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.”