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Preventing drug use and providing substance abuse treatment for persons who inject illicit drugs are crucial to preventing many blood-borne infections, including human immunodeficiency virus (HIV). However, many drug users are not currently in substance abuse treatment programs because of multiple factors including the limited availability of these programs and the lack of readiness or willingness of some drug users to enter substance abuse treatment. Consequently, substantial numbers of drug users continue to inject drugs.
This chapter summarizes new information on preventing transmission of HIV and other blood-borne infections among persons who inject drugs. Various studies indicate that persons who inject drugs should use sterile syringes to prevent the transmission of HIV and other blood-borne infectious diseases. This conclusion should be considered by clinicians providing healthcare to persons who use or inject drugs and by public health professionals planning and carrying out HIV prevention programs for injection drug users (IDUs). Health professionals should inform IDUs that using sterile syringes is safer than reusing syringes, including syringes that have been disinfected with bleach. The information in this chapter has been prepared for health professionals involved in programs serving persons who inject drugs.
The reuse and “sharing” of blood-contaminated injection equipment and blood- contaminated dissolved drugs play substantial roles in the transmission of HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), and other blood-borne infections. These infections cause illness and death among drug users, their sex partners, and, through mother-to-infant transmission, their children. More than one third (35%) of all AIDS cases reported in the United States in 1995 were directly or indirectly associated with injection drug use.
Blood is introduced into needles and syringes at the start of every intravenous injection. The reuse of a blood-contaminated syringe by another drug injector (sometimes called “direct syringe sharing”) carries a substantial risk of transmission of blood-borne infections, including HIV, HBV, and HCV. In addition, blood and blood-borne infections can be introduced into drug solutions by the use of blood-contaminated syringes to prepare drugs; the reuse of water; the reuse of bottle caps, spoons, or other containers (“spoons” and “cookers”) used to dissolve drugs in water and to heat drug solutions; and the reuse of small pieces of cotton or cigarette filters (“cottons”) used to filter out particles that could block the needle.
Multiperson use of contaminated water, dissolved drugs, and drug preparation equipment is sometimes called “indirect sharing.”
Because some “street” sellers of syringes repackage used syringes and sell them as sterile syringes, persons who continue to inject drugs should obtain syringes from reliable sources of sterile syringes, such as pharmacies.
In addition to HIV, HBV, HCV and other blood-borne infections, persons who inject drugs are at risk of other serious infections. Use of alcohol swabs to clean the injection site prior to injection has been shown to reduce the occurrence of cellulitis, injection site abscesses, and, possibly, endocarditis among persons who inject drugs.
The risks of transmission of blood-borne illnesses are compelling reasons for strengthening public health and community efforts to help persons avoid starting drug injection and to help IDUs stop using drugs. Addiction is a major factor in the use of drugs such as heroin, cocaine, and amphetamines. While the recommendations here will help reduce the individual and public health risks associated with injection drug use, the ultimate goals are to prevent at-risk individuals from initiating injection drug use and to help drug injectors stop drug injection through substance abuse treatment and recovery from addiction. For most persons who are addicted to drugs, admission to drug and alcohol treatment programs is a key step in reducing and/or stopping their drug use.
Based on the findings from various studies, the new recommendations for drug users who continue to inject drugs include:
To minimize the risk of disease transmission, persons who continue to inject drugs should be advised to always use sterile injection equipment; warned never to reuse needles, syringes, and other injection equipment; and told that using syringes that have been cleaned with bleach or other disinfectant is not as safe as using new, sterile syringes. The National Academy of Sciences report stated: “For injection drug users who cannot or will not stop injecting drugs, the once-only use of sterile needles and syringes remains the safest, most effective approach for limiting HIV transmission.” CDC recommends that all syringes used for parenteral injections be sterile. Drug preparation equipment, such as “cottons,” “cookers,” water, and syringes should not be reused because they are usually contaminated with blood.
Most syringes and needles used by drug injectors were not designed for reuse. Boiling needles and syringes for 15 minutes between uses can disinfect the equipment. However, boiling may alter the shape and functioning of the plastic syringes widely used by drug injectors in the United States. Disinfecting previously used needles and syringes with bleach (or other chemicals) can reduce the risk of HIV transmission, but using disinfected syringes is not as safe as using a new, sterile needle and syringe. The National Academy of Sciences report found that bleach disinfection is likely to be effective but “. . . is clearly an intervention to be used when injection drug users have no safer alternatives.”
Healthcare workers involved in programs that serve drug users should communicate the following recommendations to drug users who continue to inject. Adhering to these drug preparation and injection procedures will reduce the public health and individual health risks associated with drug injection for both drug users and other persons in their communities.
Persons who inject drugs should be regularly counseled to:
The availability of new, sterile syringes varies, depending on state and local regulations regarding the sale and possession of syringes and on other factors, such as the existence of syringe exchange programs sponsored by local HIV prevention organizations. If new, sterile syringes and other drug preparation and injection equipment are not available, then previously used equipment should be boiled or disinfected with bleach.
In addition, drug users should be provided information on how to prevent HIV transmission through sexual contact and, for women, information on reducing the risk of mother-to-infant HIV transmission.
Revised May 30, 1997.
Centers for Disease Control
National Institute on Drug Abuse