HAMPSHIRE COUNTY HOUSE OF CORRECTIONS
University of Massachusetts School of Nursing
HCV Prevention and
Harm Reduction Manual
University of Massachusetts School of Nursing, 2006
Information and Acknowledgements:
The purpose of this manual is to teach harm reduction and disease prevention using a
peer educational model. The material is presented in a course format and is divided
into 3 parts: 1) Overview of peer-education and harm reduction, 2) Principles of
selected diseases and infections, and 3) Harm reduction techniques and practices. The
appendix includes references and resources for more information.
We acknowledge information for parts of the manual were provided by the Harm
Reduction Coalition, 22 West 27th Street, 5th Floor, New York, New York 10001
The first edition of this manual was created by Heather Holmquist and Allison Allard.
This second edition was edited and revised by Leah Esrick. All are nursing students at
the University of Massachusetts, Amherst, School of Nursing. Professor Donna M.
Zucker is their advisor and teacher.
We are grateful for the editorial assistance and expert opinions of the Hampshire
County House of Corrections Staff, Tim Purington Director of Prevention Services
Tapestry Health, Hepatitis C One on One Support Groups, and the University of
Massachusetts, Amherst Faculty.
This manual has been made possible through an unrestricted educational gift from
Roche
Pharmaceuticals 
For copies please email Donna M. Zucker at [email protected]
Table of Contents
Introduction
i
APPENDIX 1
References
CHAPTER 1
Overview of Harm
Reduction and Peer
Education
1
Resources
CHAPTER 2
The Basics of
Disease and
Infection
CHAPTER 3
Reducing the Harm
1
1
Chapter
Overview of Harm
Reduction and Peer
Education
I
njecting drugs leaves the body at risk for diseases that are spread
through the bloodstream (i.e. HIV and Hepatitis B & C). Also, injection
exposes the body to bacteria, which causes life-threatening infections.
The Center for Disease Control and Prevention estimated that in 2003 alone
there were 30,000 new Hepatitis C infections in the United States. 2.7 million
Americans have been chronically infected with Hepatitis C. Chronic (longterm) Hepatitis C infection can lead to liver failure and death. As of 2002, the
Massachusetts Department of Health estimated that 110,000 Massachusetts
residents may be infected.
The safest way to prevent disease and
addiction is to not inject illicit drugs. However,
we accept, for better or for worse, that drug
use is part of our world.
Some ways of using are clearly safer than
others.
That’s where harm reduction comes in . . .
DEFINITION
Harm Reduction is a set of practical strategies that help to reduce the
negative consequences of drug use.
2
Harm Reduction and Risk
arm
simply
H
reduction works to minimize the harmful effects of drug use rather than
ignore or condemn them. Along these lines, the first priority of the harm
reduction philosophy is to establish quality of individual and community
life
and well-being – and not necessarily stopping all drug use. In other words,
if you’re not able to quit, SHOOT SAFE for you own sake and the sake of the
community.
There are many harms involved with drug use: arrest, incarceration, addiction, drug-related
crime, unemployment, and lack of quality healthcare are just a few. When we talk about
harm reduction in this course, we will be talking about reducing the following very specific
risks:
The Risk of Disease. Injectors are at high risk for getting HIV and/ or Hepatitis
A, B & C. Also, injectors are at high risk for abscesses and other bacterial
infections. In the following course we will be discussing the cause, effect and
treatment of these diseases. The more we know about the disease risks involved, the
more prepared we are to prevent them!
•
The Risks Involved in Preparing and Injecting Drugs. Many, if not all, of the
things that can go wrong during the process of preparing and injecting fall into one
of three categories:
•
Drug-related Problems
Hygiene-related Problems
Technique-related Problems,
Because we are forced to use black-market, unregulated drugs, we will never have
control over the quality or purity of the substances used. But while we may not be
able to do much about the actual drug we use, we can work to improve injection
technique and hygiene, which can have far-ranging effects on health.
•
The Risk of Overdose.
High penalty drug laws make people afraid to call for help
when someone overdoses. This handbook will outline overdose prevention
techniques and what to do in the event that someone you know overdoses.
The Responsibility of Harm Reduction is in Your Court .
..
he
drug
T
harm reduction philosophy states that drug users and those with a history of
use must have a real voice in the creation of programs and policies
designed to serve them. In keeping with this philosophy, participants are
encouraged to structure classes to fit their needs by giving feedback and
suggestions on material and activities. Think about what you will need to know in order to
do this work and MAKE SURE YOU GET THAT INFORMATION.
As always, we are the primary agents of reducing the harms of our own drug use, and can be extremely helpful in encouraging others to do the
We are grateful for the editorial assistance and expert opinions of the Hampshire
County House of Corrections Staff, Tim Purington Director of Prevention Services and
the University of Massachusetts, Amherst Faculty.
same. As
This manual has been made possible through an unrestricted educational gift from
Roche
Pharmaceuticals 
ii
peer educators, we accept the challenge of educating in our social circles and
communities
About Being a Peer Educator
Reasons for Being a Peer Educator
(The following reasons were given by previous Peer Educators)
 Wanting to learn more for myself to protect myself from Hepatitis A, B,
C, bacterial infections and the complications involved with injecting
drugs.
 Wanting to do this work on the outside, such as working with teens at risk
or at a Community Corrections Center or at a homeless shelter.
 Having had some experience as an educator or peer educator.
 Wanting to contribute ideas and past experience.
 Wanting to gain respect of staff by demonstrating that inmates can offer
something positive while doing their time.
 Having had personal experience with these topics (self, family, and
friends) and wanting to spare others the same.
 Being concerned about the number of Hepatitis C cases increasing.
 Wanting to make a difference with inmates’ attitudes and behaviors
(developing understanding, tolerance and trust).
 Wanting to improve my communication skills.
 Wanting to improve my self esteem.
Qualities of a Peer Educator

Motivated to Learn

Responsible

Open minded

Trustworthy - respectful of confidential and personal information

Good Listener

Respectful of other’s opinions, cultures, lifestyles

Respected by others

Committed to the integrity of the program
3
About Learning
“Tell me, I’ll forget, Show me, I’ll remember, Involve me and I’ll understand.”
–Ancient Chinese Proverb
We learn using all of our senses.
