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General Sequence	Injection Sequence	Paraphernalia	Topics	Year, Country & WebLink	Short Summary	Conclusion	Recommendation
Before Administration	Preparing Hands	Alcohol Swab	Alohol Swabs and HCV transmission	2011, France, http://jid.oxfordjournals.org/content/early/2011/10/19/infdis.jir650.ful...	A study was conducted to document the presence of HCV genome (HCV RNA) in 620 items of used injecting paraphernalia collected from representative sites. HCV RNA could be detected in approximately 30% of pooled samples of syringes and 80% of pooled samples of alcohol and cotton swabs, and the results did not differ according to whether or not materials were purposively collected from HCV-positive individuals. None of the pooled samples of water vials or ﬁltration cotton had detectable HCV RNA, and only 1 of 11 pooled samples from drug cookers was positive.	Swabs might be a potential source for HCV transmission. By decreasing HCV infectivity, transmission may be then reduced even if the same swab is used before and after injection or shared between users Questions: The harms versus the beneﬁts of using an alcohol swab after injection (rather than a cotton swab as currently recommended). Potential harm in delaying coagulation and risking possible blood exposure to another injector against the potential beneﬁt of using the swab to collect blood from the injection area and inactivate HCV.	Programs should include stronger messages to prevent sharing swabs. Messages that alcohol swabs are for use only before injection and cotton pads for use only after injection would also be necessary. Other strategies could include distribution of swabs impregnated with disinfectants active against microorganisms.
Before Administration	Preparing Hands	Liquid Disinfectant	Disinfectants and HCV Transmission with Human Serum	2010, Germany, http://jid.oxfordjournals.org/content/201/12/1859.full.pdf+html	This study evaluated : The stability of HCV infectivity at different temperature. The inﬂuence of human serum on HCV stability. The effect of ethanol, 1-propanol, and 2-propanol, active ingredients of commercial alcohol-based antiseptics and disinfectants used in medical settings, on HCV stability. The virucidal efﬁcacy of commercially available disinfectants against HCV.	Whereas HCV was surprisingly stable at room temperature and 4C, addition of human serum or incubation on different surfaces did not change the stability proﬁle of the virus. Given that high-titer preparations of HCV retain well-detectable infectivity for several days even when kept at room temperature, it is conceivable that HCV contaminated materials and infusions represent a substantial risk for transmission. Regarding the inactivation proﬁles of HCV for different kinds of alcohols, 1-propanol was the most effective alcohol. Inactivation of HCV by commercial antiseptics showed an advantage of hand scrubs over alcohol-based disinfectants at a dilution of 1:10, but are similar when undiluted.	Undiluted commercially available disinfectants and especially propanol effectively reduced infectivity of HCV.
Before Administration	Preparing Surface	Liquid Disinfectant	Disinfectants and HCV Transmission on Surface	2010, Germany, http://jid.oxfordjournals.org/content/201/12/1859.full.pdf+html	This study evaluated : The stability of HCV infectivity at different temperature. The inﬂuence of different surfaces on HCV stability. The effect of ethanol, 1-propanol, and 2-propanol, active ingredients of commercial alcohol-based antiseptics and disinfectants used in medical settings, on HCV stability. The virucidal efﬁcacy of commercially available disinfectants against HCV.	Whereas HCV was surprisingly stable at room temperature and 4C, addition of human serum or incubation on different surfaces did not change the stability prole of the virus. Given that high-titer preparations of HCV retain well-detectable infectivity for several days even when kept at room temperature, it is conceivable that HCV contaminated materials and infusions represent a substantial risk for transmission. Regarding the inactivation proles of HCV for different kinds of alcohols, 1-propanol was the most effective alcohol. Inactivation of HCV by commercial antiseptics showed an advantage of hand scrubs over alcohol-based disinfectants at a dilution of 1:10, but are similar when undiluted.	Undiluted commercially available disinfectants and especially propanol effectively reduced infectivity of HCV.
