Over the years that I've worked in needle exchange programs, I never met a drug injector who didn't know that sharing needles was risky. But a surprising number of injectors don't know that sharing other equipment -- particularly cookers or spoons and cotton -- can also carry a risk, especially for transmitting hepatitis C. In my experience, even some long-term drug users who were thoughtful and careful about their injection practices haven't thought about risks of sharing any equipment.
There's ways to share safely, and ways to reduce risks, but it requires paying attention to how someone's using drugs and who they're using them with. For needle exchange workers and volunteers -- as well as anyone else who counsels injectors -- addressing individual injection-related risk requires conversations, not just messages.
Telling everyone "just don't share anything -- not needles, not cookers, not cotton, not water" doesn't always work.
Drug use is a social act for many, if not most, injectors -- whether out of choice or necessity, for convenience or companionship. The process and experience of sharing -- sharing drugs, sharing needles, sharing other equipment -- can be utterly pragmatic and deeply personal acts. Sharing often entails looking out for each other by taking reasonable precautions to prevent transmission of HIV -- "informed altruism" as described in a recent paper (abstract here) from the Journal of AIDS by researchers at Beth Israel Medical Center and National Development and Research Institutes (NDRI).
Sharing is a social practice, with its own meanings and values. Sharing always happens within a context or environment. Educators and counselors need to move away from "don't share anything" messages to dealing with the individual meanings, values, contexts, and environments for sharing. Part of that is recognizing when and how users are protecting themselves and each other, and acknowledging that sometimes there are real barriers or disincentives to eliminating injection-related risks.
But the rest is getting the word out to injectors: You can get hepatitis C from cookers, cotton, and water -- if someone else's blood is already there. If you don't have hepatitis C, keep track of your equipment. If you do have hepatitis C, keep track of where your blood goes.