Get the facts. Learn how to prevent infection. Keep yourself and your loved ones safe.

As if grappling with addiction wasn’t challenging enough, substance use poses increased risks to health, including several different infections. It's critically important to acknowledge and discuss this because individuals who use drugs can take steps to protect themselves.

Of course, the best way to protect against infection is to not use drugs at all. But there are ways that people who use drugs can protect themselves against infections, consistent with research-backed harm reduction. Below, we provide information about HIV, hepatitis A, B, and C, “cotton fever”, and infective endocarditis, along with concrete steps that individuals can take to protect themselves when using.

HIV/AIDS

HIV stands for human immunodeficiency virus. The virus attacks the immune system, making it difficult for the body to fight off other infections and disease.

AIDS, or acquired immune deficiency syndrome, is the final stage of HIV infection, at which point the immune system is very weakened and the body is unable to fight off disease. Not all who are infected with HIV will progress to AIDS, however this is a risk if HIV is untreated.

HIV is spread when infected blood or sexual fluids (including vaginal fluid, cum, and pre-cum, but not saliva) enter the bloodstream of someone who is not infected. For those using drugs, HIV is mainly spread by contaminated needles or injection paraphernalia including syringes, cookers, and cottons used to prepare or inject drugs. Unsafe sexual practices also put drug users at risk—being under the influence of drugs may lead individuals to engage in risky sex due to impaired judgment, monetary needs, or other factors. In the US in 2016 there were 39,782 new diagnoses of HIV, of which approximately 1 in 10 (3,425) were due to injection drug use.

While there is no vaccine or cure for HIV/AIDS, there are currently many effective treatments available for HIV which can help those infected live a normal life and manage the disease. Those at risk should get tested for HIV regularly so that, if positive, they can begin these effective treatments as soon as possible. This is especially important because most people who are infected with HIV will not show symptoms, and may not even know they are infected.

image syringe services for HIV prevention
Source: CDC

For those at risk for HIV, there are many concrete steps they can take to help protect against infection:

  • Use sterile needles and injection paraphernalia every time. These can often be obtained from a local syringe services program or harm reduction center.
  • Avoid injecting drugs. The HIV virus cannot survive well outside the human body. This means that drug use behaviors that don’t involve injection, such as smoking or snorting, are a much lower risk for HIV.
  • Use condoms every time during vaginal and anal sex. Condoms protect against HIV. However, it is important to note that HIV is present in pre-cum as well as cum, and therefore condoms should be put on before having sex.
  • Use lubricant during sex. Lubricant reduces friction during sex, and therefore reduces the development of ‘microtears’, or small tears in the skin of the genitals that can enable HIV to enter the body.
  • Take PrEP daily. PrEP, or pre-exposure prophylaxis, is a once daily medication that can be taken by those at high risk of HIV infection to prevent them from getting the infection. Those at risk should consider talking to their doctor about whether PrEP is right for them.
  • Take PEP after emergency situations. PEP, or post-exposure prophylaxis, is a series of HIV medications taken to prevent infection after an individual has potentially been exposed to the virus. PEP should be taken within 72 hours of the possible exposure.
  • Get tested for HIV regularly. Knowing your HIV status, and your partner/partners’ status can help you take steps to protect yourself and those you care about.

Hepatitis

Hepatitis is a disease or infection that attacks the liver. The name hepatitis comes from the Greek for liver (hep), and swelling (itis), literally meaning swelling of the liver. When an individual is infected with hepatitis, their liver may swell or start to shut down, leading to tiredness, jaundice (yellowing of the skin and eyes), and even liver cancer. There are five types of hepatitis virus: A, B, C, D, and E.

Hepatitis A

Hepatitis A is a viral infection transmitted person-to-person by unknowingly ingesting the virus from objects, food, or drinks contaminated with small, undetected amounts of stool from an infected person. Exposure to hepatitis A occurs most typically from contaminated food or drink, but can happen during close person-to-person contact, sexual activity, and from unsanitary conditions, including using unsterile cooking, smoking, or injection equipment when using drugs. Individuals who are homeless are especially at risk for infection.