Before Administration	Preparing Surface	Liquid Disinfectant	Disinfectants for Surface	2011, Germany, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3247810/pdf/jir535.pdf	HCV cross-contamination from inanimate surfaces or objects has been implicated in transmission of HCV in health-care settings and among injection drug users. We established HCV-based carrier and drug transmission assays that simulate practical conditions to study inactivation and survival of HCV on inanimate surfaces. HCV can be dried and recovered efficiently in the carrier assay.	The most effective alcohol to inactivate the virus was 1-propanol, and commercially available disinfectants reduced infectivity of HCV to undetectable levels. Viral infectivity on inanimate surfaces was detectable in the presence of serum for up to 5 days, and temperatures of about 65-70°C were required to eliminate infectivity in the drug transmission assay.	Propanol and commercially available disinfectants reduced infectivity of HCV.
Before Administration	Selecting Cooker	Cooker	HCV Infection Seroprevalence and Risk in Sharing Paraphernalia	2012, USA, http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2011.03765.x/abst...	We conducted a systematic review of studies reporting seroincidence of HCV in relation to shared syringes and drug preparation equipment among IDUs. We identified published and unpublished studies that met inclusion criteria. We estimated the relative contributions of shared syringes and drug preparation equipment to HCV transmission.	Syringe sharing was associated with HCV seroconversion [pooled risk ratio (PRR) = 1.94, 95% confidence interval (CI) 1.53, 2.46]. And sharing drug preparation containers (PRR = 2.42, 95% CI 1.89, 3.10), Filters (PRR = 2.61, 95% CI 1.91, 3.56), Rinse water (PRR = 1.98, 95% CI 1.54, 2.56), Combinations of this equipment (PRR = 2.24, 95% CI 1.28, 3.93) The risk of HCV infection through shared syringes is dependent upon HCV infection seroprevalence in the population. The risk of HCV infection through shared drug preparation equipment is similar to that of shared syringes.	Because the infection status of sharing partners is often unknown, it is important for injection drug users to consistently avoid sharing unsterile equipment used to prepare, divide or inject drugs
Before Administration	Selecting Cooker	Cooker	Sharing Cooker While not Sharing Syringe	2001, USA, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1446500/pdf/11189822.pdf	A sterile syringe may become contaminated when the tip of the needle is inserted into a contaminated cooker or when the drug is drawn up through contaminated filtration cotton. This type of injection risk behavior appears to be quite common, and fewer injection drug users may recognize the hazard of sharing drug preparation equipment than recognize the hazard of sharing syringes. The present study suggests that HCV may be transmitted via the shared use of drug cookers and filtration cotton even without injection with a contaminated syringe.	Among injection drug users who do not share syringes, an important proportion of HCV infections may be attributed to cooker/cotton sharing.	Cookers should not be shared.
Before Administration	Selecting Cooker	Cooker	Proportion of Cooker Sharing	2010, Canada, http://www.harmreductionjournal.com/content/7/1/2	Our objective was to examine factors associated with distributive injection equipment sharing and how NSPs can help reduce distributive sharing among IDUs. Our findings show that more IDUs give away cookers than needles or other injection equipment.	More IDUs reported distributive sharing of cookers (45%) than needles (36%) or other types of equipment (water 36%; filters 29%; swabs 8%). Regression analyses revealed the following factors associated with: distributing used cookers: a history of cocaine/crack injection, an Addiction Severity Index (ASI) score indicative of a mental health problem, and older than 30 years of age. giving away used water included: male, injected methadone, injected other stimulants and moved 3+ times in the past 6 months. giving away used filters included: injected cocaine/crack or stayed overnight on the street or other public place. Factors associated with giving away swabs included: an ASI mental health score indicative of a mental health problem, and HCV negative status.	Targeting prevention efforts to reduce equipment sharing in general, and cookers in particular is warranted to reduce use of contaminated equipment and viral transmission.
Before Administration	Selecting Cooker	Cooker	Sharing or Re-usage of Cooker	2000, USA, http://www.ncbi.nlm.nih.gov/pubmed/11018406	This study (1) assembled a sample of young adult IDUs, among whom hepatitis C infection prevalence was still moderate, (2) measured incident HCV infection, and (3) determined the risk for seroconversion associated with specific forms of sharing injection paraphernalia.	The adjusted relative hazard (RH) of seroconversion, after controlling for demographic and drug use covariates, was highest for sharing cookers, followed by sharing rinse water, and then cottons. The independent effects of sharing cookers and cottons remained significant, and a final model that included each sharing practice demonstrated that sharing cookers had at the strongest association with seroconversion. This study suggests that sharing non-syringe paraphernalia may be an important cause of HCV transmission between IDUs.	Cookers should not be shared.
