• December 6, 2022

WHY Is There An Outbreak Of 190 HIV Cases In This VERY SMALL Indiana Town?

Carelessness aside, there has to be something strange going on in this small town to have such a concentrated outbreak of HIV:

IndyStar.com: From the start of the HIV outbreak, health officials emphasized that nothing set Scott County apart from many other rural communities where opioid drug use had become an epidemic. This could happen anywhere, people were told.

Many people had viewed HIV as a big-city disease, something that might afflict people in San Francisco or New York. But not in Austin, a small city of about 4,000 people 80 miles south of Indianapolis.

Then, in February 2015, the first 30 cases of HIV were reported. By mid-March, the number had climbed to 55. State health officials, the governor and the federal Centers for Disease Control and Prevention were looking for answers. Few public health crises have unfolded so rapidly.

Now, a year later, the outbreak is at 190 cases. But the sickness runs deeper.

Poverty envelops this city. Empty storefronts dot the main street. Many homes are boarded up or have makeshift tarps instead of windows. Less than 10 percent of Austin’s residents hold a college degree. One out of 5 residents lives below the poverty level, more than 1.5 times the rate in Indiana. 

Drug use here is still rampant. Some users shoot up alongside their children or even their children’s children. In the winter, as many as 20 users may huddle in a home, gathering in the one building that has heat for the day. The power of addiction is so great that even the sensation of a prick from an empty needle can bring relief.

Yet there is hope.

The response to the HIV crisis has focused attention and brought services to an area long left in the shadows.

“I think we have a lot of really good things that came out of the HIV outbreak,” said Brittany Combs, public health nurse for the Scott County Health Department. “We still have a long way to go.”

Substance abuse experts often describe five stages of recovery, each critical to long-term success. The many users in Austin are not alone in facing the arduous task, person after person here says.

The city itself is in recovery.

Stage 1: Awareness

Everyone in Austin knew drugs were a problem. They just did not understand how great that problem was.

What they did know was that poverty and despair had increased as resources had decreased, said Carolyn King, a community consultant who has worked in social services in Scott County for several years. The home of one of the nation’s largest private-label soup processing companies, Austin once had numerous low-skilled jobs. Over time, many of those jobs were automated or replaced by higher-skilled positions.

During the first decade of this century, social service after social service closed its doors. Early childhood services. Head Start. Workforce training. A domestic violence initiative. Even the thrift store had to close because people had no money.

“It was a devastating time in this community,” King said. 

Other amenities disappeared. Restaurants. Dentist offices. The grocery store.

Dr. William Cooke arrived in 2004. The New Albany native considered West Virginia or Kentucky before choosing Austin; no other community he visited seemed to need medical services as desperately.

One red flag: After graduation, high school seniors would flock to his office looking for the only way they knew to earn an income. Could you file a disability form for me? 

“They didn’t understand that disability was something they get when they’re disabled,” said Cooke, who opened his Foundations Family Medicine in an office blocks from where many drug users live.

Drug abuse was common. Scott County had the highest per capita use of OxyContin in the state. Floyd County, No. 2 on the list, had a rate half as high.

Medical professionals recognized the problem. At one point, doctors at Scott Memorial Hospital would prescribe only three days’ worth of some pain pills at a time, King said. To dissuade residents from frequenting clinics that all too freely dispensed medications, Cooke hired a pain specialist. He offered alternative pain management therapies such as physical and massage therapy. 

Nothing helped. In 2012, the British global news service Reuters wrote a piece about how Opana, a new painkiller, had replaced OxyContin as the drug of choice after a new manufacturing process made the latter more difficult to crush and dissolve for use intravenously. The dateline? Austin, Ind., where in three months nine people had fatally overdosed on prescription drugs.

Opana also was reformulated to help prevent abuse, but addicts still found a way.

Doctors at Scott Memorial Hospital, where Cooke also works, saw more and more patients come in with abscesses, hepatitis and endocarditis (a heart infection), all from intravenous drug use. For a few years, doctors realized that HIV could be the next infection to take hold, but there was little they could do to intervene.

