THE BURNED OVER DISTRICT

That it occurred is no surprise considering the lack of education about drugs and needles and disease. When all you know is what you learned on the street, you probably don't know shit. And the official reponse so far indicates that it won't go away any time soon.

The crisis would test even a large metropolis; Austin, population 4,200, is overwhelmed despite help from the Centers for Disease Control and Prevention, the state and several nonprofit groups. H.I.V. had been all but unknown here, and misinformation is rife. Attempts to halt the outbreak have been hindered by strong but misguided local beliefs about how to address it, according to people involved in the response.

Gov. Mike Pence reluctantly authorized a needle exchange program last month, but local officials are not running it according to best practices, outside experts say. Austin residents still must wait for addiction treatment, even though they have been given priority. And getting those who are H.I.V.-positive on medication, and making sure they adhere to the protocol, has been difficult.

Officials here say the need for education is urgent and deep; even local health workers are learning as they go. Brittany Combs, the public health nurse for Scott County, said she was stunned to discover from talking to addicts that many were using the same needle up to 300 times, until it broke off in their arms. Some were in the habit of using nail polish to mark syringes as their own, but with needles scarce and houses full of people frequently shooting up together, efforts to avoid sharing often failed.

After the needle exchange program started last month, Ms. Combs also learned that many addicts were uncomfortable visiting a needle distribution center that opened April 4 on the outskirts of town. So she started taking needles directly to users in their neighborhoods.

At the same time, H.I.V. specialists from Indianapolis — who have evaluated about 50 people with the virus here so far and started about 20 of them on antiretroviral drugs — are fighting a barrage of misinformation about the virus in Scott County, where almost all residents are white, few go to college and one in five live in poverty, according to the census.
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“There are still a significant proportion of people in Austin who have biases about H.I.V. and are contributing to the stigma and subsequent fear,” said Dr. Diane Janowicz, an infectious disease specialist at Indiana University, who is treating H.I.V. patients here. “I have to reassure them — if your grandkid wants a sip of your drink, you can share it. It’s O.K. to eat at the same table. You can use the same bathroom.’”

Many of the newly diagnosed here have strikingly high amounts of the virus in their blood, Dr. Janowicz said, and one patient has full-blown AIDS. Nonetheless, she said, “if they take their medicine for H.I.V., this is a chronic disease, not something they have to die from.”

Another complication is that the needle exchange has faced strong local resistance. Mr. Pence, a Republican, generally opposes such programs, saying they perpetuate drug use. Many residents here feel the same.

“If you would have asked me last year if I was for a needle exchange program, I would have said you’re nuts,” Ms. Combs said. “I thought, just like a lot of people do, that it’s enabling — that you’re just giving needles out and assisting them in their drug habit. But then I did the research on it, and there’s 28 years of research to prove that it actually works.”

Too many years of watching Fox and not enough years watching their family, friends and neighbors waste away will keep this problem alive for a while yet.