The Six Moments of Hard Reduction, a novel educational intervention to train clinicians on the risks associated with injection drug use, may help decrease the risk for drug use-associated infections commonly associated with morbidity and mortality in people who inject drugs (PWID). These findings were published in Open Forum Infectious Diseases.

This educational intervention was based on the Five Moments for Hand Hygiene model created by the World Health Organization (WHO). Given the success of the Five Moments model, the Six Moments intervention also focused on specific ‘at risk’ moments during the injection process, which could allow for successful intervention to decrease the risk for infection transmission.

The following table includes the Six Moments of Harm Reduction:

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1. Contaminated needle (prior to filling)HIV; HBV, HCV, HDV·   New needle for each injection·   Use 1 needle per person·   HBV vaccination·   HIV PrEP
2. Contaminated water/acidCandida; other mycoses·   Use sterile water·   Single-use sachet of citric or ascorbic acid
3. Contaminated cookerHIV; HBV, HCV, HDV·   Use 1 clean cooker per person·   HBV vaccination·   HIV PrEP
4. Contaminated filterEndotoxin from Gram-negative bacilli (cotton fever)·   Use sterile single-use cotton filter·   Use 1 cotton per person
5. Contaminated skinMRSA; skin flora·   Wash hands and injection site
6. Contaminated needle (after filling)Streptococcus; oral flora·   Avoid contact with mouth and other surfaces·   Use of sharps bin
Abbreviations: HBV, hepatitis B virus; HCV, hepatitis C virus; HDV, hepatitis D virus; MRSA, methicillin-resistant Staphyloccocus aureus; PrEP, pre-exposure prophylaxis.

To determine the effectiveness of the Six Moments training, participants were asked to complete pre- and post-training surveys that assessed knowledge related to harm reduction and injection-associated infections, comfort in counseling PWID, and whether they had previously referred a patient to a syringe service program. Participants were employed at more than 10 centers in the US and comprised interns and residents (26.6%), mid-level practitioners (14.6%), attending physicians (9.3%), medical students (5.3%), and other (44.0%).

At baseline, 22.6% of participants had not received prior training about harm reduction and only 10.6% had attended 5 or more harm reduction training sessions.

The researchers noted that 80% of participants had never referred a patient to a syringe service program, with most (70%) indicating this was due to lack of knowledge about the locations of these programs.

The proportion of participants who reported they were comfortable with educating PWID about the risks for injection-associated infections increased significantly after completing the Six Moments training (P <.0001).

The proportion of participants who reported moderate to extensive knowledge about injection-associated infection risk increased from 46.6% to 96.0% after completing the Six Moments training. Similar results were observed in regard to knowledge scores, as participants’ scores increased from a median of 8.0 to 9.0 on a 10-point scale after completing the training (P <.05).

This study was limited as long-term changes in harm reduction knowledge were not assessed, and the findings may not be generalizable to other clinicians with less experience caring for PWID.

In regard to the Six Moments of Harm Reduction training, the researchers concluded that “this educational intervention can be used as part of a bundle of implementation strategies to improve morbidity and mortality in PWID.”

Disclosure: An author declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Harvey L, Boudreau J, Sliwinski SK, et al. Six moments of infection prevention in injection drug use: An educational toolkit for clinicians. Open Forum Infect Dis. 2022;9(2):ofab631. doi:10.1093/ofid/ofab631