Hepatitis C: An In-Depth Guide

Safer injection

One of the best ways for people who inject drugs to avoid infection by blood-borne diseases like hepatitis C is to use new sterile equipment (that has not been used before) every time. This means not reusing any materials, including:

  • materials used for injection
    • needles
    • syringes
    • tourniquets
  • materials used for drug preparation
    • cookers and spoons
    • filters
    • water
    • swabs

The term “reusing” includes borrowing, lending, passing on, buying, selling, sharing, receiving or taking any equipment that was used by someone else. Some people do not identify risk with the word “sharing” or when reusing involves a close sexual partner (like a boyfriend or girlfriend). Risk exists, even under these circumstances.

The hepatitis C virus is able to survive outside the body for at least four days. There are conditions in which the virus can survive for weeks—for example, in blood that collects inside a needle or syringe during an injection. The amount of blood needed to pass on an infection is small and blood does not have to be visible for it to be infectious. Microscopic amounts of blood could be on the surface where the drugs and equipment are set up or on any one of the pieces of equipment. Used equipment can also cause more abscesses than new sterile equipment.

The harm reduction information that follows is offered as a public health service. Its purpose is not to encourage or condone the use or possession of illegal drugs. It is to help people make safer choices in their use of drugs that will reduce the spread of Hep C and HIV.

Hep C Prevention and Long-Term Injection Drug Use

Many people who inject drugs are able to stay safe and prevent Hep C over the long-term. Often, this is made possible by a mix of personalized safer-injecting routines, environmental support and luck.

Personalized safer-injection routines can take time to develop and differ from person to person. For example, injecting in a group but having a personal zone, avoiding injecting in places where people commonly share drugs, and always injecting with the same group of people are different ways to avoid sharing or losing track of one’s own equipment.

Steps to Safer Injection

People who inject drugs can take steps to reduce the chances that they will either contract Hep C or pass it on to others if they are already infected. The injection steps below can be divided into five distinct stages: Planning ahead, Preparation, Mixing, Injecting and Cleaning up. The equipment distributed in safer-injection kits can be obtained from local needle exchange programs.

Adapting the steps

Remember that harm reduction aims to be client-centered and practical! Think about what a person is already doing well and which safer-injection steps, given the individual and his or her context, are realistic to work on. Can steps be adapted to better suit a person? Are there priorities?

Injection in a group setting and injection during withdrawal  (“dope sickness”) are two risk situations where basic steps can be adapted to avoid or safely cope with challenges to safer injection.

Safer injection in a group setting

If a person is injecting in a group, he or she can reduce the chance of accidental sharing by marking his or her own equipment in a way that makes it easy to tell apart from other people’s equipment. Some ideas for marking equipment include:

  • using a waterproof felt pen or nail polish
  • putting a piece of tape around the barrel of the syringe, the handle of the cooker and the tourniquet
  • cutting off half the plunger top and half the handle of the cooker
  • scraping a number off the barrel of the syringe

Dividing the drugs

Sharing drugs can come with different risks depending on how the drugs are divided. If two or more people are sharing drugs, the safest option is to divide the dry drugs in the preparation stage and then each person can use their own equipment to cook and inject.

If two or more people are sharing drugs, the safest option is to divide the dry drugs in the preparation stage and then each person can use their own equipment to cook and inject.

If drugs intended for sharing were not divided beforehand, frontloading or backloading (piggybacking) are other options. This involves drawing up all of the drug solution into one syringe and using that syringe to squirt the solution into other syringes through the front end where the needle is (frontloading) or the back end where the plunger is (backloading).

  • Frontload and backload with new, unused syringes. If the syringe used to divide the hit has been used before, it could be contaminated and could easily contaminate the drugs and other equipment.
  • One way to ensure that everyone is using brand-new equipment is for everyone to open the packaging together.
  • People can learn to be comfortable frontloading and backloading by practicing with water.

Frontloading and backloading are not as safe as dividing the drug when it is dry because it is hard to make sure that another person’s equipment is sterile. However, these practices are safer than using one syringe to inject more than one person.

Safer injection and withdrawal

Differences between the amount of drugs needed to avoid withdrawal and the money available to buy drugs can cause people to have periods of forced withdrawal (“dope sickness”). The physical and psychological effects of withdrawal can negatively impact injection safety by, for example, increasing the chance a person will rush the process, share equipment or inject in an unsafe environment. Thinking about how to avoid or cope with a period of forced withdrawal before it happens can help reduce risk.