Before Administration	Selecting Cooker	Cooker	Attribution of HCV Seroconversion to Paraphernalia Sharing	2010, USA, http://jid.oxfordjournals.org/content/201/3/378.full.pdf+html	In HCV seroconversion studies, some have questioned whether underreporting of syringe sharing, a stigmatized behavior, has led to misattribution of HCV risk to other injection-related behaviors. Because the shared use of cookers, cottons, and rinse water was highly correlated, a summary variable was created to represent drug preparation equipment sharing.	Associations between sharing drug preparation equipment and HCV seroconversion are not attributable to underascertainment of syringe sharing. The incidence of HCV infection was 17.2 cases per 100 person years; no HIV seroconversions occurred. Adjusting for confounders, the shared use of drug preparation equipment was signiﬁcantly associated with HCV seroconversion, but syringe sharing was not. 37% of HCV seroconversions in IDUs were due to the sharing of drug preparation equipment such as cookers, cottons, and rinse water.	Since HCV transmission is largely due to the sharing of drug preparation equipment, programs should adjust their prevention tactics and prevent IDUs to share cookers, cottons, and rinse water.
Before Administration	Adding Acidifier	Citric/Ascorbic Acid	Acidifier Introduction and Impact on IDU Attendance	2007, UK, http://www.harmreductionjournal.com/content/pdf/1477-7517-4-21.pdf	We examined whether the introduction of citrate in SEPs has altered the number of heroin/crack injectors accessing SEPs, the frequency at which heroin/crack injectors visited SEPs and the number of syringes dispensed. Neither new (first seen in either six months period) nor established clients visited SEPs more frequently post citrate.	The introduction of citrate did not negatively affect SEP attendance. Longitudinal attenders' visited SEPs more frequently post citrate, providing staff with greater opportunity for intervention and referral.	Introduction of acidifier increase clients’ frequency visit.
Before Administration	Adding Water	Sterile Water for Injection	Sharing Used Water and HCV transmission	2010, Germany, http://jid.oxfordjournals.org/content/201/12/1859.full.pdf+html	This study evaluated : The stability of HCV infectivity at different temperature. The inﬂuence of human serum on HCV stability.	Stability of HCV infectivity at different temperature: At 4°C, HCV infectivity was only slightly reduced after 8 days. After 147 days at 4°C, infectivity was still detectable and decreased to background levels only after 252 days. whereas incubation at room temperature resulted in a 10-fold decrease of infectivity at this time point. Inactivation of HCV to background levels was detected at 37°C after just 2 days, indicating that HCV stability is temperature dependent. Influence of human serum and different surfaces on HCV stability: The addition of human serum did not change viral titers that decreased over time, reaching undetectable levels after 21 days of incubation at 21°C, and has no influence on the stability of HCV. We determined whether incubation of the virus on different surfaces (in a liquid suspension on plastic, steel, or gloves) could change HCV stability. No significant difference was detected. Influence of high temperature and different pH on HCV infectivity: Viral suspensions were incubated for 1, 5 or 10 min at temperatures ranging from 40°C to 90°C. HCV infectivity was not affected at pH values ranging between 4 and 9.	Since it is conceivable that HCV contaminated materials and infusions represent a substantial risk for transmission, it is important not to share paraphernalia.
Before Administration	Filtering	Cotton Pellet	Sharing Filtering Cotton While not Sharing Syringe	2001, USA, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1446500/pdf/11189822.pdf	A sterile syringe may become contaminated when the tip of the needle is inserted into a contaminated cooker or when the drug is drawn up through contaminated filtration cotton. This type of injection risk behavior appears to be quite common, and fewer injection drug users may recognize the hazard of sharing drug preparation equipment than recognize the hazard of sharing syringes. The present study suggests that HCV may be transmitted via the shared use of drug cookers and filtration cotton even without injection with a contaminated syringe.	Among injection drug users who do not share syringes, an important proportion of HCV infections may be attributed to cooker/cotton sharing.	Filtration cotton should not be shared.
