treatment be a cost-effective contributor to HIV/AIDS prevention in developing countries despite its high unit cost? An applied study based on a long running voucher program in Nicaragua using simulation modelling to track program impacts, determine cost-effectiveness and identify cost effective program modifications. Poster XVI International Conference on AIDS, Toronto, Canada, 13-18 August 2006.
• McKay JE, Campbell DJ and Gorter AC, Can targeted, high-cost STI treatment contribute to cost-effective HIV prevention in developing countries? Evidence from a 10-year program in Nicaragua? Oral presentation IAEN Pre-Conference Meeting, Toronto 11-12 August 2006 (International AIDS Economics Network).
• McKay JE, Campbell DJ, Gorter AC. Lessons for management of STI treatment programs as part of HIV/AIDS prevention strategies. American Journal of Public Health 2006; 96:7-9.
• Gorter AC, Segura ZE, Morré SA, Chlamydia trachomatis infections in Nicaragua: Preliminary results from a competitive voucher scheme to prevent and treat sexually transmitted infections and HIV/AIDS among sex workers, in Peña S, Morré SA (ed), An integrated approach to the understanding of Chlamydia trachomatis infection, Prous Science, Barcelona, Spain, Drugs of Today 2006, 42 (Suppl. A): 47-54
• Borghi J, Gorter A, Sandiford P and Segura Z, Counting the cost of a competitive voucher scheme for STI treatment in Nicaragua, ID21 Research Highlight: 18 January 2006
• Borghi J, Gorter A, Sandiford P and Segura Z. The Cost-Effectiveness of a Voucher Scheme to Reduce Sexually Transmitted Infections in High Risk Groups: the case of Managua, Nicaragua. Health Policy & Planning, 2005; 20(4): 222-31
• The STI-HIV-AIDS Prevention and Treatment Programme for Vulnerable Populations at High Risk, Central American Health Institute, July 2005.
• Institute for Health Sector Development (IHSD-HLSP), UK, Private Sector Participation in Health. This resource reviews a number of demand- and supply-side mechanisms for engaging with the private sector. Four case studies - from Cambodia, Nicaragua (the Nicaraguan voucher scheme), Pakistan and Tanzania - illustrate some of the mechanisms reviewed, HLSP website, 2005
• WHO, Achieving the global goals: access to services, Global consultation on the health services response to the prevention and care of HIV/AIDS among young people, Technical Report of a WHO Consultation in collaboration with UNAIDS, UNFPA and Youthnet, Montreux, 17-21 March 2003. Published in 2004, Geneva, Switzerland. A chapter describes how a competitive voucher scheme works and its pros and cons. ISBN 92 4 159132 3
• Gorter A, Segura Z, Zuñiga E and Medina J, Scaling up a successful research project to reach vulnerable populations with STI/HIV care through a competitive voucher scheme in Nicaragua. Poster presentacion powerpoint, at the 15th International AIDS Conference, Bangkok, 11-16th July 2004.
• Segura Z, Gorter A, Voucher scheme for sexual and reproductive health services, Nicaragua. In UNAIDS and the Royal Tropical Institute (2004), Techniques and practices for Local Responses to HIV/AIDS, Part 2, KIT Publishers, Amsterdam, The Netherlands. Published at website KIT (Dutch Royal Tropical Institute)
• KfW, Case study of the Nicaragua voucher scheme for sex workers, in Private Sector Participation in Health Sector Cooperation – Options and Experiences, Report February 2004, edited by Private Sector Participation, KfW Bankengruppe, Frankfurt am Main, Germany.
• Julienne McKay, Executive Summary "Economic Evaluation of a Voucher Scheme Amongst Commercial Sex Workers and Their Clients in Nicaragua", Operated since 1996 by ICAS, University of Sydney, Australia. May 2004.
• Sandiford P, Competitive voucher schemes, Can they improve healthcare for the poor? ID21, Insights Health Issue #3, March 2003
• Gorter A, Segura Z, Sandiford P, Competitive Voucher Schemes for Better Health for Vulnerable Populations and Poor. Invited presentation and clinic at the Discussion Forum on Private Provision of Health Services in Developing Countries of the World Bank, Washington DC, US, November 7, 2002.
• Gorter A, Segura Z, Zuñiga E, Torrentes R, Risk factors for syphilis within a female sex worker population in Managua, analysing data from a voucher program. Oral presentation at 18th Congress of Sexually Transmitted Infections, Vienna, September 12-14, 2002
• Gorter A, Segura Z, Zuñiga E, Torrentes R, The potential of voucher schemes for the prevention and treatment of sexually transmitted infections amongst clients of sex workers. Poster presentation XIV International AIDS Conference, Barcelona, Spain, July 2002.
• Segura Z, Gorter A, Zuñiga E, Torrentes R, A voucher scheme to reach young sex workers (including glue-sniffing girls), to treat sexually transmitted infections and to prevent HIV transmission. Poster XIV International AIDS Conference 2002, Barcelona, Spain, July 2002.
• Sandiford P, Gorter A and Salvetto M. Vouchers for Health, Using Voucher Schemes for Output-Based Aid. The World Bank Group. Public Policy for the Private Sector, Viewpoint 2002; 243, 1-4. Spanish translation here.
• Sandiford P, Gorter A and Salvetto M. Use of voucher schemes for output-based aid in the health sector in Nicaragua: three case studies. Invited presentation at the World Bank workshop on Output-Based Aid (OBA), Frankfurt, Germany, January 24-26, 2002 (link to Voucher schemes.
• Gorter A, Segura Z, Zuñiga E, Torrentes R, The ICAS voucher scheme to combat HIV/AIDS, Nicaragua. Invited presentation at the DfID Safe Passages to Adulthood & WHO Expert Meeting, Brighton, UK, December 2001. Published in the DfID/WHO Safe Passage to Adulthood series: Preventing HIV/AIDS, promoting sexual health, among especially vulnerable young people, July 2002 (series on best practices ISBN 0-85432-783-5).
• Gorter A and Sandiford P, Vouching for health: HIV prevention for sex workers in Nicaragua, ID21 News, March 2001.
• Gorter A, Segura Z, Zuniga E, Torrentes R and Sandiford P, A voucher program can efficiently target groups with high need for sexual health services, the case of Managua, Oral Presentation 13th World Aids Conference, Durban, June 2000. The program received a special mention at the last day rapporteur session of the conference.
• Gorter A, Segura Z, Sandiford P, Zuñiga E, Torrentes R, Ådahl S. “You should not tell us to use condoms, but our clients!” An extended voucher program in. Research for Sex Work Newsletter 3, July 2000, Amsterdam.
• Sandiford P, Salvetto M, Segura Z, Gorter A. Clinics for sex workers in Managua. In Harper M (ed.) 'Public services through private enterprise; micro-privatisation for improved delivery', IT Publications, London, and Oxford IBH Publishers New Delhi, 2000.
• Gorter A, Sandiford P, Segura Z and Villabella C. Improved health care for sex workers. A voucher program for female sex workers in Nicaragua. Research for Sex Work Newsletter 2, August 1999, Amsterdam.