Peer educators help US REMEMBER:
 10% WHAT WE READ (handouts)
 20% WHAT WE HEAR (presentations)
 30% WHAT WE SEE (flipcharts/ laminated posters/ plastic models)
 50% WHAT WE SEE AND HEAR (videos/ displays)
 70% WHAT WE DISCUSS WITH OTHERS (worksheets/
discussions)
 80% WHAT WE EXPERIENCE PERSONALLY (activities)
 95% WHAT WE TEACH SOMEONE ELSE (teaching classes/ reports)
Tips for Peer Educator Presentations
Be prepared
Review your lesson plan.
Review the information you plan to teach.
Practice pronouncing words that are new to you.
Know your material.
Practice.
BE A TEAM PRESENTER
Who will present each part of the lesson?
How will you back each other up?
Who is most comfortable with each part of the lesson?
4
Who feels ready to take the challenge?
MODEL THE WAY YOU WANT THE CLASS TO ACT
Be enthusiastic, motivated and attentive.
Make eye contact and smile.
Speak clearly and loud enough to be heard.
Don’t do things that you don’t want others to do (put downs,
interrupting, etc.)
Use personal experiences.
Call participants by name.
Respond respectfully and clearly to incorrect comments.
Avoid arguing.
Don’t talk down.
Ask questions which stimulate thinking.
Admit when you don’t know the answer.
INVOLVE EVERYONE
Encourage participant comments and questions.
Listen to participant comments and questions.
Give feedback.
Encourage silent participants to speak.
Don’t always call on the same people.
Thank people when they participate, especially the first time.
Refer to earlier comments.
If not everyone hears a statement, ask the person to repeat it.
HELP PEOPLE WORK ON EXCERCISES
Give clear, step-by-step directions.
Ask if everyone understands your instructions before beginning the
next exercise.
Watch to make sure they are on the right track.
Praise positive work and give direction to anyone having difficulty.
5
Let people know that you take the activity seriously, and they will too.
ENCOURAGE THE GROUP TO SHARE OPINIONS
Ask people what they think about ideas being discussed.
Remember that when people share what they think, they are sharing
their opinions.
Things to remember about opinions:
Opinions are not facts
Opinions can contain false information
Opinions are formed from personal experience
Each person has an opinion and the right to it
More Tips for Peer Education Presentations
Everyone doesn’t have to agree with other’s opinion.
Avoid making judgments and giving advice.
If you choose to express your opinion, be sure to say it is your own,
rather than “the best answer”.
Sharing how you formed your opinion can help others recognize how
they formed their opinions.
Ground Rules for Class Participation
1.
RESPECT OTHERS’ OPINIONS.
2.
AVOID PUT-DOWNS.
3.
LISTEN WHILE OTHERS’ SPEAK AND LET THEM
FINISH.
4.
PAY ATTENTION TO LECTURER.
6
5.
RESPECT PRIVACY: “I KNOW SOMEONE WHO . . . “
6.
IT’S OKAY TO PASS AND NOT SAY ANYTHING.
Homework:
Imagine you are teaching someone for the first time about ANY topic (like the
dangers of drug use, or healthy eating). How would you use that hour? What
would you do for the first 15 minutes? The second 15 minutes, the third 15
minutes and the last 15 minutes?
7
T H E
B A S I C S
O F
D I S E A S E
A N D
I N F E C T I O N
2
Chapter
The Basics of Disease and
Infection
W
hat are the disease and infection risks involved with injecting drugs?
Have you or anyone you know had experiences with infected injection
sites, HIV or Hepatitis C? In chapter 2 we will be discussing several specific
disease risks of injecting drugs.
CHAPTER 2 OBJECTIVES
To identify the etiology (cause), symptoms and modes of transmission of
Hepatitis A & B.
To identify the etiology (cause), disease progression, and symptoms of
Hepatitis C.
To name several functions of the liver and the way in which the Hepatitis C
virus affects the liver.
To identify and compare relative risks of Hepatitis c transmission.
To discuss treatment options for Hepatitis A, B and C.
To understand the etiology, symptoms and treatment of bacterial soft tissue
infection.
To understand the etiology of emboli, vein collapse, and thrombosis.
8
T H E
B A S I C S
O F
D I S E A S E
A N D
I N F E C T I O N
VERBAL PRE-TEST
(If answers are unknown, ask participants to make educated guesses in regard to
their own experience. Discuss answers given.)
1. How do you get Hepatitis A?
2. How do you get Hepatitis B?
3. How do you get Hepatitis C?
4. What organ in the body does Hepatitis C most effect?
5. Among the general population, injection drug users are most at risk for
contracting hepatitis A/B/C and HIV/AIDs. True or False.
6. There is a vaccine that will prevent you from getting hepatitis C. True
or False.
7. What are some important functions of the liver in your body?
8. What is cirrhosis?
9. The riskiest mode of Hepatitis C transmission is: a) unprotected oral
sex, b) transmission between a Hep-C infected mother and infant, c)
two heroin users (one with Hepatitis C) share a cooker but do not share
needles.
10. Tiny organisms that can cause infections like abscesses are
called_______.
11. A missed shot of heroin will not cause an abscess but the cuts in the
dope might. True or False?
12. If you notice a small swollen red bump that feels warm to the touch on
one of your injection sites, what are three things you should do?
13. Antibiotics are needed to fight soft tissue infections. True or False.
14. Charlie shoots up in the same spot on his arm every time he uses. One
day he notices that the vein he uses seems to have disappeared. What
happened?
15. what are three symptoms of cellulites?
9
T H E
B A S I C S
O F
D I S E A S E
A N D
I N F E C T I O N
Chapter 2 Vocabulary
Acute -
Short-term and intense illness
Antibiotics -
Medicine that kills bacteria
Blood Clot -
Lumped together blood cells, which slow bleeding
Cancer -
Disease process where cells reproduce rapidly
Cells -
The basic building block of life
Chronic -
Long-term illness
Circulation -
The way the blood moves around inside the body
Depression -
Extreme sadness for a long period of time
Etiology -
Cause of disease
Feces -
Shit
Infection -
Containing disease
Inflammation -
Swelling
Pharmaceutical -
From the pharmacy, medicine
Pus -
Yellowish-white substance, which comes from infected areas
Semen -
Sperm, cum, jiz
Sterile -
Not contaminated by bacteria, or any other pathogen
Symptoms -
The way your body reacts to disease, eg. Sneezing, coughing,
swelling
Transmission The spread of disease from one person to another
Toxic/ toxins Life-threatening substance
Vaginal fluids Liquid in the vagina
Virus –
Particles that cause disease
10
D E S I G N
C U S T O M I Z A T I O N
Unit #1: Hepatitis A, B & C
H
Epatitis is an inflammation of the liver that can be caused by certain
toxic drugs, alcohol, or street drugs; or that is a result of infection with
a hepatitis virus.
