AUSTIN, Indiana — To an outsider, it might seem improbable that HIV would ravage a place in rural Indiana, but not to Sherry McNeely, a nurse in this town of 4,200 people.
Almost every day, she sees the evidence of the epidemic — linked in part to drug use — in the form of discarded needles used by addicts to inject drugs. "This has been building for a while now. I find needles on the street all the time,” said McNeely, who works at Foundations Family Medicine, a health center in Austin.
It isn't uncommon to find used needles at the town’s playground, she added.
McNeely was one of several staff members at the clinic fielding interviews as local and national media descended to discuss the facility's new mobile HIV unit, where residents can get free tests for the deadly virus.
Spearheaded by Dr. William Cooke, the unit has helped thrust Austin into the national spotlight as part of a larger policy discussion. The decision by Indiana's Gov. Mike Pence to declare a public health emergency for Scott County, where Austin is located, helped start a national conversation about public health and HIV.
But Austin is also is now at the center of a medical mystery. After all, why is HIV here in such startling numbers? What makes it different from other similar places in the U.S.?
To most people, Austin wouldn't look much different from other rural towns in the Midwest. The roads are mostly quiet, and there can be a sense that time has passed it by. The local Dairy Queen sign appears to have been unchanged for decades.
But Austin's HIV epidemic problems are new and have shocked observers. Since December, HIV cases have been climbing. There are more than 80 confirmed cases of HIV, most of them residents of Scott County and most coming to light over the last several weeks. All of these current cases appear to involve the drug users injecting Opana, a brand of the powerful painkiller oxymorphone.
But the reasons for the HIV outbreak go beyond drug use and are due to a number of factors, including chronic poverty and unsafe sex.
Though exact figures do not exist, town officials say that sex workers and their clients in Austin play a role in the epidemic’s spread. Prostitution has been an issue for years, said Linda Richie Spicer, who works the counter at the town's 24 Hour Bait & Tackle Center. She is married to Austin's police chief, and she is running for mayor.
Kenny Williams, a retired painter who lives in Austin, agreed with her assessment. "These women will have sex, knowing they have HIV. They do it because they want drugs," he said.
Ruth Carrico is an associate professor at the University of Louisville, in Kentucky 40 miles south of Austin, and her specialty is in infectious diseases. She agreed that prostitution is exacerbating the HIV problem in Austin but said that there's another problem.
A lot of drug users are insular, she said. "As a group, they stick together. Their social habits keep them together and relying on each other, so that when HIV somehow enters the picture, this epidemic cascades," she said. "We've seen the same thing repeatedly with Ebola and even the measles."
It doesn't help that the public is largely unafraid of contracting HIV, according to Walter Bruyninckx, a professor of biology at Hanover College, less than a half-hour drive from Austin. One of his specialties is immunology.
"I came to Hanover in 1992," he said, "and in that time, every student we would meet would get lessons about HIV and its dangers and consequences."
Times have changed. He cited a 1996 Time magazine cover featuring a smiling Magic Johnson, living well with HIV. "That magazine cover changed the perception that people have of HIV — from thinking of it as a death sentence to now a chronic disease like heart disease, irritable bowel disease and asthma. It's something you learn to live with," Bruyninckx said. "That has led to many people ignoring the precautions."
‘As a group, [drug users] stick together. Their social habits keep them together and relying on each other, so that when HIV somehow enters the picture, this epidemic cascades.’
associate professor, University of Louisville
However, HIV is still a big deal. "The drugs have side effects, and so you have to take drugs for the side effects, and a big chunk of your daily life revolves around the disease," he said.
Of course, there are a lot of small towns that have IV drug use and prostitution, and the problems in Austin have been brewing for years, residents say. So why now? In neighboring Ohio, Judith Feinberg, M.D, a professor who specializes in infectious disease at the University of Cincinnati College of Medicine, has a theory, but it is unproved.
She thinks that there is probably an individual, maybe two people, who is newly infected or possibly someone who has advanced HIV and recently began spreading the virus to numerous fellow IV drug users in the community with a dirty needle or through unsafe sex. People who engage in those two activities are most at risk for HIV infection, so if the virus enters one of those groups, the number of people who contract it can skyrocket.
Feinberg said that many IV drug users have trouble accessing health care when they get sick. "My assumption is that they may be underinsured or not insured," she said. "If that's the situation, then they really need to get care immediately."
McNeely said, "Some people don't have electric, so they don't have TV and radio," describing how the clinic has its work cut out for it in getting the word out. Every Tuesday from 3 to 4 p.m., it will test people for HIV for free. They can get the results in about 20 minutes after having their gums swabbed, and the preliminary test is 99 percent accurate. For those who test positive, they will be given treatment, and if they are uninsured, the clinic will help them get insurance. IV drug users can go and exchange dirty needles for clean ones.
But in order for that to happen, the residents need to go to the clinic.
It may take time for word to spread and for attitudes to change. Spicer said that from what she is hearing and reading on social media, a lot of residents disapprove of the needle exchange program. "A lot of people think the program condones the drug habit," she said.
Williams said that from what he hears, "many people think that this is a trick by the police. They're going to bring in their needles and then will later be arrested."
Aside from the distrust and skepticism around the needle program, Spicer said that the community largely seems supportive of the HIV program at the clinic.
Williams is among those rooting for its success. "I hope this program works," he said. "Otherwise, a lot of people are going to die over this."
Carrico echoed that sentiment and said that Austin is hardly the only community at risk. "This is a worldwide disease. It impacts everybody. Whether or not you think we're our brothers' keepers, with HIV, we have to be," she said. "This is not a we-versus-they issue. This is an us issue."