Not everyone infected with hepatitis A will show symptoms, but many do including fever, loss of appetite, nausea, diarrhea, and jaundice (yellowing of the skin and whites of the eyes).There is a vaccine for hepatitis A, but no specific medication or cure. It is a good idea for people who use drugs, or who may be living or intimate with someone who has hepatitis A, to get vaccinated.

Unlike HIV, hepatitis A can live outside the body for several months. This means that using drugs via methods that may bring contact with someone else’s fluids—such as syringes, cookers, cottons, water containers, and surfaces used to prepare or inject drugs and even sharing pipes for smoking crack or meth—can cause exposure. Unsafe sexual practices and close contact with other individuals who are at risk or potentially infected puts individuals at risk for infection.

Historically, hepatitis A is not very common in the US—between 2012 and 2016, there were fewer than 8,000 cases nationwide—but recently there have been large outbreaks of hepatitis A among those experiencing homelessness and/or using both injection and non-injection drugs. In 2018 alone, there were more than 7,000 cases across 12 states. Given these recent outbreaks, it is critical to be vigilant about hepatitis A, and for those at risk for hepatitis A to get vaccinated.

Individuals at risk should take the following steps to protect themselves from hepatitis A:

  • Use sterile needles and injection paraphernalia every time. These can often be obtained from a local syringe services program or harm reduction center.
  • Use a sterile space to prepare and consume drugs.
  • Use good personal hygiene and proper sanitation, including washing your hands regularly.
  • Get vaccinated for hepatitis A. The vaccine, given as 2 shots over 6 to 12 months, is appropriate for most people, and protects against hepatitis A infection for at least 20 years.

Hepatitis B and C

Hepatitis B and C are transmitted when infected blood enters the blood of someone who is not infected. Hepatitis B is also transmitted when sexual fluid enters the blood of someone who is not infected.

Exposure to either hepatitis B and C virus can happen via sexual activity (including oral, vaginal, and anal sex), sharing personal items that may have touched blood (including toothbrushes, razors, nail clippers, and injection equipment), and sharing equipment that has pierced the skin (including syringes for injecting medication or other materials, tattoo needles, and piercing equipment).

Most individuals infected with hepatitis B or C will not know they are infected with the virus for several months or even years. For this reason, it is important that individuals at risk for hepatitis B and C get tested regularly so that they can start treatment as soon as possible if infected. In some cases, the body may clear the hepatitis on its own (these first 6 months of infection are known as acute hepatitis), but this is much less common than the body continuing to be infected (chronic hepatitis).

There is a vaccine and treatment for hepatitis B, but no cure. It is a good idea for those who use drugs, those who are engaged in sex work, and those who may be living or intimate with someone who has hepatitis B, to get vaccinated. For Hepatitis C, there is a cure.

Like hepatitis A, for those using drugs, hepatitis B and C can be spread through contaminated needles or injection paraphernalia. This includes syringes, cookers, cottons, water containers, and surfaces used to prepare or inject drugs. The viruses can also be spread through contaminated smoking pipes. This means that using drugs via methods that may bring contact with blood, including sharing pipes for smoking crack or meth when one individual has cracked or bleeding lips, can also be a risk factor (though not as high risk as sharing needles). Unsafe sexual practices are another risk factor.

Currently, as many as 2.2 million individuals in the US are living with chronic hepatitis B, and during 2016 there were an estimated 20,900 new cases of acute hepatitis B. Global estimates indicate that between 1 in 20 and 1 in 10 individuals who inject drugs are infected with hepatitis B, and in the US, injection drug use is the most common risk factor for becoming infected.

About 3.5 million people in the US are now living with chronic hepatitis C, and in 2016, there were an estimated 41,200 new cases of acute hepatitis C. Global estimates indicate that between 3 in 5 and 4 in 5 individuals who inject drugs are infected with hepatitis C.