While there are numerous types of hepatitis viruses,
hepatitis-B and hepatitis-C are the two that most
frequently affect injection drug users, with hepatitis-A
coming in third.
What Do I Need to Know About Hepatitis A, B & C?
1. They are preventable.
2. You can learn to protect yourself and other IV drug users.
3. You will understand the importance of getting tested for Hepatitis A, B &
C.
4. You can figure out if you have been at risk of being exposed to any of these
viruses.
5. And finally, if you test positive for Hepatitis C you can learn how to live a
longer and healthier life.
Hepatitis A vs. Hepatitis B
On the following page is a chart comparing Hepatitis A and Hepatitis B in four
areas: a) transmission (how you get the virus), b) symptoms and disease
progression (how you know you have it and how long it will last), c) prevention
(how to avoid getting the virus), and d) treatment options (what to do if you know
you have the virus..)
To help you sort through and understand this information, you will be asked to
complete the worksheet on page x.
12
T H E
B A S I C S
HOW DO I GET IT?
O F
D I S E A S E
A N D
I N F E C T I O N
HEPATITIS A (HAV). . .
. . . caused by a virus found
in feces (shit). You can get
HAV if you have contact
with contaminated feces.
The most common way this
happens is through
swallowing contaminated
food or water. You can also
get it through sexual acts
like rimming (licking
someone’s asshole) or
sucking a guy off
immediately after he’s had
anal sex.
HOW DO I KNOW I’VE
GOT IT? HOW LONG
WILL IT LAST?
Almost everyone infected
recovers completely in
about 4 to 8 weeks. You
may have no symptoms, or
you may suffer from
nausea, vomiting, jaundice
(yellow skin and/ or eyes),
diarrhea, and/or extreme
lack of energy.
HOW DO I AVOID
GETTING IT IN THE
FIRST PLACE?
1. Wash your hands
thoroughly after
using the bathroom,
and before cooking
or eating
2. Use protection when
having sex,
especially when
practicing anal sex,
or combinations of
anal-oral sex
3. Get vaccinated.
It will usually clear up on
its’ own. Hepatitis A is
rarely dangerous, unless
you have Hepatitis C.
ONCE I HAVE IT, WHAT
DO I DO?
12
HEPATITIS B (HBV) . . .
. . . caused by a virus found
in blood, semen (cum),
vaginal fluids, breast milk,
and saliva (spit). It is spread
by sharing syringes or
infected water when
injecting. It can also be
spread by sharing other
injection equipment (like
cottons and cookers) and,
perhaps, snorting or
smoking devices (like
straws or crack pipes). HBV
is transmitted through
unprotected sex.
Similar symptoms as HAV
start gradually, usually
lasting a month or two.
Sometimes you may not
know you’re infected
because you don’t look or
feel sick: the virus can
remain active within your
system, and you can still
infect others.
1. Use protection when
having sex
(condoms, dental
dams, latex gloves).
2. Inject safely.
3. Use less risky
methods to take
drugs, like snorting
and smoking with
your own straws and
pipes.
4. Get vaccinated.
Most people recover
completely within 6 months
(acute). 5-10% of people
remain capable of spreading
the virus for the rest of their
lives (chronic).
T H E
B A S I C S
O F
D I S E A S E
A N D
I N F E C T I O N
Worksheet #1: Hepatitis A & B
1. List several times when you may have put yourself at risk or accidentally
been at risk for Hepatitis A. Be specific.
2. List several times when you may have put yourself at risk or accidentally
been at risk for Hepatitis B. Be specific.
3. Which can become a chronic (long-term) condition: Hepatitis A or
Hepatitis B? Which virus will go away on its’ own?
4. What would you say to a friend who you think might be at risk for Hepatitis
B? How might you convince someone you know to get vaccinated for
Hepatitis A or Hepatitis B? Try to anticipate ways in which they may blow
you off.
13
T H E
B A S I C S
O F
D I S E A S E
A N D
I N F E C T I O N
Hepatitis C in the Body
H
epatitis C (Hep-C) is a small virus spread by blood-to-blood contact. HepC travels through the bloodstream to the liver. It enters the liver cells and
interferes with normal liver cell activity. This stresses the liver, causing it
to become inflamed (sick or irritated). Hepatitis C affects everyone differently.
Eventually, however, Hep-C will damage your liver and keep it from working
properly. This is what makes you sick.
Hep-C is transmitted
blood-to-blood.
Sometimes the body will clear
itself of the virus within 2-6
This doesn’t mean just touching months of being infected. This is
someone else’s blood. It means called acute hepatitis. Only 1520% of those infected will get rid
getting blood infected with
of the virus.
Hep-C virus directly into
your bloodstream. You
cannot get Hep-C through
casual contact with an
infected person, like shaking
hands or eating off the same
plate.
T
The Liver is the Organ
Most Affected by Hep-C.
Hep-C makes
your liver work
even harder at
the many jobs
it must do to
keep the body
healthy.
he liver is a strong, vital organ that keeps your body functioning smoothly.
Your liver processes almost everything you take into your body. It
performs over 500 necessary jobs everyday.
What does the liver do?
Some of the most important things are:
1. Helping the body digest food.
2. Removing toxins from your system, such as alcohol, drugs and
medications.
3. Regulating the chemicals produced by your other organs, such as
kidney and spleen.
4. Storing and releasing nutrients for the body, such as vitamins, minerals
and sugars.
5. Making platelets, which help your blood to clot.
ACTIVITY (Brief Answer)
14
T H E
B A S I C S
O F
D I S E A S E
A N D
I N F E C T I O N
BASED ON WHAT YOU KNOW, WHAT ARE SOME WAYS TO TAKE
CARE OF YOUR LIVER?