 Strategies for harm reduction include:

  • avoiding withdrawal by putting aside drugs or money for buying drugs to use in an emergency
  • avoiding withdrawal by collaborating with others to collectively buy drugs
  • snorting or smoking the drug (instead of injecting) during an episode of withdrawal
  • bringing new needles and other equipment if going to areas where other people are injecting and asking for some of their drugs during an episode of withdrawal
  • accessing a supply of methadone during an episode of withdrawal

You may wish to explore this with people who inject drugs.

Planning ahead

Planning and preparation play an important part in reducing the risk of contracting or passing on hepatitis C infection and other harmful consequences associated with injection drug use. Two things a person can think about ahead of time and prepare for are:

1. How to inject: Knowing how to prepare and inject drugs gives an individual more control over decisions about safer-drug use and preventing hepatitis C and HIV. This is especially true for women and youth, who may rely on others to inject them. People can learn how to inject safely by talking with a harm reduction worker or watching a peer video.

Learning how to prepare and inject drugs safely is also important for new drug users of any age or sex. Many new cases of hepatitis C happen among new drug users. This is partly because new users may not know about the risk of getting an infection or about the steps of safer injecting. 

2. What supplies are needed: Being prepared by having on hand a stash of all new equipment needed helps a person avoid borrowing or sharing used equipment. Needle exchanges give out new equipment for free. Supplies given out by needle exchanges vary from region to region but should include:

  • alcohol swabs
  • cookers
  • sterile water
  • vitamin C powder or citric acid
  • filters
  • tourniquets or ties (made of pliable, easy-to-tie-and-release material)
  • sterile/new syringes 

People should be encouraged to use new equipment every time. In cases where there is no access to needle exchanges, local pharmacies also sell most items. For people who do not have access to supplies or cannot spend money on new equipment but want to reduce the risk of hepatitis C or HIV, items can be cleaned between each use but not shared between people. Bleach does not kill hepatitis C. (For information about cleaning needles and other equipment, see the FAQ When can I use bleach against Hep C?)

Needles and syringes are not all the same. This is important to keep in mind when it comes to hepatitis C transmission.

  • In general, the thickness of the needle should match the thickness of the vein the person is injecting into. Using a needle that is too large or too thin for a vein can cause more bleeding and more opportunities for infection.
  • A smaller amount of blood collects in fixed-needle syringes than in syringes with detachable needles. The hepatitis C virus can survive for longer—sometimes for months—in syringes with detachable needles than in fixed needle syringes (i.e. weeks).

A person uses equipment based on factors such as individual preference, the particular drug, the condition of his or her veins and what is available. Remember that not everyone has choice around what type of equipment is available in his or her area.  


1. Some places are safer for injecting than others. A place that is dry, well lit and has running water so people can wash their hands thoroughly is preferable. This will help to reduce the chance of infections. The ideal place is also one that is away from interference, especially from the police, and helps people feel that they can take their time injecting safely and cleaning up afterwards.

  • No running water? Hands can also be wiped with an alcohol swab included in injection kits. Wiping in one direction can clean the hands effectively. Wiping in circles or back and forth simply moves bacteria around.

2. The work surface can be cleaned with soap and water or a new piece of newspaper can be used to create a clean space for setting out equipment.

3. All the equipment should be kept within reach.


1. Dissolving the drug fully will prevent insoluble particles from entering the bloodstream and causing health problems (such as chalk lung). Adding sterile water from the ampoule to the cooker will dissolve the drug.

  • If a person is injecting a pill, crushing it as finely as possible with a sterile crushing tool (two spoons or a pill crusher) will reduce the chances of injecting undissolved particles. If it has a coating, this will not dissolve and can cause vein damage if it enters the bloodstream. Clean fingers, a clean cloth or paper and sterile water are the best tools to use to remove the coating—saliva, dirty fingers or dirty clothes can lead to bacterial infections (such as cotton fever or abscesses). 
  • Cool water that has been boiled beforehand can also be used to dissolve the drug. A syringe can be used to transfer water from the cup of cooled boiled water to the cooker, but if a person draws up water with a used syringe, both the water and the cup have been contaminated. If other people continue to use the same water and cup, their equipment can be contaminated, too.
  • A pinch of vitamin C about one-quarter the size of the rock is us e  d  t o help  dissolve brown heroin and crack. Too much vitamin C will make the  solution too acidic and can cause vein problems. Vinegar and lemon juice are not recomme nded, as they can cause fungal infections and damage veins.

2. Applying heat can help drugs dissolve more completely and reduce the complications that come with injecting undissolved particles.

  • Some drugs will clump when heated, so a test can be done first by dissolving a small sample. Others, such as cocaine, do not need to be heated at all.
  • If the cooker touches the flame, soot may get into the solution and cause health problems when injected.