Before Administration	Filtering	Cotton Pellet	Sharing Cotton Pellet	2000, USA, http://www.ncbi.nlm.nih.gov/pubmed/11018406	This study (1) assembled a sample of young adult IDUs, among whom hepatitis C infection prevalence was still moderate, (2) measured incident HCV infection, and (3) determined the risk for seroconversion associated with specific forms of sharing injection paraphernalia.	The independent effects of sharing cookers and cottons remained significant, and a final model that included each sharing practice demonstrated that sharing cookers had at the strongest association with seroconversion. This study suggests that sharing non-syringe paraphernalia may be an important cause of HCV transmission between IDUs.	Decrease the practice of sharing cookers and filtering cottons.
Before Administration	Choosing Syringe	Syringe	Syringe Re-use Behavior and Housing	2011, Canada, http://www.ncbi.nlm.nih.gov/pubmed/21355916	Systematic reviews and meta-analyses show that needle exchange programs reduce HIV and HCV transmission for IDUs but far less is known about the injection practices of IDUs enrolled in these programs. This study adopts a mixed methods approach to quantify high-risk injection practice patterns among IDUs enrolled in a needle exchange program and gather qualitative data to understand underlying injection behaviour rationales and patterns.	Univariate analysis showed all respondents reporting at least one high-risk practice within the past month. Multivariate logistic regression analysis using input from the clientele confirmed the importance of housing status as a determinant of injection practices.	The importance of housing status points to the need to combine needle exchange and appropriate housing.
Before Administration	Choosing Syringe	Low Dead Space Syringe	HIV & HCV Transmission and Low/High Dead Space Syringes	2009, USA, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2654245/pdf/nihms92365.pdf	This study examines the association between using and sharing high dead-space syringes (HDSSs) - which retain over 1,000 times more blood after rinsing than low dead-space syringes (LDSSs) - and prevalent HIV and hepatitis C virus (HCV) infections among injecting drug users (IDUs).	A history of using and sharing an HDSS were significantly more likely to be HIV-positive than participants that had never shared any type of syringe and never used an HDSS. The interaction between a history of syringe-mediated drug sharing and using an HDSS was significantly associated with HCV infection. Similar to sex risk behaviors, the risks of HIV transmission associated with direct and indirect syringe sharing are influenced by a number of factors, and the protective role of LDSSs may be analogous to the role of male circumcision or antiretroviral therapy.	LDSS should be prefered to HDSS.
Before Administration	Choosing Syringe	Low Dead Space Syringe	Factors Affecting Needle and Syringe Preference, Gender	2002, USA, http://www.ncbi.nlm.nih.gov/pubmed/12365524	IDUs, a group at elevated risk for HIV transmission, use syringes manufactured in two styles, one of which (the integral cannula type) retains substantially less blood after intravenous use than the other (the detachable needle type). In this report, we examine some of the factors associated with use of syringes with detachable needles among 500 IDUs in San Antonio, Texas, using data from epidemiological surveys, ethnographic studies, and historical observations. Ethnographic data suggested the following perceived benefits with detachable needle syringes : Removing the needle while preparing and drawing up the drug reduces the probability of dulling it by accidentally jamming it into the spoon or cooker. A drug solution can be drawn into a syringe more rapidly through the larger opening of the cannula than through the much smaller opening of a needle. If a needle clogs during an injection, it can be replaced easily on a syringe with a detachable needle. In an integral cannula syringe, the plunger must be removed and the solution must be dumped back into a cooker before the needle can be unclogged.	Integral cannula syringes were used when they started injecting, The smaller dead space used substantially less drug. Overwise, many drug users preferred not to booting because it increases the risk of losing the vein and missing the injection (accidentally moving the tip of the needle out of the vein and injecting some of the solution into tissue), which results in bruising and possible abcess. Needle gauge is another factor that influences. Many IDUs, particularly those who began injecting more recently and still have good veins, prefer the smaller 28 gauge needles because they tend to be less painful to use and do less damage to veins. Conversely, some IDUs who have been injecting longer and have poor veins may prefer the larger 25 gauge needles because they do not clog as easily, and they can penetrate thick scar tissue without bending. In cities where syringes are difficult to obtain prefer the larger gauge needles because they are more durable. Fluid can be drawn into larger gauge needles and expelled much more rapidly than from smaller gauge needles. Males reported detachable needle use more commonly (43%, OR=1.37) than females (26%).	Harm reductsion programs should take these factors into consideration while selecting paraphernelia to be distributed and promoting low dead space syringes.
