Adam Wren, a contributing editor at Indianapolis Monthly, writes about Indiana politics.

It wasn’t supposed to happen here. Not in Austin, a one-doctor-and-an-ice-cream-shop town of 4,200 in southeastern Indiana, nestled off Interstate 65 on the road from Indianapolis to Louisville, where dusty storefronts sit vacant and many residents, lacking cars, walk to the local market. Not in rural, impoverished Scott County, which had reported fewer than five new cases of HIV infection each year, and just three cases in the past six years. Not in a state where, of the 500 new cases reported annually, only 3 percent are linked to injection drug use.

But it did. And it could happen in many more backwoods towns just as unprepared as Austin.


As the largest HIV/AIDS outbreak in Indiana’s history roils this Hoosier hamlet, it reflects the changing face of the epidemic in the U.S., as a disease that once primarily afflicted gays and minorities in deep-blue cities rises in rural red states. This new evolution of HIV is also forcing a new generation of Republican policymakers to confront its orthodox opposition to remedies such as government-funded needle-exchange programs.

Over the past decade, the virus cascaded from urban cities like San Francisco, New York and Washington, D.C., into poor, rural swaths of red states in middle America—opening a new front in the national fight against the spread of HIV. “It started in the coastal states among middle-class white gay men, and then the epidemic evolved into affecting more and more minorities in the South,” says Carlos del Rio, an AIDS researcher at Emory University in Atlanta. “Obviously, now the epidemic is changed. Now, what we're seeing is it impacting the rural communities.”

In this Indiana burg, the virus is not spreading among networks of gay men, but in rapid, cluster-like fashion within jobless white families who inject prescription painkillers with dirty needles.

“This is an HIV outbreak in a rural setting that is linked to an injection drug use,” says Jennifer Walthall, Indiana’s deputy state health commissioner. “That hasn’t been seen in the U.S. to date.” Since November, Walthall’s state health department has identified 163 cases of new HIV infections, including three preliminary positives. Eighty percent also tested positive for hepatitis C. “This was not on the radar,” Walthall says.

In April, Walthall’s office, along with the Centers for Disease Control and Prevention, issued a health advisory to public health departments nationwide—a preemptive salvo to stave off similar outbreaks among injection drug users. The missive targeted health departments in rural counties east of the Mississippi River, where opioid abuse and needle-borne infections are spiking, according to the CDC.

Scott County’s outbreak was so severe that Indiana Gov. Mike Pence, long an opponent of funding needle exchanges as a member of Congress, issued an executive order in March that gave local health officials authority to establish a “limited and focused” 30-day needle exchange. Last Thursday, Jerome Adams, Indiana State Health Commissioner, declared a public health emergency in Scott County through May 2016, extending the needle exchange in Austin for another year. In Kentucky, where new HIV and hepatitis C infections are also skyrocketing, state lawmakers approved in March a law that would allow health departments and local governments to launch their own needle exchanges.

Such moves by Republican governors and legislators would have once been considered GOP heresy. A federal ban on funding such exchanges has deep roots. In 1988, during a debate over passage of the appropriations bill for the Departments of Labor, Health and Human Services, and Education, North Carolina Republican Sen. Jesse Helms introduced a rider that effectively banned federal funding of needle exchanges (specifically, the language applied to anything that “promote[d] or encourage[d] homosexual sexual activities”). A decade later, in 1998, President Bill Clinton’s administration endorsed the idea of needle exchanges—though didn’t go so far as to propose a reversal of the federal funding ban. “Well, as long as your needle is clean, what’s a little heroin or cocaine among friends?” then-House Speaker Newt Gingrich responded, sarcastically. “Your government would like to give you a free needle but doesn't have the courage to do it.”

In December of 2009, President Barack Obama, backed by congressional Democrats, overturned the ban. And two years later, in 2011, House Republicans reinstated it.

Last week, Connecticut Gov. Dannel Malloy asked Congress to repeal its ban on federal funding for syringe exchanges. In his state, such exchanges have been legal since 1992. In 2002, 40 percent of Connecticut’s new HIV infections came from injection drug use, according to Malloy. More than a decade later, that share plummeted to 8.5 percent. “The prescription opioid and heroin epidemic ravaging our country and the recent outbreak of HIV and hepatitis in the Midwest underscore a federal policy that is failing our public health system,” he wrote.

