Hepatitis C Prevention for People Who Inject Drugs
Using New Insights and Best Practices to Prevent Infection
With over 30,000 infections reported in 2014 -- at least 70% of which occurred among people who inject drugs (PWID) -- and all the challenges that can come with HCV prevention, it can sometimes feel like infection is inevitable in people who inject drugs, but it doesn't have to be.
Hepatitis C virus is mainly transmitted from blood to blood contact when someone shares a syringe or other injecting equipment with someone infected with the virus. The gold standard of HCV prevention is using a new syringe and unused injection equipment each and every time you inject, and you never have to share anything. This is easier said than done: Sometimes you have no other option but to re-use a syringe. When faced with this situation, there are things you can do to help prevent infection.
The strategies given here also serve to prevent HIV. We are fortunate that there are some very thoughtful researchers who have looked are various ways to prevent HCV infection. Their work helps people make informed decisions over how to best minimize their risk for infection. The information in this article draws on this work, focusing on ways in which HCV can be transmitted through the sharing of injecting equipment, ways to kill HCV, and some practices that people who have been injecting drugs for a long time yet never got HCV do to stay negative. This is not an exhaustive review of safer injecting practices, for that we have a list of resources at the end of this article to help you learn more on the subject.
A word on preventing hepatitis C infection: There's a lot to think about in this article, and it can look so overwhelming as to feel like it's almost impossible to do all the things listed below. The principles of harm reduction will guide our work here--you do what you can, with no judgment around what you can't.
Safer Injecting: More Than Just the Syringe
The primary way in which HCV infection occurs is through the sharing of syringes: That's where the most blood is (especially in high dead-space syringes) and that is the most direct way for HCV to get into a person. That said, the sharing of other injecting equipment -- cookers, cotton, water -- can lead to HCV infection, too.
Hepatitis C can live for a while on surfaces and in injecting equipment ("works" like cookers, cotton, and water).
Syringes: The type of syringe matters. All syringes have a thing called "dead space," that is a small amount of space where fluid -- in this case blood -- remains even when the plunger if fully depressed. The dead space is also called a "void." You may be using low dead space (or low void) or high dead space (or high void) syringes when you inject. Ask your local syringe access program or pharmacy where you get syringes for specifics about the syringe you are getting, but in general, syringes with a fixed needle are low dead-space (low-void) and ones with a detachable needle are high dead-space (high-void). Low dead-space ones are easier to clean if you have to re-use them. If you're not sure what type of syringe you have, bleach works really well on either type. For other disinfectants, check out the instructions below for the number of times you need to use them and rinse and repeat to kill hep C.
Surfaces: The research on surfaces is on things like tables or counters. Wiping them down with a bleach or other cleaners will kill hep C. They haven't really studied how well you can disinfect a cooker, but cleaning it with bleach should be good enough to do the trick if you have to re-use one.
Water: If you get HCV-infected blood in water, it can contaminate the container it's in. The type of container matters: Plastic and aluminum can hold HCV-infected blood in its pores even if you dump out the water. If you place clean water back in that plastic or aluminum container, that water will get contaminated with hep C. Recycle the plastic or can and get a new one. Glass won't do this: If blood gets in the water of a glass container, dump the water, clean the glass with bleach and rinse it out well with soap and water and you'll be able to put in fresh water for use in drug prep.
Cotton: There's no way to disinfect cotton if it gets HCV-infected blood in it.
What Kills Hepatitis C: Bleach, Rubbing Alcohol, Dish Soap and More
If HCV is such a tough virus, is there anything that can kill it and reduce the chances for transmission? Researchers from Yale have looked at various disinfectants to see what works and what doesn't work. Bleach kills HCV nearly all the time, and there are other cleaners or disinfectants you can use, too, that also work against the virus.
Bleach: Bleach has been shown to kill HCV in more than 99% of contaminated syringes. There are many variables, though: How fresh is your bleach? How much blood is in the syringe? Research has shown that when you draw up the bleach and immediately rinse it out, you'll disinfect the syringe. If you see blood in the syringe, rinse it once with cold water to dilute the blood. After you've rinsed out the bleach, rinse the syringe thoroughly with cold water.
Over time, bleach can damage the syringe and needle, so ideally you don't have to use the same needle and bleach it over and over: After 20 rinses with bleach, there is a lot of damage to the syringe. Besides, the more you have to use a syringe, the duller the needle point becomes and the greater the risk for abscesses and damaged veins. Get a new, unused syringe as quickly as possible: Ideally, you just use one syringe (and other equipment) for each injection.
Alcohol, hydrogen peroxide, and kitchen sink detergent (for example, Dawn Ultra) can kill HCV also, and are less damaging to the syringe. But they are all less effective than bleach, and require multiple rinses. They are good alternatives when an unused syringe or bleach are not available.
Alcohol and hydrogen peroxide: Rubbing alcohol (check the label for 70% isopropanol), hydrogen peroxide, and Lysol can kill HCV. Draw up alcohol, rinse, and repeat twice more for a total of three rinses. You can do the same with hydrogen peroxide and Lysol. The length of time doesn't seem to matter: You just have to do the draw-up, rinse, and repeat pattern three times.
NOTE: Neither beer (5% alcohol) nor fortified wine (20% alcohol) is strong enough to kill HCV.