“We would scratch our heads as a medical community once in a while and say, ‘Why don’t we see more HIV than we do?’” Cooke said. “It’s a matter of time. It was something we just kind of knew.”

Like many other rural communities in the United States, Scott County had few options at its disposal to deal with the problem. No services. No funding. The nearest methadone clinic was 40 miles away, and many people who could have benefited had no reliable transportation to get there.

Those who used slipped further from sight, and those who did not found it easier to forget the users existed than to help them.

“It set up this environment where there was this subculture of individuals that were hiding, disconnected from the rest of the community,” Cooke said. “It was really frustrating. … It was not like we didn’t know there was an IV drug problem in rural America, but we just kind of ignored it.”

Many of those who used lived within a few blocks of one another in a neighborhood of one-story homes, many with boarded-up windows and doors. Often several generations of a family used together. Few held steady jobs. For the most part, they, like many of the residents of Austin who are not addicted to drugs, were poor and white.

Jesse McIntosh, 23, started using marijuana with friends when he was 13. In 10th grade, Austin High School kicked him out for skipping class. He slid further into drug abuse, starting with Percocet, then OxyContin and then Opana. He started off snorting Opana, but then, like many of his friends, McIntosh started injecting it. Not for fun. To ease his addiction pains.

A cycle of drug use, drug-related arrests, jail and release followed.

Each time he was incarcerated, he would go through withdrawal, and as soon as he was free, he would go right back to using drugs.

“That’s all I knew, was to use,” he said. “That was the only people I knew.”

No one worried about contracting HIV. People shared needles. People would reuse the same needle until it broke.

Then a health worker in neighboring Clark County noticed something unusual. In December 2014, the number of HIV cases began to rise. Public health workers routinely investigate every case of HIV, interviewing the newly diagnosed and asking them about anyone they might have inadvertently infected. Quickly, health investigators realized that these new cases all had something in common: The people had used intravenous drugs.

In mid-January, the local workers alerted the Indiana State Department of Health. They were seeing an unusually high number of HIV cases.

Stage 2: Taking action to address the problem

Public health nurse Combs knew drug use was common among some people, but she rarely came into contact with users as she educated people about immunizations and communicable diseases and ran a clinic for the elderly.

As testing for HIV spread, she rapidly gained a clearer sense of the scope of the problem. Disease investigators went to one house shared by six people. All tested positive for HIV.

Health officials held a conference call with the New York State Health Department, which had weathered a hepatitis C outbreak among intravenous drug users in a rural health program. The New York experts kept touting the benefits of a clean needle exchange program.

But Indiana law banned such programs.

We don’t know what else you can do to stop the spread, the New York experts said.

“And we were like, ‘Crap, we have a major problem,’” Combs said.

State Department of Health officials had daily discussions about the pros and cons of a needle exchange program, said State Health Commissioner Dr. Jerome Adams.

The CDC strongly advocated one.

Gov. Mike Pence previously said he was opposed to a needle exchange as anti-drug policy. But in this instance, a needle exchange would not be used to prevent the use of drugs but to help stop the spread of HIV. After weeks of discussion, on March 25, 2015, Pence declared a public health emergency for Scott County that allowed for a needle exchange. Two days later, the Department of Health reported that 81 people had tested positive for HIV.

Users who were not HIV positive realized they were lucky. McIntosh, who had entered treatment in Indianapolis a few months before the HIV outbreak, breathed a deep sigh of relief.

“I thank God in heaven that I dodged the HIV,” he said. “I shared needles with a lot of people, and Lord knows that I didn’t do anything to prevent it.”

Each week, as health officials reached out to test those who had been in contact with previously diagnosed individuals, the number of cases rose. At the peak of the epidemic, 22 new cases were being diagnosed each week.

Austin found itself in an unenviable spotlight. Media trucks descended from around the world to document an HIV outbreak that government officials called unprecedented.

At one point, Adams said, the CDC was providing President Barack Obama with daily updates about the situation in Southern Indiana.

More at IndyStar.com

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