Republicans in Congress are unlikely to address that health risk anytime soon.

“The politics of trying to prevent diseases and stigmatize groups are pretty rough,” says Don Des Jarlais, who President George H.W. Bush and Congress appointed to serve as commissioner on the U.S. National Commission on AIDS in 1989. Des Jarlais, now director of research at Beth Israel Medical Center and Rothschild Chemical Dependency Institute in New York City, was appointed to his post one year after the ban began. “It’s probably going to take more cases of HIV among rural Americans before we get the federal ban change.”

Now that the disease has arrived in red states, governors like Pence who blocked the programs nationally find themselves moving forward at home—or at least more open to the idea of letting local governments shoulder the responsibility.

Earlier this month, after already extending the needle exchange by another 30 days, Pence signed into law a measure that allows the state’s 92 counties leeway to create their own needle exchanges amid public health disasters. At the Community Outreach Center in Austin, citizens can procure a fresh supply of clean needles and various public services, such as HIV testing, immunizations, ID cards and access to mental health counseling.

“This measure will save lives and give public health officials the broadest range of options to confront this and other public health emergencies in the future,” Pence said of the law, which took effect immediately, in a statement. “Hoosiers may be assured that our administration will continue to work tirelessly to confront the crisis in Scott County in a compassionate and focused way until public health and public safety are restored.”

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At an Austin Community Center on a recent Thursday around lunchtime, the needle exchange—housed in an unremarkable, low-slung building next to Interstate 65—was quiet. On a folding table near the front sat a box of condoms and an array of STD pamphlets. A worker there reported a typical amount of foot traffic, with nine visitors cycling through the exchange that morning. Among 173 individuals, officials have traded 17,527 used needles for more than 18,713 clean needles.

In the beginning, though, Austin’s addicted feared entering the center, believing that authorities would track and punish them for possessing syringes. Better to take their chances with their old needles, they reasoned, labeling used syringes with bits of tape or markers.

So Brittany Combs, Scott County’s plainspoken public health nurse, came to them. Combs has spent the past few weeks traversing the backroads and rural driveways of Austin in a 2014 white Dodge Durango, asking those she meets if they or anyone they know need clean needles. In turn, they point her to the area’s drug hotspots—the town’s north side is the hardest hit.

As she travels the town, Combs peers into the faces of the new rural red-state HIV epidemic: They are predominantly white, economically disadvantaged, and in their 30s. (Cases have been reported in adults as young as 18 and as old as 64, according to the state’s Joint Information Center). And they are often related: For some families here, shooting up Opana, a legal painkiller, has become something of an intergenerational pastime.

Austin Police Chief Don Spicer said his officers had entered houses where families shared the same needle, and that those drug users are leaving evidence of their addiction scattered across the town. “We’ve been finding syringes for many years,” Spicer says. In ditch lines. Off main streets. And, more rarely, even in parks. Spicer recalled a case three years ago when one Austin family lost three family members within a six-week stretch—all to Opana abuse.

“Sometimes two, or even three generations will all be IV drug users,” Combs says. “That’s one of the ways it spread so quickly: [People will say] ‘I only share [needles] with my family.’ They trusted them and shared needles with them. It’s pretty shocking.”

In Austin’s case, the spread of disease is linked to tight-knit clusters of addiction, says Indiana State Epidemiologist Pam Pontones. “In injection-drug-use networks, that virus can spread very quickly, because that is a high-risk route of transmission,” she says.

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Nationwide, gay men of all races are still the primary source of new HIV infections, and cases are still concentrated in urban centers. But according to data from AIDSVu at Emory University, of the 10 states with the highest rates of new infections, the majority are clustered in red states across the I-95 corridor and Mississippi Delta region.

“The virus doesn’t know any politics,” says Greg Millett, vice president of policy at amfAR, the Aids Research Foundation. “What’s clear about HIV is that it’s in the largest urban centers, which have been in blue states. But the policy in those areas have been effective in confronting it.”

Take New York, for example. In 2013, New York City saw 50 new infections spurred by injection drug use—a third of the number of infections the tiny town of Austin has seen in the past five months. A 2014 report by New York State Department of Health AIDS Institute found that in 1992, 52 percent of new infections derived from injection drug use. In 2012, after needle exchanges had been operational for more than two decades, those cases accounted for 3 percent of new diagnoses.