During Administration	Choosing Syringe	Low Dead Space Syringe	Survival of HCV and Low/High Dead Space Syringes	2010, USA, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2932767/pdf/nihms219637.pdf	We used two different kinds of syringes : U-100 1-ml insulin syringe with an attached 27 gauge, 0.5-inch needle with low void volume of 2 μl. 1-ml tuberculin syringe with a detachable 26-gauge, 0.5-inch needle with high void volume of 32 μl.	The virus decay rate was biphasic. Insulin syringes failed to yield viable HCV beyond day 1 at all storage temperatures except for 4°C in which 5% of syringes yielded viable virus on day 7. Tuberculin syringes yielded viable virus from 96%, 71%, and 52% of syringes following storage at 4°C, 22°C and 37°C for 7 days, respectively, and yielded viable virus up to day 63.	HCV survival is dependent on the type of syringe; syringes with detachable needles (high void volume) appear far more likely to transmit HCV. They should be transitionned to low void volume syringes.
During Administration	Administrating	Syringe	HCV Infection Seroprevalence and Risk in Sharing Syringes	2012, USA, http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2011.03765.x/abst...	We conducted a systematic review of studies reporting seroincidence of HCV in relation to shared syringes and drug preparation equipment among IDUs. We identified published and unpublished studies that met inclusion criteria. We estimated the relative contributions of shared syringes and drug preparation equipment to HCV transmission.	Syringe sharing was associated with HCV seroconversion [pooled risk ratio (PRR) = 1.94, 95% confidence interval (CI) 1.53, 2.46]. And sharing drug preparation containers (PRR = 2.42, 95% CI 1.89, 3.10), Combinations of this equipment (PRR = 2.24, 95% CI 1.28, 3.93) The risk of HCV infection through shared syringes is dependent upon HCV infection seroprevalence in the population.	Because the infection status of sharing partners is often unknown, it is important for injection drug users to consistently avoid sharing syringes used to prepare, divide or inject drugs
During Administration	Administrating	Syringe	HCV Infection Seroprevalence and Risk in Backloading	2012, USA, http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2011.03765.x/abst...	We conducted a systematic review of studies reporting seroincidence of HCV in relation to shared syringes and drug preparation equipment among IDUs. We identified published and unpublished studies that met inclusion criteria. We estimated the relative contributions of shared syringes and drug preparation equipment to HCV transmission.	Syringe sharing was associated with HCV seroconversion [pooled risk ratio (PRR) = 1.94, 95% confidence interval (CI) 1.53, 2.46]. And ‘backloading’, a syringe-mediated form of sharing prepared drugs (PRR = 1.86, 95% CI 1.41, 2.44). The risk of HCV infection through shared syringes is dependent upon HCV infection seroprevalence in the population. The risk of HCV infection through shared drug preparation equipment is similar to that of shared syringes.	Because the infection status of sharing partners is often unknown, it is important for injection drug users to consistently avoid backloading with an unsterile syringe.
During Administration	Administrating	Syringe	Distributive Sharing with One/Two-Piece Syringe	2009, Hungary, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628960/pdf/nihms-83091.pdf	In Budapest, Hungary, we assessed whether syringe type, syringe cleaning and distributive syringe sharing were associated with self-reported and laboratory-confirmed HCV infection among Hungarian IDUs. Only few (7%) reported that they used any two-piece syringes. Most (71%) reported using only one-piece syringes and not engaging in receptive syringe sharing. 12% reported using only one-piece syringes and engaging in receptive syringe sharing but always cleaning the syringe before reusing it. 11% reported using only one-piece syringes and engaging in receptive syringe sharing and not always cleaning the syringe. One in five (20%) reported engaging in distributive syringe sharing. The majority (61%) reported sharing cookers or filters. About a quarter (27%) reported squirting drugs from one syringe into another syringe.	Using any two piece syringes was significantly associated with self-reported HCV infection Distributive syringe sharing was not associated with self-report of being HCV infected. Engaging in receptive sharing of only one-piece syringes but always cleaning before reuse was not associated with testing HCV positive Any receptive sharing of only one-piece syringes and not always cleaning before reuse was significantly associated with testing HCV positive. Receptive syringe sharing of one-piece syringes but always cleaning before sharing was not associated with HCV infection, indicating that thorough cleaning of one-piece syringes seems to diminish HCV risk.	For one-piece syringes, cleaning should remove enough blood from the syringe to considerably decrease the risk of HCV infection upon reuse. Amphetamine injectors, who used no heat or acid to prepare the drugs, did not have higher levels of HCV infection : heat and/or acidic environments may not be as important as syringe cleaning to reduce HCV infection risk for those who used one-piece syringes.