ANSWERS:
(1. cut back on the street drugs and alcohol, 2. drink lots of
water, 3. eat well and reduce stress, 4. Try to eat a low-salt,
low-fat diet, 5. Exercise on a regular basis)
15
T H E
B A S I C S
O F
D I S E A S E
A N D
I N F E C T I O N
Chronic Hepatitis C
T
he liver can withstand lots of damage because it is capable of repairing
itself. Like a sore on your skin, the liver will scab as it heals, but it will also
leave a scar. A small amount of scarring on the liver is called fibrosis. A
scar on your liver is different than a scar on your skin. The scar on your
liver makes it harder for your liver to work the way it’s supposed to. The more your
liver scars, the less it can do. Cirrhosis is a condition of severe scarring, which
affects the blood flow through the liver.
In about 3% of Hep-C infected people, the liver becomes so badly damaged that it
can no longer work properly. At this stage, called liver failure, the only medical
option is a liver transplant. Liver transplants are difficult, expensive and hard to
get. Injection drug users and people living with HIV may not be able to get liver
transplants at all. Even worse, if you do get a liver transplant, Hep-C almost always
reappears in the new liver. This is why it is so important to prevent Hep-C, and to
find out early if you’ve been infected – so you can start taking care of your liver!
In its early stages Hep-C is difficult to recognize from just the symptoms because
many of them are similar to symptoms you get from other diseases, like flu or HIV.
Some reported symptoms from the early stage include:
 Headaches
 Loss of appetite
 Nausea (wanting to throw up)
 Stiff/ aching joints
 Brain fog/ cloudy head
 Depression
The following are symptoms that are more likely to show up at an advanced stage
of the disease, once the liver has become damaged:
 Pain in the right side, over liver area
 Dark urine
 Pale feces
 Constant tiredness and lack of energy
 Jaundice (yellowing of skin and eyes)
16
T H E
B A S I C S
O F
D I S E A S E
A N D
I N F E C T I O N
 Severe itching on the skin, usually the arms and legs
 Water retention, with bloating in lower stomach area and legs
 Easy bruising/ bleeding, including in the esophagus (throat)
 Severe mental confusion
What’s a Vaccine?
A vaccine is a shot containing weakened or dead parts of a disease.
Essentially by getting vaccinated, you’re being infected with a weaker version
of the disease. That way your body builds up ways to fight the disease when
your body comes into contact with the disease again. In short, vaccines prevent
you from getting the disease.
Vaccination against hepatitis A and B are available.
The vaccine is different, but each requires 2 shots over 6 months.
There is a combined hepatitis A and B vaccine, also given in 3 shots over 6
months. To get full protection (immunity) against hepatitis A & B, you must
get all the shots in the series. Hepatitis A & B are the most dangerous when
you also have hepatitis C. Getting hepatitis A, for example, when you already
have hepatitis C sometimes leads to liver failure. So get vaccinated!
Currently there is no vaccine for hepatitis C.
Look in the back of this Guide under Resources, for places you can go for
hepatitis A & B vaccines.
17
T H E
B A S I C S
O F
D I S E A S E
A N D
I N F E C T I O N
Hepatitis C Role Play
D I R E C T I O N S :
C H O O S E
A
P A R T N E R .
U S I N G
T H E
I N F O R M A T I O N
A B O V E ,
C L A S S
T H E
O N
A N D
In this Role Play Person #1 has two minutes to convince Person #2 that Hepatitis C
is not worth the risk. Both people must be respectful and may not interrupt each
other. Ground rules of class participation must be followed at all times.
C H A R T
T H E
F O L L O W I N G
P A G E
T O
H E L P
Y O U
A C T
Person #2: This person is worried about Person #1. S/he knows the facts about
Hepatitis C and knows that the virus is definitely something to worry about.
O U R
D I S C U S S I O N
I N
Person #1: This person is at risk for getting Hepatitis C. S/he knows s/he is not
being careful and may get the virus. However, s/he thinks that Hepatitis C is
nothing to worry about and that it’s unlikely that the virus will cause problems.
O U T
After the conversation is completed, work together to remember what you said that
were helpful in arguing your case.
T H I S
S I T U A T I O N
18
T H E
B A S I C S
O F
D I S E A S E
A N D
I N F E C T I O N
Hep-c Disease Progression
Of All People Infected With Hep-C (100%)
Clear the Virus
15-20% clear the virus within
2-6 months of being
infected
Chronic Hepatitis C
80-85% remain chronically
infected. Nearly all
will show characteristics on examination
Of all People
Chronically Infected
with
Hepatitis C
Stable
20% will never suffer significant
liver damage or symptoms
(17% of all infected)
Liver Disease
80% will get some
long term symptoms or liver damage
over a period of 10-40 years (68% ofall infected)
Of all People
Who Develop
Liver Disease
Cirrhosis
About 20% will develop Cirrhosis
after an average of 20-30 year
(13-15% of all Infected)
Stable
75% will remain stable
over 5-10 years
(10-12% of al infectedl)
Liver Failure or Cancer
25% may have liver failure or
cancer over 5-10 years
(3-4% of all infected)
19
T H E
B A S I C S
O F
D I S E A S E
A N D
I N F E C T I O N
Hep-C Transmission
H
ep-C is spread through contaminated blood. Since 1992 blood transfusion
have been screened for Hep-C. Because of this it is now very rare to get
Hep-C from a transfusion. The sharing of injecting drug equipment by
injection drug users is the most common way the virus is spread. It is
estimated that between 60-80% of injection drug users in the United States have
Hep-C.
Hep-C is much more easily transmitted by contaminated needles and syringes than
HIV because it is a much hardier virus and there is more of it in the blood. Even
when needles or syringes are not directly shared, Hep-C can be transmitted by small
amount of blood in other injection equipment that is shared, like the water or
cooker.
Besides injection, you may be able to get Hep-C from snorting cocaine or heroine
with other people and sharing the straw used for snorting. Also, Hep-C can be
sexually transmitted, particularly through anal sex.
Hep-C Relative Risk Activity
D I R E C T I O N S : B R A I N S T O R M P O T E N T I A L S I T U A T I O N S
W H E R E Y O U M I G H T B E A T R I S K F O R H E P - C . W R I T E
E V E R Y O N E ’ S I D E A S D O W N O N I N D E X C A R D S . N O W , A S
A G R O U P , R A N K T H E D I F F E R E N T S I T U A T I O N S
A C C O R D I N G T O D E G R E E O F R I S K , F R O M M O S T
H A R M F U L T O L E A S T H A R M F U L .
Examples are:

You’re in the shower and somebody has just jerked off, leaving a blob of cum on the floor.
You accidentally step in it.

You have protected sex with someone who has a sexually transmitted disease.

