Module 2: HCV transmission and risk prevention - section 1

In this document:

HCV transmission and risk factors

Activity: Large and small group work
Section Time: Approximately 30 minutes

This section provides participants with the opportunity to discuss and clarify their understanding around HCV transmission and the factors that contribute to transmission risk.

Initiate this module by showing Slide 2.2 (Group work) and asking the large group to brainstorm the ways in which HCV is transmitted and record responses on a flip chart:


Allow participants time to offer their own understanding of the likelihood of transmission in any given situation. Facilitate discussion by asking participants:

  • To question any myths that might be raised
  • To explore areas of uncertainty
  • To gain consensus on a hierarchy of transmission risk
  • To establish the most common way the virus is transmitted
  • Allow 15 minutes for this activity and use Slide 2.3 (HCV transmission) to assist this process if needed:

Initiate this activity by establishing small groups. Show Slide 2.4 (Group work) asking them discuss and record answers onto flipchart paper:


After 10 minutes reconvene the large group and ask representatives from each small group to summarise their answers.

Facilitate feedback discussion and ensure the following points are made:

  • HCV is very small and highly infectious and only minute amounts of infected blood needed to transmit infection
  • The main risk for PWID arises from sharing infected needles and syringes
  • There may be enough blood in equipment used to prepare drugs for injection such as water, spoons and filters for the virus to be transmitted
  • Sterile needles and syringes and injecting related paraphernalia should always be used
  • Risk can occurs through accidental sharing of equipment
  • Risk of transmission through batch preparation of drug for more than one person
  • Backloading and frontloading of drug poses significant risk
  • Don't share toothbrushes or razors
  • Use of condoms for penetrative sex
  • Certain environments such as prison enhance risk

The following films are shown to support the last activity after feedback has been taken.

How small is the hepatitis C virus? – an animated film

Activity: Video presentation
Section Time: 2 Minutes
Materials required: Access to QuickTime movie as part of training manual resource pack or online resource:        http://www.harmreductionworks.org.uk/2_films/how_small_is_the_hep_c_virus.html

Show Slide 2.5 (Video) and introduce film:


This film shows how small the hepatitis virus is and how readily it can be transmitted. It is a short but powerful animation designed to get across the messages that just because a syringe looks clean, it may still be infected and that besides needles and syringes, it is important to avoid sharing spoons, filters and mixing water.

HIV and HCV survival in syringes – film on hepatitis C survival research

Activity: Video presentation
Section Time: Approximately 2 minutes
Materials required: Access to QuickTime movie as part of training manual resource pack or online resource: http://www.harmreductionworks.org.uk/2_films/viral_survival_in_syringes.html

Show Slide 2.6 (Video) and introduce film:


In 2007 researchers at Yale University developed a methodology for assessing how long HIV survived in used syringes, but until 2008 no test existed that could detect whether the hepatitis C virus had survived – so we could only speculate as to how long it survived. With high prevalence, many had speculated that it could survive, and remain infectious, for long periods of time outside the body. This short documentary describes the findings of the hep C survival study, and explains what they mean for our understanding of why hepatitis C prevalence is so high amongst injecting drug users.

Supporting content:

HCV is mainly transmitted when infected blood directly enters another person's bloodstream. As with HIV, you cannot transmit or catch hepatitis C by touching, kissing, hugging, or from sharing cutlery and crockery. Major routes of transmission are injecting drug use and to a much lesser degree, healthcare related procedures, needle-stick injuries in healthcare settings, tattooing and body piercing. The sharing of personal items, such as razors and toothbrushes, is less likely but a possible route of HCV infection. Vertical (mother-to-child) transmission is documented although unusual except in babies born to mothers with very high levels of HCV RNA.

HCV has been found in semen and vaginal fluid, however the risk of sexual transmission of hepatitis C is considered very low. The risk is higher for some sexual activities, especially where there is potential exposure to blood. These could include longer and more energetic sex, anal sex, fisting, sex with a woman during menstruation, and group sex. Sex workers and people with multiple partners may be more vulnerable to infection. Sexual transmission has been reported among HIV+ve men who have sex with men and practice high risk behaviour such as unprotected sex with multiple partners. It is generally thought that people with compromised immunity including those living with HIV maybe at higher risk of contracting HCV if exposed to the infection and the presence of ulcerative sexually transmitted infections (STIs) may facilitate HCV sexual transmission.

Hepatitis C is more common among non-injecting drug users than the general population. It is not clear why. It may be possible to catch HCV through blood-to-blood transfer from sharing straws or rolled bank notes for snorting drugs, and maybe from crack pipes. Studies of HCV infection in drug users who do not inject have indicated an increased risk of HCV infection.

Before 1990, exposure to contaminated blood and injecting drug use were the main causes of HCV transmission. The introduction of blood screening for HCV dramatically reduced viral transmission through transfusion of infected blood which has been brought down to virtually zero in Western Europe, and the US, leaving injecting drug use as the main cause of transmission. PWID now account for up to 60−90% of newly identified cases of HCV in EU countries.

HCV is a tougher and smaller virus than HIV. HCV is readily be passed on by using any injecting equipment, which has been in contact with an infected person's blood. Lending and borrowing injecting equipment is common. This includes not only needles and syringes - the main vector for HCV transmission, but also paraphernalia such as cookers for mixing drugs, water, swabs, filters and tourniquets. The probability of becoming infected after sharing paraphernalia is currently not known, but must be treated as a potential and important risk. Persistent injecting of drugs is the key factor for HCV transmission globally.

Sharing injecting equipment among people who inject drugs is the most common route of HCV transmission. Due to the high infectivity of the virus, there is a risk that HCV can be transmitted from sharing other injecting equipment such as water, tourniquets, filters and spoons has also been associated with HCV transmission although this is less common.

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