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Small Indiana city races to curb HIV’S spread

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AUSTIN, Ind. >> Jeanni McCarty, a nurse and native of this threadbare city of 4,200, hurried up and down Main Street in Saturday’s bright sun, handing out stacks of fliers to any business that would take them. They were announcing a hastily planned specialty clinic — FREE, they emphasized in red — that would provide HIV treatment to anyone who needed it.
 
Quite suddenly, a lot of people around here do. And the number keeps growing.
 
More than 80 people in Scott County have tested positive for HIV since December, mostly in the last few weeks. They range in age from 20 to 56, and health officials say that almost all of them live in Austin, which sits along an interstate about 80 miles south of Indianapolis, surrounded by rural open space. The outbreak, the worst in Indiana’s history, stems largely from the intravenous use of the prescription painkiller Opana, which everyone from the police to pastors to the owner of the city’s sole grocery store recognizes as a plague on one ragged neighborhood in particular.
 
Gov. Mike Pence declared a public health emergency in the county on Thursday, and against his political beliefs, he also authorized a short-term needle-exchange program last week in hopes of stopping transmission of the virus through contaminated needles.
 
McCarty and her boss, Dr. William Cooke, the city’s only physician, have been at the forefront of organizing a whirlwind response effort. Cooke’s medical practice, Foundations Family Medicine, will house the new clinic, with infectious disease specialists from Indiana University coming once a week along with mental health counselors and addiction specialists.
 
The weekly clinic will open on Tuesday, with six of Cooke’s 15 exam rooms devoted to it. Teams of state workers from Indianapolis will be on hand to sign up uninsured patients for Medicaid, which Pence, a Republican, recently expanded under the Affordable Care Act to cover most low-income adults.
 
The question now is how many of the newly infected will show up — and whether the effort, which is being led by the Indiana State Department of Health and involves the federal Centers for Disease Control and Prevention, will keep the number of new cases from spiraling further.
 
“I really, truly don’t know what to expect,” an exhausted McCarty said after distributing the fliers, including to several worried people who asked for HIV tests on the spot. “Even if only a couple come, that’s more than we had before and then maybe they can talk others into it.”
 
There is reason for urgency. The transmission rate has been about 80 percent, Cooke said, meaning that 8 in 10 of those who have acknowledged sharing needles with someone who has the virus have tested positive. That indicates “a very high viral load in the community right now,” he said.
 
Health officials from Clark County, which is south of here but is in charge of HIV testing for 11 counties, have been going out since February to test people at their homes, using oral swabs that deliver preliminary results in 20 minutes and asking those who are tested to disclose their needle-sharing and sexual partners.
 
For the last week, a team from the CDC has been helping with that work; a spokeswoman for the agency said it was not aware of any other jurisdiction’s ever declaring a public health emergency because of an HIV outbreak.
 
For those who are HIV positive, case managers have been assigned on the spot to help link them to counseling and treatment. But most have not started treatment yet, partly because the closest HIV clinic is in Louisville, Ky., about 35 miles south of here.
 
“Our first three, we had appointments for them at the Louisville clinic and to a person, none of them showed up,” said Dr. Kevin Burke, the public health officer who oversees HIV testing in the region. “That may be fatalism. But at the same time, this population doesn’t have reliable transportation.”
 
Some will not be going to the clinic for now because they are in the Scott County jail. Sheriff Dan McClain said 11 of his 120 inmates had tested positive so far, but that they had not started treatment because the cost is so high — upward of $20,000 a year per patient, according to Burke — and he wants a guarantee of financing first.
 
“That’s a discussion I’ve had with the governor,” McClain said. “Once we get that support, we’ll screen whoever comes through our doors, medicate them, educate them and eventually refer them over to Dr. Cooke.”
 
For now, only inmates identified as having shared needles or having had sex with someone who has tested positive are being screened, he said.
 
“Most of them take it no differently from somebody telling them they have a cold,” the sheriff added. “They’re resigned to the addiction.”
 
That is where the needle exchange may prove crucial to the containment effort, he and others said, although many believe that 30 days — the length of time Pence authorized it for — will not be nearly long enough. The clinic will also help those who are willing get into detoxification and addiction treatment programs, Cooke said.
 
To understand how this could happen in Austin, or perhaps any small, poor, insular American town, is to take a drive with Donald Spicer, the city’s longtime police chief, through a neighborhood known as the North End. There, people in their 20s wandered the streets one afternoon last week, alone or in small groups, often averting their eyes as the police cruiser passed. “No trespassing” signs were posted in most yards, and many were strewn with ragtag furniture and trash. As many as two-thirds of the modest homes are rented out, Spicer said, and they are often neglected to the point of crumbling.
 
“We have houses I like to refer to as shooting galleries, where they all lay around and get high all day,” he said.
 
Tammy Breeding, 41, who lives in the neighborhood, put a handwritten sign on her lawn that says, “No loitering or prostituting is allowed in front of these premises.” She said that she had taken several hundred pictures “of all this stuff going on” since moving back to Austin last summer, and that she had gotten a license to carry a handgun because she feared for her young children.
“I do nothing but call into the tip line,” she said.
 
Spicer said his force of seven had made about 60 arrests this year, almost all of them drug-related. Interstate 65, which runs from Mobile, Ala., to Gary, Ind., is a conduit for illegally trafficked prescription drugs that make their way here, he said. People also travel to Louisville for drugs, he said. Spicer and McClain said that local doctors had been their partners in trying to solve the problem and had not been lax prescribers, but that people who did have valid prescriptions sometimes sold Opana for at least $30 a pill.
 
The jobs situation, though bleak, could be worse. Austin is home to a canning plant, a Pepsi plant and an auto-parts plant. It is close enough to Louisville, a relatively thriving city of 600,000, for people to commute. But unemployment remains high, perhaps partly because of addiction problems that go back a generation, Spicer said.
 
In retrospect, an outbreak of HIV was inevitable, Cooke said. The county has seen a torrent of hepatitis C cases in recent years, he said, and a number of overdoses and cases of endocarditis, an infection of the lining of the heart that can be caused by injecting drugs with dirty needles.
 
“We had all the ingredients in place for this,” he said on Saturday morning, after finishing an overnight shift in the hospital emergency room in Scottsburg, about five miles away. “I suspect a lot of rural America does.”
 
As the response effort begins, the organizers are also looking to quell fear in the community. An elderly patient told a physician assistant at Cooke’s practice that she feared catching HIV from pushing a shopping cart. McCarty said the practice had received several threats after announcing its plans to house an HIV clinic. Anxiety over the outbreak even affected the annual Easter egg hunt at a local park: A group of volunteers scoured it for needles on Saturday before hiding the candy-filled eggs.
Money remains a question mark — the governor has not said how much will be attached to the 30-day public health emergency, or to continuing treatment for those affected.
“My biggest fear with this is they come in like a hurricane, and then after 30 days, they leave us high and dry,” Spicer said. “Don’t leave us. Stay with us until we get past this thing.”
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