Prevention in Focus

Fall 2013 

Staying Safe: what people who inject drugs know about preventing Hep C and HIV

By Scott Anderson

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.4 Peer 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

Strategies for dealing with people who want to share injection drug use equipment

Planning for prevention

Staying Safe participants plan in advance how to access new equipment prior to using drugs.9 They also share harm reduction strategies and new injection equipment with people in their social network. Another key strategy they use includes teaming up with someone else, with one person buying the drugs and the other person getting new syringes and drug use equipment, so that both people can safely inject.1 These activities prevent situations where sharing equipment could occur.

Navigating peer pressure

Some people avoid situations where they know that people could pressure them to share needles and other injection drug use equipment. These participants inject with people they know use safe injection practices, or they inject alone (however, this does create its own hazard of overdosing alone with no one to help). Other participants use strategies such as coming up with reasons that are acceptable to the group for refusing to share drug use equipment, for example, having a fear of blood.10 Some participants bring extra needles and other drug use equipment when they are injecting in group situations in case anyone asks them to share.7

Environmental factors matter for “staying safe”

Staying Safe researchers identified several environmental factors that support “staying safe” strategies. These include having a regular income, social support, access to new needles/syringes and other drug use equipment, available treatment for drug use, and a steady drug supply. Despite having a range of strategies for “staying safe,” participants in the study have had a challenging time maintaining these strategies when these environmental factors are disrupted. For some, losing housing, not being able to get drug use equipment, being arrested or dealing with poverty can make carrying out “staying safe” behaviours an even greater challenge.11

What can service providers do?

Many of the strategies used by participants in the Staying Safe project could be adopted by anyone who injects drugs and the service providers who provide harm reduction education.

Front-line workers can organize informal peer education sessions where “staying safe” strategies are shared. Participants could be encouraged to share these strategies with their friends and acquaintances. “Staying safe” strategies can also be incorporated into existing peer harm reduction training programs.

Where needle exchange programs are unavailable, frontline workers and people who use drugs can advocate for their establishment. Established needle exchange programs could allow people to stock up on needles and other drug use equipment so they can have a long-term supply or share with others.

When offering one-to-one support, service providers can strategize with people who use injection drugs about how to avoid withdrawal, including brainstorming about how to keep their income and drug use in balance. Conversations could also include discussions about short-term management of withdrawal that doesn’t involve borrowing drug use equipment. One example could be sharing the Staying Safe project participants’ strategy of taking a “maintenance dose.”

Another way frontline workers can support the efforts of people who use injection drugs to “stay safe” is by supporting clients to stabilize their environment through finding housing and income supports and maintaining relationships with family and friends.

People who use injection drugs have created many important strategies to avoid hepatitis C and HIV and these along with other harm reduction measures have helped to reduce rates of hepatitis C and HIV in Canada. The sharing of their expertise is one way to further contribute to decreasing the rates of hepatitis C and HIV in Canada among injection drug users.


Staying Safe Intervention reduces risk for Hep C and HIV in people who inject drugs

Prevention & Harm Reduction

Safer injection

The epidemiology of HIV in people who inject drugs in Canada – CATIE Fact sheet


  • 1. a. b. Friedman SR, Mateu-Gelabert P, Sandoval M, Hagan H, Des Jarlais DC. Positive deviance control-case life history: A method to develop grounded hypotheses about successful long-term avoidance of infection. BMC Public Health. 2008 8(94). Available at:
  • 2. a. b. Public Health Agency of Canada. I-Track: Enhanced Surveillance of Risk Behaviours among People who inject Drugs. Phase I Report, August 2006. Surveillance and Risk Assessment Division, Centre for Infectious Disease Prevention and Control, Public Health Agency of Canada, 2006.
  • 3. Public Health Agency of Canada. Hepatitis C in Canada: 2005–2010 Surveillance Report. Centre for Communicable Diseases and Infection Control, Infectious Disease Prevention and Control Branch, Public Health Agency of Canada, 2011.
  • 4. Gibson DR et al. Effectiveness of syringe exchange programs in reducing HIV risk behaviour and HIV seroconversion among injecting drug users. AIDS. 2001 15:1329–1341.
  • 5. Friedman SR. The dialectic among drug injectors’ agency, their social environments, and “staying safe” from HIV and hepatitis C. Ontario HIV Treatment Network Conference, Nov 11–13, 2012. Toronto, ON
  • 6. Opiate withdrawal. Available at:
  • 7. a. b. c. d. Mateu-Gelabert P, Sandoval M, Meylakhs P, Wendel T, Friedman SR. Strategies to avoid opiate withdrawal: Implications for HCV and HIV risks. International Journal of Drug Policy. 2010  21(3):179-185.
  • 8. a. b. Friedman SR, Sandoval M, Mateu-Gelabert P, Meylakhs P, Des Jarlais DC. Symbiotic goals and the prevention of blood-borne viruses among injection drug users. Substance Use and Misuse. 2011 46(2–3): 307–315.
  • 9. Sirikantraporn S, Mateu-Gelabert P, Friedman SR, Sandoval M, Torruella RA. Resilience among IDUs: Planning strategies to help injection drug users to protect themselves and others from HIV/HCV infections. Substance Use and Misuse. 2012 47(10):1125–1133.
  • 10. Friedman SR. The dialectic among drug injectors’ agency, their social environments, and “staying safe” from HIV and hepatitis C. Ontario HIV Treatment Network Conference, Nov 11-13, 2012. Toronto, ON
  • 11. Mateu-Gelabert P, Treloar C, Calatayud VA, Sandoval M, Zurian JC, Maher L, Rhodes T, Friedman SR. How can hepatitis C be prevented in the long term? International Journal of Drug Policy. 2007 18 (5):338–340.

About the author(s)

Scott Anderson is CATIE's hepatitis C researcher/writer. Prior to working at CATIE, Scott was a research coordinator at the Centre for Addiction and Mental Health, where he led studies examining healthcare access for marginalized groups.