“Indiana could be the canary in the coal mine when it comes to the potential for the outbreak in rural areas among injection drug users,” Millett says. “In some of these red states, they are making fixes to bad public health policy after the fact.”

Millett says he’s now tailoring his arguments for needle exchanges to appeal to fiscal conservatives. Treating 160 new HIV cases in Indiana will cost taxpayers an estimated $57 million. A needle exchange would cost a fraction of that amount, Millett said.

Still, not every red state may be willing to pivot on needle exchange policy like Indiana. If they don’t, the results could be disastrous. Conservative states like Kentucky, Tennessee, Virginia and West Virginia have seen skyrocketing rates of new hepatitis C infections, which indicate injection drug use and needle sharing, high-risk behaviors that can lead to a spike in HIV infections. In these states, new hepatitis C infections surged by 364 percent from 2006 to 2012. Kentucky's needle exchanges are expected to be up and running soon.

This year, state legislators in Florida and Texas introduced pilot programs for needle exchange bills. In Florida, a pilot needle exchange bill that would be run by the University of Miami appears to be stalled as lawmakers enter a special budget session, and such legislation has never made it to the governor. The Miami area has seen some of the nation’s highest rates of new HIV infections in recent years, according to the CDC. Asked about Republican Gov. Rick Scott’s position on needle exchanges, a spokesperson said the governor would review any legislation that comes to his desk. In Texas, San Antonio state Rep. Ruth Jones McClendon, a Democrat from San Antonio, is also pushing for a pilot needle exchange, a proposal that is now under consideration in the Senate, but unlikely to survive the final days of the state’s legislative session. A spokesman for Republican Gov. Greg Abbott did not return calls or email messages seeking comment on whether he supported the measure.

Out of the 50,000 new HIV infections tallied each year, about 8 percent stem from injection drug use. In Indiana, last year, that figure was 3 percent. This year, if Indiana’s annual number of new HIV infections holds steady at 500, the 163 infections and three preliminary positives in Austin would account for more than 30 percent of the state’s new infections, a tenfold increase. The national percentages could also grow dramatically as opioid abuse surges in hollowed-out stretches of the nation.

“Over the last several years, people started injecting these painkillers and increasingly switching to heroin,” says Daniel Raymond, policy director for the Harm Reduction Coalition, which supports needle exchanges. “So a lot of red and purple states are now confronting rising hepatitis C rates and potential HIV outbreaks like the one in Scott County.”

In the early days of the Obama administration, there was a legislative opening for a permanent repeal of the ban on federal funding for needle exchange programs. Bill Piper, who works on national affairs for the Drug Policy Alliance, lobbied federal lawmakers in red states to make the policy change. Piper’s pitch: The virus would be coming to their districts in the future, as injection drug use increased.

“When they thought about injection drug use, they thought about Baltimore or New York City,” Piper says, “but we tried to explain to them that this was becoming a rural issue.”

Needle exchange advocates express hope and doubt—in nearly equal measures—that the Scott County outbreak jars loose congressional Republican opposition to federal funding.

“The new laws in Indiana and Kentucky, along with the attention to the Scott County HIV outbreak, will spark a new debate on needle exchange and give cover to other politicians in conservative states to take on needle exchange,” Raymond says.

Kentucky Republican Hal Rogers, who chairs the powerful House Appropriations Committee, has seen injection drug use and hepatitis C infections explode in his district in recent years. But Rogers believes decisions to establish needle exchanges should be made at the local level, according to Jennifer Hing, his communications director.

As she said in a statement, “While he will continue to monitor the implementation of these programs and their impact, he continues to support the ban on the use of federal funds for needle exchange programs and intends to focus federal resources on education and treatment programs that support communities in their drive to end the cycle of dependency.”

Rep. Tom Cole, a Republican from Oklahoma who chairs the Subcommittee on Labor, Health and Human Services, Education and Related Agencies, where any shift on the policy would begin, declined an interview through a spokeswoman.

And some Republican governors don’t want to seem to talk about the issue, either—or, at least, prefer to cede the debate to local governments. As a member of Congress, Gov. John Kasich supported the federal ban. In Ohio, though, needle exchanges sanctioned by public health boards amid public health emergencies now exist in Cincinnati, Cleveland and Portsmouth. In an email, Kasich’s press secretary declined to elaborate on the governor’s position on needle exchanges.