You have anal sex with someone who swears up and down she’s never had sex before, but
you know she has a bad heroin habit.

You share needles with someone who had a blood transfusion in 1998.
20
T H E
B A S I C S
O F
D I S E A S E
A N D
I N F E C T I O N
Living with Hep-C
There is treatment for Hep-C
T
here are two goals to this treatment:
 Getting rid of the Hep-C virus.
 Stopping the damage the virus causes your liver.
Today the best pharmaceutical therapy is pegylated interferon plus ribavirin.
Unfortunately, this medication is expensive and difficult to take, due to its side
effects (even more so for people managing drug habits). If you’re using, it’s a good
idea to look for a doctor who has experience treating active users. Before starting
the therapy, it is important to weigh the potential benefits of the medication against
the very common negative side effects (heavy fatigue, chronic fever, lack of
appetite, insomnia, depression, etc.).
Homework for Next Week
You are asked to talk to men in parole about Hep – C.
After the meeting someone wants to talk about how he
should go about getting tested and get some treatment.
What will you say? Come back next week with a plan.
21
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W hat
O F
D I S E A S E
A N D
I N F E C T I O N
do you know about HIV?
What is HIV?
HIV (Human Immunodeficiency Virus) is the virus that causes AIDS (Acquired Immune
Deficiency Syndrome).
You can get HIV by:
Coming in contact with HIV-infected blood (for
example sharing needles for drugs)
Through sexual contact with people who are
already infected with HIV. During sex, HIV can
enter the body through the vagina, vulva, penis,
rectum, or mouth.
HIV-positive mothers can also pass the virus to
their children during pregnancy, delivery, or
through breast milk.
What can HIV do?
HIV weakens your immune system. HIV becomes AIDS when your immune system can't
keep fighting illnesses and you start getting diseases called opportunistic infections. They
take advantage of your weakened immune system. Most doctors prescribe drugs to help
prevent opportunistic infections when your CD4 count drops below 200. A CD4 count is a
measure of your T-cells. T-cells are a kind of white blood cell that fights infections as
part of your immune system.
Treatment for HIV can slow the virus and delay the onset of AIDS. There is no set time
when HIV will become AIDS. Some people get AIDS-related illnesses within a few years.
About half of all people with HIV develop AIDS within 10 years if they're not treated. It's
important to talk to your doctor about your treatment options for HIV.
Reprinted with permission from www.Aidsmeds.com
Where can I get a test?
Look in the back of this guide under Resources for testing centers.
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I N F E C T I O N
Unit #2:
Bacterial Infection and Other
Complications of Injection Drug
Use
S
Oft tissue infection involves the skin, the underlying fat, connective tissue
and muscle. A soft tissue infection occurs when the skin is broken by a cut,
scrape, puncture, or wound. Then, bacteria find its way into the open area.
Skin abscesses and cellulitis are the two most common bacterial soft tissue
infections. Wound botulism and necrotizing fasciitis (flesh-eating disease) are more
serious bacterial infections, which are less common. Soft tissue infections, if left
untreated, can be very painful and lead to worse infection, loss of limbs, and/or
death.
Embolism, vein collapse, and thrombosis are not bacterial infections. However,
they are risks of IV drug use.
What Do I Need to Know About Bacterial Soft Tissue
Infection and Emboli, Vein Collapse, and Thrombosis?
1. They are preventable.
2. You can learn to protect yourself and other IV drug users.
3. You can figure out if you’ve put yourself at risk for infection or other
complications.
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Verbal Pre-test
(If answers are unknown, ask participants to make educated guesses in regard to
their own experience. Discuss answers given.)
1. Tiny organisms that can cause infections like abscesses are called
________.
2. If you notice a swollen red bump that feels warm to the touch, what are
three things you can do?
3. Antibiotics are needed to fight soft tissue infection. True or False.
4. Charlie shoots up in the same spot on his arm every time. One day he
can’t find the vein he uses. What happened?
5. What are three symptoms of cellulitis?
6. You know you have to go to the doctor when:
a. You’re having a lot of pain.
b. You have a very high fever that won’t go away.
c. The site of injection is turning green or black.
d. All of the above.
7. To prevent blood clots off into bloodstream, I should . . .
a. Stick a needle in a site that isn’t healed.
b. Only use veins that do not bend when pushed.
c. Use the same site for every shot.
d. None of the above.
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O F
D I S E A S E
A N D
I N F E C T I O N
What Are Bacteria?
B
Acteria are microscopic organisms that feed off their environment. The
‘environment’ can be the toilet seat, eyebrows, or hands. Bacteria are
everywhere, but a few types cause infections and disease. The main
bacteria that cause abscesses are staphylococcus (staff-lo-coc-us) aureus
(or-e-us).
What Are Abscesses?
A
bscesses are pockets of bacteria and pus underneath the skin and
occasionally the muscle. The body creates a wall around the bacteria in
order to keep the bacteria from infecting the bloodstream or uninfected
soft tissue.
Abscesses are caused when bad bacteria come into contact with healthy flesh. One
way this happens is through dirty injection practices. Bacteria can be pushed
directly into the body when you shoot up. Another way abscesses happen is by
missing the vein when you’re shooting. The missed shot leaves contaminants in the
tissue that get infected. This is especially true with speed and coke. By itself, heroin
won’t give you an abscess if you miss a shot, but the cut in the dope might!
Because they are pockets of infection, abscesses cause swollen lumps under the
skin which are often red (Or in darker skinned people, the infected area will be
darker than the skin around it.), warm to the touch, and painful.
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D I S E A S E
A N D
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If you think you might have an abscess . . .
Go see a
doctor!
Large abscesses
need to be
drained by
trained
professionals.
With an abscess that isn’t going away and is
increasing in size, it’s best to go see a
professional. The abscess will need to be drained
and must be packed correctly with sterile gauze
in order for the abscess to not return.
With large abscesses, antibiotics are
needed to kill the bacteria and you need
to see a doctor.
In the meantime, the best thing to do is to keep the area
clean with soap and water and apply hot compresses or soak the area in warm water
and Epsom salts. This will increase the circulation in the area and either help the
abscess to go away without opening or help bring it to a head (like a whitehead
pimple, except don’t try to pop it yourself!) so it can be
drained at a clinic.
Signs that the infection is
really serious:
1.) There’s a dark red
line running away
from the abscess. This
can indicate blood
poisoning, which can
kill you.
2.) You have a very
high and persistent
fever.