3. Adding a new sterile filter to the cooker and drawing up the liquid through this filter further reduces the amount of particles that could make it into the bloodstream.

  • Reusing filters can spread Hep C and also cause health problems such as cotton fever.

4. Removing air bubbles from the syringe will prevent air embolisms, which are rare medical complications that happen when gas or air gets into the bloodstream. Air bubbles can be removed from a syringe by following these three steps:

  • pointing the needle skywards
  • flicking gently on the side
  • pushing the plunger up slowly to push out any air bubbles and until a small droplet of liquid appears on the tip of the needle


1.  Cleaning the injection site using an alcohol wipe or soap and water will prevent bacteria, dirt and other germs on the skin from getting pushed into the veins by the needle. 

  • People can plan ahead so they don’t have to touch the site once it’s clean,  which can transfer bacteria back to the injection site. For example, they can consider cleaning more than one site in case they miss the vein the first time around.
  • Wiping in only one direction will push the dirt and bacteria off the injection site. A circular or back-and-forth motion will just move the germs and dirt around and they will stay on the skin.

2. Finding a vein to inject into is the next step.

  • Rotating sites allow veins time to rest and repair after being used and will help prevent them from collapsing or becoming infected with abscesses. Typically, veins in the hands and arms are the best sites to use. Some parts of the body are very dangerous to inject into and people are strongly encouraged to avoid using them. These parts are the neck, groin, penis, eyes, feet and breasts.
  • Some techniques for finding a vein include:
    • using a thin, pliable tourniquet that is easy to release
    • running warm water over the site
    • tightening the shirt sleeve on the upper arm
    • making a pumping action with the fist
    • swinging the arm in a circle

3. With the needle bevel up (the opening of the needle facing up), the needle is slowly inserted into the vein. The needle should be at about a 35-degree angle and inserted in the direction of the heart (the direction of blood flow) to reduce vein damage.

  • Using the needle to “fish around” for a vein will cause bruising and damage the veins. Instead, it is recommended that the person remove the needle and try again. The site will need to be cleaned again if it was touched by anything but the needle.

4. Flagging will ensure that the needle is in the vein. Flagging involves pulling the plunger back slowly until a little blood flows into the syringe. When people miss the vein during injection, they can cause abscesses or may not get high from the drug, depending on which substance is used. Injecting into arteries will cause intense pain and swelling in the limbs and has the potential to cause excessive blood loss as well as waste the drug and its desired effects.

  • When flagging, if the blood is frothy or brighter red than usual, or if the plunger is pushed back by pressure from the blood, the needle has likely hit an artery. This can result in serious blood loss. Removing the needle slowly and applying pressure to the spot with a clean tissue will help stop the bleeding. Raising the limb can help, too. If bleeding continues and there is swelling or pain after 10 minutes, medical attention is needed.

5. Once the person is sure that the syringe is in the vein, he or she releases the tourniquet and slowly pushes the plunger in to inject the drug.

  • If a person is trying a new drug, using again after a long break or recently switched dealers, taking half a hit or half a dose to test the potency of the drug can help prevent overdose.
  • Releasing the tourniquet before injecting or as quickly as possible after injection is important. Injecting into a tied-off vein can cause pressure in the vein and lead to vein ruptures.

6. The needle is slowly removed at the same angle as it was inserted, to reduce vein damage. Pressure is applied on the spot for a few minutes with a clean, dry gauze, tissue or cotton ball to stop the bleeding. Using an alcohol swab for this will actually cause more bleeding because the alcohol prevents the blood from clotting.

Cleaning Up

1. Disposing of all used equipment, including needles and filters, will prevent other people from coming into contact with contaminated supplies. This will reduce the risk of transmitting hepatitis C and other blood-borne infections as well as the risk of causing abscesses.

  • Sharps containers are available from most needle exchange programs. The used needle can also be put in an empty plastic bottle that has a tight-fitting lid (like a bleach bottle or pop bottle).
  • Attempting to re-cap a needle may lead to an accidental needle-stick, which could spread hepatitis C and HIV.
  • It is important to dispose of all the other equipment in the sharps container as well. None of the equipment should be reused or shared because of the risk of transmitting hepatitis C from blood-to-blood contact between people and because used equipment can cause more abscesses and other infections than new sterile equipment. 

2. Because the hepatitis C virus can live on surfaces for many days, the final steps are for the person to wash both the work surface and his or her hands with soap and water, and to dispose of any newsprint or paper that was used during injection.

Revised 2011.