Last session, state Rep. Barbara Sears, the Republican majority floor leader from Toledo, shepherded a bill to allow local jurisdictions to create their own needle exchanges—without declaring a public health emergency first—through the Republican-controlled House. The measure died in the Senate.

“I don’t care whether you’re an “I,” “D,” “R,” “G,” “L,” this health issue needs to override that,” says Sears, who plans to reintroduce the bill in July. “We need to start to make a change ... We need to take a look at the greater good.”

In Tennessee, where the CDC reported in May that hepatitis C rates had surged since 2006, a spokesperson declined an interview with Gov. Bill Haslam, chair of the Republican Governors Association, deferring the request to the state health department. “We are closely monitoring those developments and gathering data on the issue as we continue our routine surveillance for these diseases,” the spokeswoman said.

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Austin’s outbreak began last November when a disease intervention specialist with the Scott County Health Department interviewed three newly diagnosed HIV patients—one in an outpatient clinic, one in an area hospital and one in a drug rehab program. Two said they had recently injected drugs, had shared syringes and had a range of sexual partners. In the following days, health department officials would trace a network of local injection drug use, uncovering eight additional users who tested positive for HIV.

By January, Combs, the county’s public health nurse, had heard word of the uptick in new infections. Months later, as officials from other county health departments flood into the county to help with the recovery effort, many told her: This could have been us. It could be us, soon. “It’s going to spread to other places—that’s our fear,” she says.

The stigma of being treated is still a problem, says Des Jarlais, the Beth Israel Medical Center researcher. Scott County is experiencing the same stigmatization that surrounded the 1990 death of Hoosier teenager Ryan White, a hemophiliac who contracted the virus through a contaminated blood treatment. White hailed from Kokomo, a town two hours north of Austin (Coincidentally, advocates commemorated the 25th anniversary of White’s death just last month, as the Scott County outbreak began to peak.) “That was the original problem with the Ryan White situation,” Des Jarlais says. “It’s still there for Scott County.”

In the days after the needle exchanged open, Austinites avoided visits to the outreach center and community clinic, as flocks of national and local reporters descended on the town. When I visited the center earlier this month, hoping to observe the exchange and speak with those using it, Amy Reel, the state health department’s director of public affairs, intercepted me, asking me to avoid the public facility. “We’ve had multiple reports that the customers have seen cameras and turned around,” she explained later. “We’re asking that reporters not visit the outreach center.” Almost immediately after allowing residents to seek treatment outside the media spotlight, participation in the clinic and exchange increased, Reel said.

It’s unlikely officials will ever identify a so-called patient zero in Scott County anytime soon, if ever. Yet Des Jarlais has his own theory of how the virus found its way into Austin. “Scott County is on a major trucking route,” Des Jarlais says. “No one has tracked down how the virus got into Scott County, but that’s how it got there.”

In a way, the same factors that seemingly immunized the town from such outbreaks—its distance from urban cores where the virus made its mark in the 1980s and 1990s, for instance—actually made Austin vulnerable. Lack of familiarity with the virus played a role. As did small-town family bonds and a misplaced sense of trust. That’s not to mention that 19 percent of residents of Scott County live below the poverty line, according to recent Census data. Or that for the past five years straight, Scott County has been the state’s least healthy county—ranked No. 92 out of 92 counties— in an annual analysis by the Robert Wood Johnson Foundation at the University of Wisconsin Population Health Institute for the rankings.

“All of those were signals that something was wrong and there’s very limited access to services,” says William A Cooke, the town’s only doctor who runs the rural health clinic Foundations Family Medicine. He added: “We’ve been here for a long time, asking help for a long time.”

Adams, Indiana’s State Health Commissioner, said in a statement released last week that the peak of the outbreak may be in sight. “We are building a model for prevention and response should this type of outbreak happen in other communities in the U.S.” Adams said. “I would like nothing better than to tell you this unprecedented HIV epidemic will never happen again anywhere else.”

Des Jarlais hopes Austin becomes a cautionary tale that could prevent future outbreaks of the virus in rural areas across the nation, where public health resources are scant and misinformation and stigma are abundant.

“It’s going to make a lot of areas realize that they are vulnerable to HIV/AIDS, particularly a lot of rural areas,” says Des Jarlais. “That will create an awareness that the HIV epidemic is not over.”