3.) You’re having a
lot of pain.
4.) The area begins to
lose feeling or turn
green or black.
 If it’s draining – let it – do not pick at it!
 Keep the area covered with sterile gauze you can buy at a
pharmacy, and change the dressing twice a day until the pus
stops draining and at least once a day until the abscess is
completely healed.
 Dressings that directly touch the wound should be
dampened with sterile saline (which you can also buy at a drug
store) and the covered with dry gauze and tape. Properly
dressing an abscess will keep it free from further infection.
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Other Soft Tissue Infections
Cellulitis
C
Ellulitis is a bacterial infection of the skin and underlying tissues. Inflamed
red skin that feels hot and painful is the first sign of cellulites. The
inflamed red area surrounds the outside of the wound site. The infected
area is swollen and intensely painful. Fever, weakness sweats, and other
flu-like symptoms follow. The infection may stay around the area of the wound/
puncture site, or may spread over a whole limb or area of the body.
Wound Botulism
W
ound botulism is caused by a bacteria that produces a toxin on the skin
where a puncture wound is made. Eventually, the toxin stops your
breathing and paralyzes your muscles.
Necrotizing Fasciitis
N
Ecrotizing fasciitis is a bacterial infection commonly known as “flesheating disease”. It enters the body through broken skin and then affects the
surrounding tissue and nearby muscle. Symptoms of necrotizing fasciitis
include increasing redness, swelling, fever and extreme pain at the wound
or injection site. The flesh around the site of infection begins to decay and looks as
if it has been “eaten away”. Since this infection is fatal, early treatment with
antibiotics is crucial to survival, although treatment does not prevent death in all
cases. Wound must be kept very clean.
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Other Complications of Injection Drug Use
Embolism
A
N embolism is something such as air, fat, dirt or other particles that can
block a blood vessel. For example, particles from injected pills that are not
completely powder and clumps of bacteria can both cause emboli. Emboli
can be extremely serious.
Emboli can be avoided by filtering out any particles from the shot. Also, it’s not a
smart idea to inject pills, even if it seems like the pill is completely crushed.
Vein Collapse
V
Ein collapse occurs when veins close up due to repeated injections into
the same site, repeated infections in the same spot, or other trauma to the
veins and surrounding tissues. Using barbed or dull needles can cause
vein collapse. You know you have a collapsed vein when you can’t draw
blood from it and when the vein “disappears”.
Thrombosis
T
Hrombosis is the formation of a blood clot which can block a blood vessel.
Each time you take a shot, it leaves a hole in the vein. Our bodies’ way of
healing is to form a blood clot, which prevents us from losing excess blood.
Sticking a needle through a hole that isn’t healed can push a blood clot into
the bloodstream. This clot could get stuck somewhere else in the body, including
the brain.
To prevent this from happening, don’t use veins that do not bend when pushed as
they may have blood clots that can break off and lodge in the lungs or other parts of
the body and cause serious damage.
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Activity
You see a friend with a lump the size of a big egg near a
vein on the inside of his elbow and suspect he has an
abscess. What can you tell him to do?
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R E D U C I N G
T H E
3
Chapter
H A R M
Reducing the Harm
M
categories:
ainlining is one of the most dangerous ways to get drugs into your
body. Many, if not all, of the things that can go wrong during the
process of preparing and injecting drugs fall into one of three
(1) hygiene-related
(2) technique-related
(3) drug-related
Because we are forced to use black-market, unregulated drugs, we will never have
control over the quality or purity of the substances used. But while we may not be
able to do much about the actual drugs we use, we can work to improve injection
hygiene and technique, which can have far-ranging effects on health.
CHAPTER 3 OBJECTIVES
To understand the importance of hygiene in preventing disease.
To understand the role clean needles play in preventing Hep-C and HIV.
To understand ways to reduce harm to the veins through shooting.
To compare risks involved at various injection sites on the body.
To be able to get resources and help when needed.
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Unit #1: Hygiene-Related Harm Reduction
H
Ygiene is a science that deals with the maintenance of health. Specifically,
by washing the body, brushing the teeth, and using clean utensils to
prepare food we cut down on the number of pathogens in the
environment. Pathogens cause disease.
When it comes to injecting drugs, hygiene is very important. Injecting into the arm,
for example, creates a puncture in the skin through which pathogens can directly
enter the blood stream. We can cut down on the risk of this happening by keeping
the injection site, hands, and equipment clean with alcohol, bleach, or soap and
water.
It is also important to remember that sharing and reusing dirty needles allows
pathogens (like HIV/ Hep-C & B viruses, and bacteria) directly into our bodies.
While bleaching needles and equipment can help prevent disease, there is no
substitute for a brand new needle!
What Do I Need To Know About Hygiene?
1.
The way to prevent bad bacteria from hurting you is to get rid of them with
soap, water, alcohol, or bleach.
2.
Needle exchange saves lives.
VERBAL PRE-TEST
(If answers are unknown, ask peers to make educated guesses based on their own
experience. Discuss answers given.)
1. What substance is used to clean injecting equipment and syringes?
2. What substance(s) can be used to clean skin?
3. What are some ways to protect your self from bacterial infection?
4. What are some ways to protect your self from Hep-C and HIV?
5. What are the steps involved in cleaning a syringe?
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Preventing Bacterial Infection
I
n chapter 2 we learned that infections like abscesses are caused by bacteria.
One way to avoid abscesses and other infections is to make sure all of the
injecting equipment, your hands, and skin are free of bacteria (in other words,
clean) before you put the needle into your skin.
Alcohol pads work well to clean a site. Wipe in one direction to remove bacteria,
fungus, or other germs so they don’t get into your bloodstream.
If you don’t have alcohol wipes, use soap and water, hydrogen peroxide, or rubbing
alcohol (even drinking alcohol if it has a high proof).
One of the Single Most Important Things You Can Do To Prevent
Infection . . .
CLEAN YOUR SKIN BEFORE YOU SHOOT EVERYTIME!
To protect yourself against bacterial infection . . .
•
Clean the spot you plan to inject into before you shoot.
•
Don’t touch the drug with your fingers – fingers have bacteria on them.
Wash your hands well before touching equipment or preparing the drug.
•
Keep the cotton & cooker in a clean plastic bag. Clean your fingers before
touching. Don’t share.
•
Don’t touch the syringe with your fingers, mouth, etc. Touch only the
cotton when drawing up. Don’t press the needle against the side of the
cooker.