Kitchen sink detergents (Dawn Ultra): Recent research has shown that common cleaning supplies, such as Dawn Ultra, can kill HCV. Put the liquid soap into some water to dilute it and make it easier to draw into the syringe. Rinse and repeat at least one more time. The length of time doesn't seem to matter: You just need to draw-up, rinse, and repeat the pattern three times.
Industrial-grade disinfectants should not be used. These include Barbicide (that blue stuff they use in barbershops and nail salons) as well as Cavicide and Clorox Quartanary Cleaner (both used in medical settings) that can be used on surfaces and for cleaning up blood spills, but should not be used in injecting or other drug-using equipment.
Wiping down surfaces where drug preparation and blood occur with bleach is also a good thing to do to avoid blood contact from surfaces.
Best Practices for Staying HCV-Negative: Lessons on Staying Safe
Although it can feel like injecting drugs and HCV go hand-in-hand, it can be prevented, and there are people who have been injecting for years and years but who have never been infected with HCV. In addition to bleach and other disinfectants, there are a number of practices that people use to help minimize their risk of HCV.
If you're ready to stop injecting drugs, that's the most direct way to keep hepatitis C infection from happening. This is not always easy: Sometimes it can be hard to get into a treatment program, there may not be one that is a good fit for you, or you may not be ready to stop right now.
If you can't stop, and you want or need to keep injecting drugs, there are things you can do to prevent infection (these can also be used to prevent reinfection). There are several practices for preventing hep C that longtime injectors who have never been infected have used. Again, refer back to a principle of harm reduction, which says that drug users themselves are the experts and "the primary agents of reducing the harms of their drug use and seeks to empower users to share information and support each other in strategies which meet their actual conditions of use." It is with this in mind that the "Staying Safe Project" sought to learn directly from people who inject drugs (PWID) on how people can potentially stay HCV negative while injecting drugs. The study was international in its scope, but the tips below come from an article published from the London study.
The following list describes a selection of strategies and practices that people who have stayed HCV negative use. You may be able to do some of these things, while others may be difficult. Do what you can and don't beat yourself up over the things you find challenging:
Set Up Your Own Personal Rules About Not Sharing Injecting Equipment and Disposing of Syringes
If possible, don't share anything: syringes, cookers, water, cotton filters, and tourniquets for both drug preparation and injection. If you need to re-use a syringe, clean it out with bleach or other disinfectants (see above), and do the same with cookers. Cotton filters and water can't be disinfected if HCV blood gets in them. You'll need to discard them and get unused cotton filters and fresh water.
When done with syringes and works, dispose of them in a sharps container (those red containers people put syringes in) and/or take them to your local syringe access site to dispose of them.
Take Charge of Your Drug Preparation and Injection
Try to take time to slowly and carefully prepare for your injection. Wash your hands with soap and water before you begin. Wipe down the surface where your drug preparation is going to happen with bleach or other cleaners. If you don't have anything, lay down some newspaper or napkins to prepare on.
Prepare your own drug mix. If you're injecting with others, volunteer to do the prep and split it with them in a way that does not lead to blood getting into the process. For example, split the drug up before preparing it all so each person has their own. You can also use an unused syringe to draw up the prepared drug and use it to put into each person's syringe ("backloading" or "frontloading"; check out the Harm Reduction Coalition's "Getting Off Right" booklet for more safe injecting info).
Separate and/or Mark Your Drug Injecting Equipment
Mark your syringes and injecting equipment to avoid mixing your stuff with that belonging to others. You can use a permanent marker or scratch off a number on the barrel of a syringe and so on. Store your injecting equipment in a kit that is clearly yours.
If possible, keep an extra stash or two of unused syringes and injecting equipment. You can keep one for yourself, and have one for someone else who might need something.
Prepare and Plan Ahead
If you inject heroin, the need to avoid withdrawal symptoms and getting dope-sick can lead a person to take more injecting risks than they usually would. Snorting or smoking a little before injecting could take the edge off while you prepare your injection (remain mindful of the risk of drug overdose: inject less if you took a little before). Stockpiling a little methadone or buprenorphine to take when you need it can help during these times, too.
Take a Break From Injecting for a While
If you can sniff or smoke your drug, try that for a while. This can give your veins a break and make injecting later a little easier. If there's no unused syringes or injecting equipment, try sniffing or smoking the drug to avoid sharing works.
If you smoke, try not to share pipes, especially if you have cracked lips or sores in your mouth: Blood from a pipe is a less efficient way of HCV transmission, but it can happen. The same is true with sniffing: sharing straws can lead to blood-to-blood contact in the nose. Again, it's less efficient than injecting, but definitely possible. Grab a few extra straws from a coffee shop so you have some on hand when needed (see the box for more harm reduction tips to reduce risk).
Preventing hepatitis C is not easy, but there are things you can do to help minimize your risk. In addition to the strategies listed here, you can find more information in the resources listed below. Regardless of what you do, try to integrate HCV testing into your care, and test routinely, at least once a year, but you can do it more frequently too, if you like.
For more information and one-on-one support around hepatitis C harm reduction and prevention, you can call the HELP-4-HEP line at (877) HELP-4-HEP, (877) 435-7443.