Hepatitis C is a hearty virus that is spread through blood and can live on a dry surface for 7 days. It can live even longer in syringes and ink wells. The heartiness of hepatitis C outside of the body means that transmission of the virus can occur long after blood has dried and in ways people may not be aware of.

Sharing of syringes and injection drug use equipment is often the main way hepatitis C is transmitted. When we break it down there are two types of sharing that put people who use substances at risk of contracting/transmitting hepatitis C.

The first is direct.

Direct sharing refers to the use of a syringe with another person during the injection process. If syringes are cleaned with bleach before using them the hepatitis C virus can be killed successfully. This practice of cleaning syringes for the reduction of overall risk, although effective at reducing hepatitis C transmission, isn’t ideal because the reuse of syringes results in the point becoming jagged and bent (see below) which leads to a higher chance of vein damage, collapse and missing when injecting.


The second is indirect.

Indirect sharing refers to the use of all the other equipment or supplies people may share during the process of injecting or using substances. Sharing of the cooker (spoon), cotton, water, straws to snort cocaine or other substances, and pipes to smoke meth, heroin or crack are lesser known but also carry significant risk.

Through working with people who are recovering and actively using substances I have learned that many of the indirect ways hepatitis C is transmitted are not widely known. Admittedly, this may not be the case in other parts of the country, but in the Southern part of Indiana where I work with people from rural counties this is something I hear frequently. This may be directly related to the fact that information is less available and stigma is higher in these rural communities.

I’ve had various conversations with people who have been using for 15-20 years and weren’t aware that straws transmitted hepatitis C.

“I wish I’d known 20 years ago what I learned today,” is a frequent comment. Putting aside the fact that 20 years ago we were just learning the ins and outs of hepatitis C prevention, the takeaway is that people feel as though they haven’t been given all the information, and as a result have put themselves unnecessarily at risk.

Many people who inject drugs know not to share syringes. So why do they? It should just be as easy as having clean supplies and not sharing, right? Well, nothing is really that simple, especially when talking about substance use.

It is true that often people share because they don’t have access to clean and sterile syringes. This problem is solved by making syringe exchange programs and harm reduction supplies easily available.

The other reason is a bit harder to solve.

This is because sharing is also hierarchical and communal. The act is one of bonding. This means refusal to share may be perceived as something being wrong with one of the two people present.

While working in Scott County, Ind during the HIV outbreak I heard stories that going home on a Sunday, sitting around the table, and injecting as a family was not out of the ordinary and took the place of lunch.

This revelation may be jarring. but these foundational tenets of a culture help explain why people share. Stemming hepatitis C transmission, and all of the other health risks that come with substance use, means addressing these nuances objectively through harm reduction.

There are situations where using a condom just isn’t possible. Those situations can range from intimate partner violence to sexual coercion. The same is true about sharing syringes and other equipment during substance use. We need to ramp up our focus on indirect sharing in rural areas and harder to reach populations so that people don’t assume if they’ve never injected drugs and aren’t a baby boomer they don’t have to worry about contracting hepatitis C. This limited viewpoint will lead to a rise in people contracting hepatitis C and not being aware of it.