Spotlight Series on Hepatitis C

Staying Safe: What People Who Inject Drugs Know About Preventing Hep C and HIV

Fall 2013

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People who borrow and lend drug injection equipment, including needles, are at risk of getting and passing on hepatitis C and HIV. However, there are people who have been injecting drugs for a long time who have managed to "stay safe" from hepatitis C or HIV. What have these people done to avoid infection for so long? The Staying Safe project sought to examine the strategies that these people have used to stay free of hepatitis C and HIV. Sharing these strategies may help others also "stay safe."1

Are Many People Who Inject Drugs at Risk?

Some people who inject drugs borrow used needles or other injection drug use equipment, which can put them at risk for HIV and hepatitis C. According to a national study of people who use injection drugs, 15% had borrowed someone else's needle or syringe and 31% had borrowed other injection equipment (such as cookers, water or filters) in the past 6 months. Half of participants had also lent used needles to others in the past 6 months.2

According to the same national study, 66% of people who use injection drugs have or have had hepatitis C3 and 13% have HIV.2 The HIV/hepatitis C co-infection rate was 12% which means that many people living with HIV also have hepatitis C.

There are existing programs that have been proven to reduce the risk of HIV and hepatitis C transmission. Needle and syringe exchange programs provide clean needles and syringes to people who inject drugs. They reduce needle sharing and have been shown to reduce risk behaviours and HIV and hepatitis C infection rates.4Peer outreach programs, which reach hidden and marginalized communities, expand the scope of services and deliver information and services to a greater number of people. These programs are critical in helping reduce the transmission of HIV and hepatitis C.


The Staying Safe Project

The Staying Safe project is different from many studies looking at hepatitis C and HIV infection among people who inject drugs. Unlike other studies, it focussed on people who inject drugs as experts in their own health. Twenty-one people who use injection drugs were interviewed to find out what strategies they used to avoid HIV and hepatitis C infection. These people were chosen for the study because they had managed to stay negative for a long time (8 to 15 years). The original study was conducted in New York City and was led by Samuel Friedman, a long-time researcher in the social aspects of injection drug use. It has been adapted in many cities including Sydney and Melbourne, Australia; London, England; Valencia, Spain; St. Petersburg, Russia; and Vancouver, B.C.5 However, this article will focus on the results from the New York study.

What Can the Staying Safe Project Tell Us?

Staying in Control of Withdrawal Is Key to "Staying Safe"

Drug withdrawal is an awful experience. People who are going through withdrawal can experience anxiety, insomnia, nausea, vomiting, diarrhea, muscle aches and pains, and other symptoms.6 Since withdrawal feels so terrible, people do whatever they can to stop the symptoms, including re-using equipment to get a "fix."7

Staying Safe participants use two main tactics to manage or avoid withdrawal: balancing their income with the cost of drugs and maintaining good relationships so they have access to resources when needed.

Balancing Income and the Cost of Drugs

In order to gain an income, some participants maintain legal jobs or receive some form of social assistance. Others are involved in the underground economy, such as selling drugs or sex work. One of the key ways people who use injection drugs manage withdrawal is by balancing their income with their needs, including food and drugs. This can be challenging, since long-term drug use can lead to increased drug tolerance, meaning that using gets more expensive over time, because drug users have to increase the dose in order to achieve the same effect. However drug users who try to ensure they have enough money to support their drug use are more likely to avoid HIV and hepatitis C infection.

Many participants have gone through times when they could not maintain their income and were unable to afford the same amount of drugs they were taking. In these situations they had to decrease their drug use, which led to withdrawal symptoms. Participants have many strategies for addressing withdrawal, which allow them to avoid activities that could lead to infection.

Short-term strategies include:

  • Taking a "maintenance" level of drugs (just enough to avoid withdrawal)
  • Using other medications to manage withdrawal symptoms, such as methadone (used for opiate treatment), other pain pills or prescribed psychiatric pills
  • Toughing out the symptoms of withdrawal.7

Long-term strategies include:

  • Storing drugs for times when money is low
  • Using methadone to decrease drug use to an affordable level
  • Weaning themselves down to a level of drug use that is within their means.

Maintaining Relationships

To avoid withdrawal when money gets low, a number of participants in the study borrow money from family members or friends to buy drugs or borrow drugs from their drug dealer. Participants are sure to pay them back in order to maintain the relationship and be able to borrow again in another time of need.7

Participants also rely on their social connections to obtain access to a place to stay, a shower, or somewhere to store things while they are homeless. They maintain these relationships by being respectful to friends or family and never taking their belongings to buy drugs. These relationships help people to maintain a certain amount of stability during periods of low income or homelessness, which reduces the likelihood they will borrow drug use equipment.8

Another strategy that participants use is making sure that they and the partner they inject with have a morning bag (or "wake-up bag") of drugs before they go to sleep. This can prevent situations where partners ask to use drugs or drug use equipment when they experience withdrawal symptoms in the morning.8

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