During Administration	Administrating	Syringe	Frontloading	1996, Germany, http://www.ncbi.nlm.nih.gov/pubmed/8882671	To determine whether frontloading (i.e., syringe-mediated drug-sharing) is a risk factor for HIV, HBV and HCV infection among IDU.	Having practised frontloading more than 100 times was significantly associated with HIV infection, and HCV infection, but not with HBV infection. In communities where sterile injection equipment is readily available, and IDU have substantially reduced their overall levels of needle-sharing, the practice of frontloading appears to be a major risk factor for infections by blood-borne viruses among IDU.	Prevention activities should specifically address frontloading as a risky behaviour.
During Administration	Administrating	Syringe	Gender and Sexual/Injection Risk Behavior	2003, USA, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3456106/pdf/11524_2006_Artic...	Female IDUs represent a large proportion of persons infected with HIV in the United States, and women who inject drugs have a high incidence of HBV and HCV infection. Therefore, it is important to understand the role of gender in injection risk behavior and the transmission of blood-borne virus. We compared self-reported risk behavior between 584 males and 260 female participants from cross-sectional baseline data.	Females were significantly younger than males and were more likely to engage in needle borrowing, ancillary equipment sharing, and being injected by someone else. more likely than males to report recent sexual intercourse and to have IDU sex partners. In logistic regression models for borrowing a used needle and sharing drug preparation equipment, increased risk in females was explained by having an injection partner who was also a sexual partner. Injecting risk was greater in the young female compared to male IDUs despite equivalent frequency of injecting. Overlapping sexual and injection partnerships were a key factor in explaining increased injection risk in females. Females were more likely to be injected by another IDU even after adjusting for years injecting, being in a relationship with another IDU, and other potential confounders.	Interventions to reduce sexual and injection practices that put women at risk of contracting hepatitis and HIV should be promoted.
After Administration	Stemming Blood	Dry Swab	Cotton Pad and HCV transmission	2011, France, http://jid.oxfordjournals.org/content/early/2011/10/19/infdis.jir650.ful...	A study was conducted to document the presence of HCV genome (HCV RNA) in 620 items of used injecting paraphernalia collected from representative sites. HCV RNA could be detected in approximately 30% of pooled samples of syringes and 80% of pooled samples of alcohol and cotton swabs, and the results did not differ according to whether or not materials were purposively collected from HCV-positive individuals. None of the pooled samples of water vials or ﬁltration cotton had detectable HCV RNA, and only 1 of 11 pooled samples from drug cookers was positive.	Swabs might be a potential source for HCV transmission. Questions: The harms versus the beneﬁts of using an alcohol swab after injection (rather than a cotton swab as currently recommended). Potential harm in delaying coagulation and risking possible blood exposure to another injector against the potential beneﬁt of using the swab to collect blood from the injection area and inactivate HCV.	Programs should include stronger messages to prevent sharing swabs. Messages that alcohol swabs are for use only before injection and cotton pads for use only after injection would also be necessary. Other strategies could include distribution of swabs impregnated with disinfectants active against microorganisms
After Administration	Cleaning Equipment	Bleach	Efficiency of Bleach Against HCV	2002, USA, http://www.ncbi.nlm.nih.gov/pubmed/12410020	Hepatitis C virus (HCV) has emerged as a major public health problem among injection drug users. In this analysis we examine whether disinfection of syringes with bleach has a potentially protective effect on anti-HCV seroconversion. Participants who reported using bleach all the time had an odds ratio for anti-HCV seroconversion of 0.35, whereas those reporting bleach use only some of the time had an odds ratio of 0.76, when compared with those reporting no bleach use.	These results suggest that bleach disinfection of syringes, although not a substitute for use of sterile needles or cessation of injection, may help to prevent HCV infection among injection drug users.	To prevent HCV infection, bleach disinfection of syringes should be promoted when new paraphernalia cannot be used,
After Administration	Cleaning Equipment	Rincing Water	Sharing or Re-usage of Rinse Water	2000, USA, http://www.ncbi.nlm.nih.gov/pubmed/11018406	This study (1) assembled a sample of young adult IDUs, among whom hepatitis C infection prevalence was still moderate, (2) measured incident HCV infection, and (3) determined the risk for seroconversion associated with specific forms of sharing injection paraphernalia.	The adjusted relative hazard (RH) of seroconversion, after controlling for demographic and drug use covariates, was highest for sharing cookers, followed by sharing rinse water, and then cottons. The independent effects of sharing cookers and cottons remained significant, and a final model that included each sharing practice demonstrated that sharing cookers had at the strongest association with seroconversion. This study suggests that sharing non-syringe paraphernalia may be an important cause of HCV transmission between IDUs.	Rinse water should not be shared or re-used.
