Several years ago a friend of mine died from complications arising from HIV and Hepatitis C (HCV) co-infection.

I remember how frustrated he felt by not being believed that his HCV was acquired sexually. He was not a person who injected drugs, so he didn’t share or use injecting equipment.

This was commonly believed to be the way most people acquired HCV. Today, with the emerging and compelling evidence that HCV is transmitted sexually, I am sure he would feel somewhat vindicated, despite having experienced the damaging lack of validation on his claims.

While HCV is a more robust and infectious virus than HIV, just how easy it is to acquire sexually is not fully understood. The way HCV is most commonly acquired is blood-to-blood transfer (one person’s blood being transferred to another person’s blood stream) either through a sharp object like a needle or a break in the skin. The amount of HCV infected blood required to cause infection only needs to be microscopic. This is why people who inject are advised not to share any injecting equipment at all – water, spoons, swabs, tourniquets and needles – hence the message ‘a sterile fit for every hit’. Included in this not-to-be shared list is straws for snorting, syringe barrels for ‘booty bumping’ (injecting a drug rectally) and pipes. The principles to prevent sexually acquired HCV take a similar approach to sexual activity. Any activity that is likely to cause small, micro tears in your skin, will allow the virus to enter your blood stream. Thinking about and reflecting on the sex you have can sometimes be clouded, as you know. How you fuck and who you fuck with is always varied, so it’s about finding ways to let loose and have a great fuck, while managing possible infection.

What’s important is thinking about your risk for sexual transmission of HCV, the things that increase your risk and the ways to reduce your chances of acquiring an infection.

There are a number of effective things to do to reduce your risk of acquiring HCV. Change your gloves and condoms regularly and definitely change between partners. Ensure toys are not shared and are washed in warm soapy water. Even if a condom has been used on a toy, change the condom between each partner or each session. HCV can survive outside the body for a long time, so it’s really important to wash your hands between changing condoms and gloves. It can be really easy to contaminate cleaned or sterile equipment with unwashed hands. HCV has also been detected on the outside of lube containers so it is important to keep these washed and clean. There are other factors that increase risk which include ‘chem’ or ‘wired’ sex as these sessions tend to last a lot longer and therefore increase the risk of micro tears. Your pain experience can be altered or pain might be part of the pleasure, so there might be no warning of damage to the skin linings of the arse or cock or other areas from fisting, nipple play or cock and ball torture or if it is blood play.

Generally, the longer and rougher the sex is, the greater potential for skin tears and, if HCV is present, the greater the risk for an entry point for HCV. When you’re hooking up for a session with a random fuck or fuck buddy, it’s important to check that they have cleaned their gear since their last session. There are reports coming out of London where HCV has been contracted from casual hook ups where the host did not clean their toys from a previous session from several days before. HCV can last longer in moist, warm and dark environments. A long play session or out partying all night increases the likelihood of becoming dehydrated which makes your skin more susceptible to damage. It is possible that cracked and bleeding lips can increase risks for HCV transmission.

There is an increased risk in the presence of other sexually transmitted infections as well. In a Kaiser Permanente San Francisco HIV pre exposure prophylaxis (PrEP) program, Kaiser Clinicians reported in the February 18 issue of Clinical Infectious Diseases, that two people with new HCV infection were gay men who reported multiple sex partners and had other STIs. Both had new gonorrhoea, syphilis and rectal chlamydia. One man reported receptive anal sex with a partner who had a penis piercing and was bottoming during group sex. The men reported no injection drug use, no occupational exposure and had no tattoos. There is also evidence that having HIV increases the risk of acquiring HCV. The reason for this is not exactly clear even with an undetectable viral load. A study published by Merchante et al in AIDS 2014, discussed that while there are effective treatments available for HCV and that the virus can be cleared, it does not prevent HCV reinfection. It is important to note this study also found evidence that for someone with HIV who has successfully cleared HCV, there is a greater risk of developing liver complications and hepatocellular carcinoma (cancer of the liver).

According to Hepatitis NSW, of the number of all people living with HIV in Australia, it’s estimated that one in eight people are living with HIV/HCV co-infection. It is estimated that of the gay men in NSW with HIV 13-20% are living with co-infection.

So here’s a check list of important things to include when you’re planning your next hot session:

Take regular breaks to rehydrate with water – have a snack, fruit or meal and recover
Change gloves and condoms between partners and wash your hands after removing a used glove or condom and before putting on a new one
Clean equipment, sex toys, and anything that has been touched during sex with soapy water
If you’re injecting or snorting, ensure you have your own equipment (barrels or straws) and have a ‘sterile fit for every hit’
Check in with random or regular fuck buddies about the cleaning of their gear
Let your sex buddy or partners know what’s going on and what you’re doing
Seek more information
Get tested regularly for sexually transmitted infections and HCV at least yearly