Individuals at risk should take the following steps to protect themselves from hepatitis B and C:

  • Use sterile needles and injection paraphernalia every time. These can often be obtained from a local syringe services program or harm reduction center.
  • Do not share personal hygiene items. This includes not sharing toothbrushes, razors, or nail clippers with someone who is infected with hepatitis, or whose hepatitis status you do not know.
  • Use condoms every time during oral, vaginal, or anal sex.
  • Get tested for hepatitis B and C regularly. Knowing your own hepatitis B and C status as well as your partner/partners’ status can help you take steps to protect yourself and those you care about.
  • Get vaccinated for hepatitis B. The vaccine, given as 2, 3, or 4 shots over 1 to 6 months, is appropriate for most people, and protects against hepatitis B infection for at least 30 years.
safer-injecting-strategies
Source: HRC
additional-syringe-prevention-strategies
Source: HRC

"I’ve come close to sharing needles with two people who were HIV positive, and one who is Hep C positive, but luckily I had the blessing of getting a [sterile] needle. I also have been saved from disasters that I did not know about including infections, cotton fever, rotating, never sharing, bleaching. I also obtain sterile wipes and antibiotic ointment to hinder infections, and talking openly about my using is helping me quit. The harm reduction model is the most common-sense model available…"
Anonymous, Our Stories: Personal Testimonies

‘Cotton Fever’

Cotton Fever is an illness that happens to some people after they inject drugs. Symptoms of the illness include fever, headache, nausea, chills, and muscle and joint pain. Cotton Fever is caused when bacteria, from reused cottons/filters or needles, is injected into the body. There is no cure, treatment, or vaccine for cotton fever itself, however the disease is generally not serious, and the symptoms can be treated with fever reducer (like aspirin) as appropriate.

Cotton fever cannot be passed from person to person – the only way to be infected is by using unsterile syringes or cottons/filters. Individuals at risk for Cotton Fever can protect themselves by using sterile syringes and cottons/filters every time.

Infective Endocarditis

Infective endocarditis is a disease that attacks the heart. When someone is infected with endocarditis, clumps of bacteria form in the heart, and can then break loose and travel to different parts of the body. This can lead to many varied symptoms, including fatigue, aching joints and muscles, swelling in the feet and legs, and blood in the urine, among others.

Infective endocarditis (IE) generally occurs when bacteria or fungi enter the bloodstream and spread to the heart. Exposure to the bacteria that cause endocarditis can be caused by certain dental procedures or oral activity, infection, catheters, needles used for tattoos or piercings, and injection drug use.

Most individuals infected with endocarditis do not know right away that they are infected, but if left untreated, endocarditis can quickly lead to life-threatening complications. It is important for those at risk for endocarditis to seek medical attention if they start noticing unexplained symptoms associated with the disease. Treatment for infective endocarditis includes antibiotics and sometimes surgery.

IE cannot be passed from person to person – it is caused by unsterile needles or injection paraphernalia, which includes syringes, cookers, cottons, and water. Individuals who inject drugs have more than 6 times the odds of infective endocarditis than those who do not inject, and these odds jump to 4 times for those who inject at least daily.

Individuals at risk should take the following steps to protect themselves from IE:

  • Use sterile needles and injection paraphernalia every time. These can often be obtained from a local syringe services program or harm reduction center.
  • Avoid injecting drugs. The bacteria that cause IE are much less likely to cause harm if they do not enter the bloodstream directly. This means that drug use behaviors that don’t involve injection, such as smoking or snorting, are a much lower risk for IE.

Drug use increases the risk for these infections and many other dangerous or life-threatening things.  


Knowing these risks as well as the prevention strategies can help protect individuals that use drugs. For more information on how to protect your health when using drugs, or for tips to share with your loved one, read more here.

[Harm reduction] is a resource which arms one with knowledge which I otherwise would be ignorant of – therefore using without knowledge on how to reduce infection – maintaining healthful practices rather than ignoring them, and how to make sure my body get what it needs if I choose to use.
- Anonymous, Our Stories: Personal Testimonies

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