After Administration	Disposing Equipment	Syringe	Risk of Transmission via Needlestick	2003, Australia, http://www.ncbi.nlm.nih.gov/pubmed/14723407	Discarded needle syringes create considerable anxiety within the community, but the extent of needlestick injuries and level of blood-borne virus transmission risk is unclear. We have undertaken a review of studies of blood-borne virus survival as the basis for advice and management of community needlestick injuries.	HBV, HCV, and HIV can all survive outside the human body for several weeks, with virus survival influenced by virus titer, volume of blood, ambient temperature, exposure to sunlight and humidity. HBV has the highest virus titers in untreated individuals and is viable for the most prolonged periods in needle syringes stored at room temperature. However, prevalence of HBV and HIV are only 1-2% within the Australian IDU population. In contrast, prevalence of HCV is 50-60% among Australian IDUs and virus survival in needle syringes has been documented for prolonged periods. There have been no published cases of blood-borne virus transmission following community needlestick injury in Australia. The risk of blood-borne virus transmission from syringes discarded in community settings appears to be very low.	Despite this, procedures to systematically follow up individuals following significant needlestick exposures sustained in the community setting should be developed.
After Administration	Substituting	Methadone	Seroprevalence Among IDUs on Methadone Treatment	2010, The Netherlands, http://www.harmreductionjournal.com/content/7/1/25	Opioid drug users on methadone treatment are routinely offered voluntary screening for HIV, HBV and HCV. Data on uptake and outcome of anti-HIV, anti-HBC, and anti-HCV screening among Opioid DUs receiving methadone were obtained from Amsterdam from 2004 to 2008 and Heerlen from 2003 to 2009. Annual screening uptake for HIV, HBV and HCV varied from 34 to 69%, depending on disease and screening site. Of users screened, 2.5% were HIV-positive in Amsterdam and 11% in Heerlen; 26% were HCV-positive in Amsterdam and 61% in Heerlen. Of those screened for HBV, evidence of current or previous infection (anti-HBC) was found among 33% in Amsterdam and 48% in Heerlen. In Amsterdam, 92% were fully vaccinated for HBV versus 45% in Heerlen.	On average, more than half of the ODUs in methadone care were screened for HIV, HBV and HCV. Screening data indicate that HBV vaccination uptake was rather high. While the HIV prevalence among these ODUs was relatively low compared to other drug-using populations, the high HCV prevalence among this group underscores the need to expand annual screening and interventions to monitor HIV, HBV and HCV in the opioid drug-using population.	Participation in both NSPs and methadone programs is associated with decreased risk of acquiring HIV and HCV among people who have ever injected drugs. Methadone services should be promoted.
After Administration	Substituting	Methadone	OST and High Coverage of NSP on HCV Transmission	2011, UK, http://canadianharmreduction.com/sites/default/files/2011%20impac%20t%20...	To investigate whether opiate substitution therapy (OST) and needle and syringe programmes (NSP) can reduce HCV transmission among IDUs. Design Meta-analysis and pooled analysis, with logistic regression allowing adjustment for gender, injecting duration, crack injecting and homelessness were performed on a total of 2986 IDUs surveyed.	Both receiving OST and high NSP coverage were associated with a reduction in new HCV infection. Full harm reduction (on OST plus high NSP coverage) reduced the odds of new HCV infection by nearly 80%. Full harm reduction was associated with a reduction in self-reported needle sharing by 48% and mean injecting frequency by 20.8 injections per month. There is good evidence that uptake of OST and high coverage of NSP can substantially reduce the risk of HCV transmission.	Opiate substitution therapy and high coverage of needle and syringe programmes should be implemented to substantially reduce the risk of HCV transmission.
