Pubdate: Fri, 06 Jan 2017
Source: Morning Call (Allentown, PA)
Copyright: 2017 The Morning Call Inc.


A syringe is pictured along West Main Street in downtown Austin, Ind., in
Scott County on Tuesday, March 24, 2015. (Christopher Fryer / AP)

Years ago, William Cooke sensed a crisis building. The only doctor in
rural Austin, Indiana, noticed that intravenous drug use was soaring in
his town of roughly 4,300, where 23 percent of residents live below the
poverty line. He feared that people addicted to injectable painkillers
might be plucking used needles off lawns, shooting up -- and passing them

A surge of drug overdoses hit Cooke's family practice, where he'd treat
anyone with $10. More hepatitis C infections followed. Next came an HIV
diagnosis in December, rare in southeastern Scott County. By Friday, the
number of new cases had climbed toward 80.

Last week, Indiana Gov. Mike Pence declared the outbreak a public health
emergency, the worst in state history, authorizing a short-term needle
exchange program. The announcement came as a surprise: Rates of new HIV
transmission have been declining in Indiana for years, from 463 reported
in 2002 to 205 in 2012.

Workers from the Centers for Disease Control and Prevention (CDC)
descended upon Austin, the epicenter, about 70 miles south of Indianapolis
- -- prompting some to wonder: How could an HIV outbreak ravage rural

Cooke knew drug use and infectious disease was a deadly combination.
Without preventative resources, an outbreak could be triggered by one
person with HIV sharing a needle.

"We saw this coming a long time ago," he said. "There's a lot of poverty
and very few resources available to the community. We've been asking for
help for some time."

A legislative panel has approved a measure that would allow high-risk
counties to create needle exchange programs following an HIV outbreak in
southern Indiana.

Health officials say 81 people who either live in Scott County or have
ties to it have tested positive for HIV. Indiana prohibits needle...

A legislative panel has approved a measure that would allow high-risk
counties to create needle exchange programs following an HIV outbreak in
southern Indiana.

Health officials say 81 people who either live in Scott County or have
ties to it have tested positive for HIV. Indiana prohibits needle...
(Tribune wire reports)

Patients came to him already sick. Most had illegally used Opana, a
prescription painkiller that delivers a potent high, especially when
ground into water and injected into veins, CDC investigators found. The
nearest hospital with social services and HIV testing, Cooke said, was
only five miles away. But many of Austin's drug users lacked

"When you don't have a health-care system where people have access to
testing and treatment, the introduction of one infection into a community
of drug users can turn into an outbreak," said Tony Fauci, director of the
National Institute of Allergy and Infectious Diseases.

Injecting drugs fuels nearly 10 percent of new HIV cases in the U.S.,
according to a 2012 CDC study that examined a national population sample
of 13,000. Nearly half of those who tested positive for HIV did not know
they had it.

Abuse of painkillers -- and sharing needles -- compounds the risk. The
problem is growing across the country. Prescription opioids are easy to
find and highly addictive. Prescriptions for these drugs have increased
tenfold since 1990, according to a Harvard Medical School report. Doctors
wrote 259 million prescriptions in 2012 -- "enough for every American
adult to have a bottle of pills," the CDC reported.

Users can illegally purchase drugs like Opana in liquid form and inject
it. The number of opioid-related deaths in Indiana more than tripled over
the past decade, increasing from 200 in 2002 to 700 in 2012, according to
the Indiana State Department of Health.

HIV outbreaks more commonly occur in urban areas, Fauci said, where drug
culture is more often prominent. The last HIV outbreak he remembers
outside a major metropolitan happened in Belle Glade, Florida, population
17,839, where doctors said poverty and drug use contributed to more than
400 AIDS deaths in the '80s and '90s.

Belle Glade's catastrophe proved that HIV is mobile. No small town is safe
merely because it is a small town. A lack of both medical and social
support increases any area's risk. Infrastructure also plays a role.

A National Institute of Health study from 2005 found that residents of
rural areas who had driver's licenses visited a doctor more than twice as
often as those who did not. People who said they used public
transportation reported 4 more chronic care visits per year than people
without access to a bus or train.

Beth Elaine Meyerson, co-director of the Rural Center for AIDS/STD
Prevention at Indiana University, said several forces drive rural
outbreaks -- and not just in Austin. Communities nationwide struggle with
limited access to affordable health care, counseling and testing. Many
residents are uninsured. Tackling an outbreak requires far more, in these
cases, than administering medication.

"We must also address those individual, social, community and policy level
factors that fuel illness -- like socioeconomic disadvantage and social
disadvantage," Meyerson said in an email. "We do this by building into
systems of care strong adjunct services that support continued engagement
with treatment."

HIV users who receive sustained treatment become 96 percent less
infectious, she added.

But people who don't think they can afford health care tend to avoid the
doctor's office, said Caitlin Priest, director of Public Policy at
Covering Kids and Families of Indiana. That drives up risk for everyone.

"Part of the puzzle is ensuring access to care," Priest said, "and to that
end we need to put boots on the ground in that area and conduct massive
enrollment events to ensure that eligible Hoosiers are connected to the
ACA Marketplace, or any other coverage program for which they may be

Cooke, who opened his practice in Austin 10 years ago, never expected to
battle an HIV outbreak. Now he's on the frontlines, driving from house to
house, offering free testing. He's educating residents about both
painkiller addiction and HIV treatment. He's thinking through ways to
implement telemedicine, bring treatment and counseling to residents'
living rooms.

And with more money and resources pouring in from the state, he's no
longer alone. The town's first-ever HIV clinic is scheduled to start
treating patients Tuesday.

"Funding is generally limited on what can be done in rural areas," Cooke
said. "In responding to this medical emergency, I'm hoping we can build a
model here -- something we can replicate in other rural communities."
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