The Effectiveness of Bleach in the Prevention of Hepatitis C Transmission - Final Report

4. Bleach Use Among Injection Drug Users

Although bleach, if used properly, may be effective for disinfecting IDU equipment, the effectiveness is irrelevant if people who use injection drugs do not have access to bleach, do not use it, and/or use it incorrectly. Jamner et al. reported that although a majority of injection drug users were aware of the potential benefits of bleaching needles and intended to use bleach, relatively few of them actually did⁵⁵. And while early HIV prevention efforts seemed to show that injection drug users quickly took up the practice of disinfecting shared needles with bleach⁵⁶, these encouraging early trends were not sustained.

Today, while most people who use injection drugs may use bleach occasionally or even most of the time, few use it all the time⁵⁵ and most do not use it correctly. A 1993 study assessed whether or not injection drug users were aware of recommended bleaching guidelines^e and whether such awareness led to improved bleaching behaviours. They found that only 35% of interviewed drug users knew both that full-strength bleach should be used and that the exposure time must be at least 30 seconds. More importantly, 75% of injection drug users who had shared equipment in the last three to six months reported either not using bleach or using it inconsistently. Only 7% knew the guidelines and reported always using full-strength bleach⁵⁸. Studies have also observed that a majority of drug injectors expose their works to bleach for less than the recommended 30 seconds, compromising the effectiveness of the disinfection^46,59.

It should also be noted that although these guidelines were developed in response to HIV research, the data were not then nor are they now considered definitive⁴⁶, and no follow-up research has been done to determine whether or not compliance with these guidelines effectively and reliably prevents transmission of HIV, HCV or other bloodborne pathogens.

Interventions to teach and encourage the proper use of bleach have been tested but few have been effective, either because of the time and complexity required for adequate disinfection, or because of decreasing compliance over time. Carlson et al. found that interventions including the provision of the CDC/NIDA/CSAT bleaching guidelines and one-on-one instruction on the use of these guidelines did improve bleach use. However, these improvements were slight and were not sustained⁴⁶. Likewise, McCoy et al. found that among Miami injection drug users who were taught bleach cleansing methods, compliance decreased as stricter criteria (e.g., longer times, pre-cleaning, more rinses, use of water and bleach) were required⁵⁹. In contrast, some targeted interventions have been successful in convincing people who use injection drugs to bleach their injecting equipment. Rietmeijer et al. observed that exposure to their intervention program (peer and role model counselling regarding bleach use, distribution of bleach kits and written materials encouraging bleach use) was significantly associated with an increase in consistent self-reported bleach use (OR 1.8; 95% CI 1.0 - 3.2; p < 0.05)⁶⁰. And a San Francisco study found that reported use of bleach to disinfect needles was protective in a multivariate model of anti-HCV⁶¹. However, these reports rely on IDU self-report, and other studies have found that self-reported bleach use often does not reflect true bleach usage⁵⁹.

It is extremely difficult to influence behaviour in a population where individuals are making decisions while high on drugs, have very low self-esteem and little sense of, or desire for, self-care. Even among injection drug users who are positively predisposed to using new needles and/or bleaching used ones, "w hen forced to choose between postponing drug use and an unsafe injection, the discomfort of withdrawal and the attraction of the drug effect will typically result in injecting⁵⁵." It is unlikely, therefore, that any bleach-based intervention program will achieve good compliance, and will therefore not be able to change behaviour significantly enough to interrupt disease transmission.

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Notes

• In 1993, the Centers for Disease Control (CDC), the National Institute on Drug Abuse (NIDA) and the Center for Substance Abuse Treatment (CSAT) issued a joint bulletin containing provisional guidelines on the use of bleach to disinfect hypodermic syringes. These guidelines recommended that injection drug users who do not stop injecting and sharing injection equipment use full-strength household bleach to disinfect equipment and keep the bleach in contact with the equipment for at least 30 seconds. They also describe the specific procedure that should be followed for disinfecting syringes⁵⁷.

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