Preventing Hepatitis and HIV
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H A R M
I
n chapter 2 we learned that viruses like Hepatitis B & C and HIV are spread
through blood products, which means that one way of getting the virus is by
sharing a needle with someone who has the virus. Even if you cannot see blood
in the syringe the virus may still be there. You are at risk for getting a bloodborne virus if you:
•
Share a needle with someone who has a blood-borne virus.
•
Share equipment with someone who has a blood-borne virus (For example,
sharing a cooker and cotton, and then dividing the drug by drawing up into
a contaminated syringe may pass the virus along.).
•
Inject with used syringes.
•
Let someone else hit you (There’s the chance of exposure to infected
blood.).
Bleach is known to kill the Hepatitis virus and HIV. A dirty needle may be cleaned
with bleach. Bleaching your works will be helpful in preventing both bacterial
infection and Hepatitis/ HIV. However, this method of preventing disease is far
from 100%. successful.
How to Bleach Your Works in Three Easy Steps
1. Fill the syringe with water. Tap it with your finger to loosen blood drops.
Shake the syringe. Shoot out the bloody water. Repeat these steps until you
cannot see any blood in the syringe.
2. Fill the syringe with bleach. Make sure the bleach touches the inside of the
syringe for at least two minutes, the length of time it takes to kill Hep-C virus
and HIV. Shoot it out.
3. Rinse out the Bleach with new clean water. Shoot it out.
Repeat Each Step 3X
REMEMBER: THERE IS NO SUBSTITUTE FOR A NEW SYRINGE!
Syringe Exchange
Northampton Needle Exchange
16 Center Street, Northampton, MA 01060
Promoting Safety and Education Regarding Injection Drug Use
This is a completely anonymous program in a non-judgmental environment. Once
enrolled, used syringes may be exchanged for new ones and you may legally carry
clean syringes in Massachusetts. You may stop by our office for free alcohol wipes,
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bleach kits, condoms, or information on any of our services. Our services include
the following:
Assistance in Accessing Substance Abuse Treatment
•
Detox
•
Methadone Maintenance
•
In/ Out- Patient Rehab Programs
Health Outreach Program
•
Help prevent the spread of HIV & Hep-C
•
Educate other users
•
Earn rewards for your efforts
They also offer: Referrals for STD services, instruction on safer injection
practices, HIV Anti-body counseling & testing, HIV/ AIDS education, Food
Distribution Program, assistance in accessing health care, housing, etc.
Activity:
List 4 things a harm reduction center can do for you or
someone you know?
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Unit #2: Technique-Related Harm Reduction
What do I Need To Know About Shooting Safely?
1. Shooting in a place which is well lit and where you can take your time is
key to reducing risk.
2. Missing a shot can be a huge deal, especially when you hit an artery or
nerve.
3. Some parts of the body are higher risk injection sites.
4. There are ways to protect the veins while shooting.
VERBAL PRE-TEST
(If answers are not known, ask peers to make educated guesses based on their own
experience. Discuss answers given.)
1. What should you do if you think the needle has missed the vein?
2. What are some signs that the needle may have missed the vein?
3. Why is it important to avoid hitting an artery? What might happen?
4. What parts of the body are the riskiest injection sites? Why?
The Safest Shot
Steps For A Safe Shot
1.
Insert your needle at a 15-35 degree angle, opened towards your
heart. The higher the angle (the more straight up) the greater the
chance of blowing the vein.
2.
Pull back on the plunger to see if you are at the right spot (blood
should be dark red and slow moving). If you don’t get good return
you may not be in the vein and will miss the shot.
3.
Remove the needle in the same angle in which you injected to
minimize bruising. If the site is bleeding, apply pressure.
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W
T H E
H A R M
ANYTIME YOU HIT
SOMETHING THAT
hen you think you’ve hit a vein, ALWAYS pull FEELS LIKE A
back the plunger a little. If dark red blood comes VEIN, BUT IT
into the syringe, then you’ve hit a vein. Vein blood HURTS, PULL
never comes into the syringe on its own you have to
OUT!!
pull the plunger back.
If you hit a spot on the surface that you can see, that’s a vein. You are only going to
hit an artery if you are searching for a spot deeper down.
Artery Vs. Vein
B
Lood cells circulate the body, carrying the nutrients our bodies’ need.
Blood flows through a system of tubes made up of arteries and veins.
Arteries pump blood that has received oxygen away from the heart and
out into the body. For example, blood in the arteries flows from your shoulder
towards your fingers. Arteries are bigger and deeper (away from the skin) than
veins. The blood flows much faster through them.
Veins pump blood that has already been around the body back to the heart. For
example, blood in the veins flows from your fingers to your shoulder. Veins are
smaller than arteries and are closer to the surface.
You Know You Hit An Artery When . . .
•
You feel a pulse.
•
The color of the blood is bright red.
•
The blood may even be a little foamy or frothy.
•
The blood has a lot of force behind it. Sometimes you don’t even have to
pull the plunger back, the blood just comes out of the syringe.
IF ANY OF THESE THINGS HAPPEN, PULL OUT!! HITTING AN ARTERY CAN
KILL YOU! APPLY PRESSURE TO THE PLACE WHERE YOU PULLED OUT. IF
POSSIBLE, HOLD YOUR ARM OR LEG OVER YOUR HEAD. IF THE BLEEDING
DOESN’T STOP, YOU HAVE TO CALL 911 AND GET SOME HELP.
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You Know You Hit A Nerve When . . .
•
It hurts like hell!
•
No blood comes into your syringe when you pull back the plunger.
Where’s the Shot?
Arms
Relative Risk
Lowest risk
Best choice! Upper arm is better than
lower. Why? It’s closer to the heart.
Hands
Relative low risk
It can be harder than you think to get a
good shot, though. If you scar or track
here, you can’t hide it. If you blow your
veins here, your hands can stay swollen.
Rotate these sites frequently.
Legs
Medium Risk
Why? Circulation problems. Blood is a
long way from the heart. Plus, getting
off in your legs is more likely than your
arms to leave blood clots that could
break off and get stuck in your heart or
lungs.
Feet
Medium Risk
Veins here take a long time to heal.
Circulation here is super slow. Plus, it’s
hard to keep a healing spot clean when
you are wearing socks and shoes.
Groin
High Risk!
Why? The femoral vein is big, and fairly
easy to find. But it’s really close to the
femoral nerve and artery. Be sure to
avoid the artery by checking for a pulse.