After Administration	Safer Sex	Male Condom	Gender and Sexual Risk within IDUs	2013, Spain, http://www.ncbi.nlm.nih.gov/pubmed/23578527	Female were more likely than male IDU : to have had a steady sexual partner (68% versus 45%), to have had an IDU steady sexual partner (47% versus 15%) and to have exchanged sex for money or drugs in the last 6 months (26% versus 2%). There were no gender differences in injecting risk behaviours. HIV prevalence was 39% in women and 32% in men. HIV prevalence among female IDU who reported having exchange sex for money or drugs was 53.3%. The prevalence of HCV was 67% and 74% in female and male IDU, respectively.	There are differences in sexual risk behaviours between male and female IDU. The higher prevalence of HIV among women than among men, together with a lower prevalence of HCV, provides evidence that sexual transmission of HIV is more important among female IDU.	Prevention and health education programs should provide appropriate specific actions depending on gender.
After Administration	Safer Sex	Male Condom	Gender and Sexual Risk Behavior	2003, USA, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3456106/pdf/11524_2006_Artic...	Female IDUs represent a large proportion of persons infected with HIV in the United States, and women who inject drugs have a high incidence of HBV and HCV infection. Therefore, it is important to understand the role of gender in injection risk behavior and the transmission of blood-borne virus. We compared self-reported risk behavior between 584 males and 260 female participants from cross-sectional baseline data.	Females were more likely than males to report recent sexual intercourse and to have IDU sex partners. In logistic regression models for borrowing a used needle and sharing drug preparation equipment, increased risk in females was explained by having an injection partner who was also a sexual partner. Overlapping sexual and injection partnerships were a key factor in explaining increased injection risk in females. Females were more likely to be injected by another IDU even after adjusting for years injecting, being in a relationship with another IDU, and other potential confounders.	Interventions to reduce sexual and injection practices that put women at risk of contracting hepatitis and HIV are needed.
After Administration	Safer Sex	Male Condom	MSM IDUs and Injecting and Sexual Transmission Risks	2012, England, http://www.ncbi.nlm.nih.gov/pubmed/22628667	Although transmission of HIV among IDUs has been limited since the 1980s, IDUs and MSM have higher HIV and HCV prevalences than the general population. MSM who are also IDUs may therefore have a higher risk of infection than male IDUs who only have sex with women.	MSM-IDUs had a higher prevalence of HIV and of HCV and were about four times more likely to have unprotected sex with multiple partners. Among those who injected in the 4 weeks prior to participation, the MSM-IDUs had a higher level of needle/syringe sharing suggesting elevated risk from injecting and possibly sexual transmission.	Public health interventions should specifically target at MSM-IDUs.
After Administration	Safer Sex	Female Condom	WSW IDUs, Prevalence, and Transmission Risks	2012, USA, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447865/	Women injection drug users who have sex with women (WSW IDUs) constitute 20% to 30% of American women IDUs. Compared with other women IDUs, WSW IDUs have higher HIV prevalence and incidence rates and a greater likelihood of engaging in high-risk injection and sexual practices with men.	Compared with other young women IDUs, WSW IDUs were more likely to have been institutionalized or homeless, to have engaged in riskier behaviors, to have had high-risk sexual and injection networks, and to have been anti–hepatitis B virus–positive. In high-HIV-prevalence sites, they were more likely to have been infected with HIV. These differences cannot be accounted for by their greater involvement in sex work. WSW IDUs were more likely : To have positive test results for HBV (but not for hepatitis C virus, chlamydia, or gonorrhea) and were more likely to be infected with HIV in high-prevalence. To engage in high-risk behaviors (receptive syringe sharing, sharing rinse water, and sex trading) and reported having more male sexual partners. To report having unprotected sex with MSM; having sex with an IDU or someone they knew or thought was infected with HIV; and injecting drugs with MSM, WSW IDUs, someone at least 5 years older, and someone who “had hepatitis.” To have ever injected drugs with MSM in low-HIV-prevalence, but not high-HIV-prevalence, sites.	Prevention and health education programs should provide appropriate specific actions depending on gender and sexual orientation.

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