If you feel it, don’t hit there!
Neck
High Risk!
The carotid artery is here. Hit this and
you could die.
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you could die.
Vein Care
W
hen you stick a needle in your skin, it leaves a hole that needs to heal.
The same is true with your veins. You can keep your veins in good
shape if you let a spot heal before you hit on it again. Vein care is very
important when injecting drugs to avoid infection and maintain good
health.
If you don’t let your veins heal, you may get: . . .
• Collapsed veins (the vein is closed completely)
•
Infections
•
Leaky veins, wasted shots
•
Abscesses from leaks and wasted shots
•
Thrombosis
To Protect Your Veins . . .
•
Alternate Veins – let one spot heal while you use another. A vein takes at
least a couple of days to heal. More time is better.
•
If you use the same vein, shoot downstream (away from the heart).
Shooting downstream from your last hit prevents you from pushing any
blood clots into your bloodstream.
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•
If you hit yourself, practice injecting with your other hand, in your other
arm. It may be awkward, but it gives you more options.
•
If you can, tie off (use a tourniquet). This makes finding a vein A LOT
easier. But once the needle is in the vein, take the tie off before you hit!
Leaving the tie on while you hit pits too much pressure on the vein. You
could lose the vein this way.
Activity:
List 3 techniques that can help you stay our of the hospital
emergency room?
Unit #3: Drug-related Harm Reduction
K
nowledge is power. The more we know about the drugs we’re putting
into our bodies, the better able we are to reduce the harm involved in
injecting.
Heroin (“junk”, “smack”, “dope”, “brown”, “chiva”, “H”, “manteca”) is
a drug made from the opium poppy, and belongs to a class of drugs called
“opiates.” Some opiates are natural (morphine, opium, and codeine) and some are
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synthetic, or manufactured in a lab without using the poppy (Demerol, methadone,
fentanyl). Heroin is “semi-synthetic:” it is produced from morphine through a
chemical process that makes it about three times stronger than morphine and gives
the user a “rush” when injected because it easily gets to the brain. Heroin breaks
down in morphine inside the human body.
Heroin is a pain-killing drug that makes the user less aware of and better able to
tolerate physical or emotional pain. It is most often snorted 9inhaled into the nose),
smoked, or injected. Injecting and smoking are the fastest ways to feel the effects of
heroin; snorting takes a bit more time for the drug to be absorbed. Injecting is the
riskiest method to use in terms of overdose because the entire dose enters the body
at once.
Heroin bought on the street often contains “cuts”, or substances
other than heroin put there by the dealer. These cuts can be harmful
to the user. Sometimes what is sold on the streets as heroin is not
heroin at all but some other substance that won’t get you high, or
some type of synthetic opiate – like fentanyl – that is much stronger
than heroin and puts the user at greater risk for overdose.
Vocabulary to Think About:
•
Tolerance
•
Dependence
•
Withdrawal
•
Criminal
What are the Effects of Heroin?
The effects of heroin are experienced differently by different people. Effects of
heroin often include:
•
Constipation
•
Nausea
•
Itchiness
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H A R M
•
Slowed breathing
•
Decreased libido or sexual interest
•
Increased energy
•
Pinpoint pupils
•
At higher doses, sedation (“nodding off”)
Women might have irregular periods or stop having them altogether. Heroin users
often also report feelings of warmth, euphoria, contentment, and well-being. Not
everyone who uses heroin experiences all of these effects all of the time. Finally,
regular use of opiates will lead to physical dependence.
Contrary to popular belief, heroin itself does not cause serious long-term health
problems for the generally healthy person. However, the practice of injecting and
the fact that people don’t know what they’re getting when they buy street drugs can
present significant short-and-long-term health risks.
Overdose
One of the most serious health risks of using heroin is the possibility of overdose.
When a person uses too much heroin, their breathing becomes so depressed that it
stops altogether and their body shuts down. People with respiratory problems like
pneumonia should therefore be extra careful when using heroin.
To avoid overdose . . .
•
Do a tester shot – or a small amount – every time you get a new supply of
drugs so that you can find out how potent they are.
•
Don’t mix drugs! Chances of overdose increase if you mix heroin and
other drugs that depress the body such as alcohol, barbiturates (Seconal,
Tuinal), and benzodiazepines (Valium, Ativan). Mixing a shot of heroin
with cocaine (“speedball”) or amphetamine is also more dangerous than
using either by itself.
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•
If you haven’t used for a while, you no longer have the same tolerance.
A dose that would have been fine in the past may now kill you.
•
Use with a responsible and caring friend. If something happens, your
friend can hopefully see you through it.
A person who has overdosed on heroin will usually . . .
•
stop breathing
•
have no pulse
•
vomit
•
turn bluish
•
have cold skin.
If you see these signs, CALL 911 IMMEDIATELY!
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In the meantime . . .
Try to keep them up, moving around, and breathing. If this isn’t possible, at least
keep their airways clear, lean their body forward so that the lungs don’t fill with
fluid, and apply CPR. Learning CPR is probably the single most important thing
you can do to help someone survive an overdose.
Don’t leave the person alone. You’ll need to be there when the ambulance comes so
that you can help your friend through this scary experience. If you’re worried about
the police showing up with the ambulance, try to stash or get rid of your drugs and
works before they show up.
However, we accept, for better or for worse, that
drug use is part of our world, and some ways of
using are clearly safer than others.
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Appendix
I. Resources
A. Hepatitis C One on One Support Groups
http://www.people.umass.edu/dzucker/heponeonone.html
Includes AA and NA Support Group Numbers
B. Help - Counseling
Tapestry Health- (800) 696-7752
http://www.tapestryhealth.org/
C. AIDS Care – Hampshire County
10 Main Street Florence, MA
413-586-8288
D. American Red Cross – CPR Classes
125 State Street Northampton, MA
413-584-8887
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II.
T H E
H A R M
References
• Harm Reduction Coalition: Straight Dope Series:
Hepatitis C Pamphlet - 2003
• Berkeley Distribution: Abscess 411
available @ www.harmreduction.org
Pamphlet
• Harm Reduction Coalition’s Getting Off Right Ch 1-4
available @ www.harmreduction.org
• Hampshire County Jail Peer Education AIDS
Booklet
• UMass School of Nursing, Skin Tissue Infection
Student Brochure - 2003
45
Notes
46