A trio of deadly afflictions is ripping through a rural county in southern Indiana.
More than 130 patients in Scott County, Ind., tested positive for HIV in less than a year, making the community of about 24,000 people the site of one of the worst outbreaks in decades.
Among the infected are 114 who also tested positive for another blood-borne disease — hepatitis C, which attacks the liver.
Most of the HIV and hepatitis C patients share another sickness — the root of the HIV epidemic and a driving factor in the proliferation of hepatitis all along the Appalachian Mountains. They are also addicted to opiates.
Needle-sharing among addicts is the No. 1 risk factor in contracting hepatitis C and HIV. Laws that track the purchase of syringes keep drug users from buying fresh needles for each new high.
"A lot of people use the same needle over and over," said Amanda Newton, a clinician and director of marketing at the Jefferson Alcohol and Drug Abuse Center in Louisville, Ky. "They get sores and the needles break off in their arms."
Health officials in Louisville, just 35 miles south of Scott County, are bracing for the worst.
Last week the city's health department opened the state's first needle exchange, where drug addicts can trade their used syringes for sterile ones. Officials hope the program will keep contaminated needles off the streets and prevent the spread of disease.
Kentucky saw sharp increases in heroin overdose deaths and hepatitis C cases over the last decade, signs that could foreshadow an HIV crisis. Louisville health department officials hope the needle exchange will prevent an HIV outbreak.
"A huge motivator in this is the HIV epidemic just 35 miles away from the city — caused mostly by folks who are addicted to heroin and sharing dirty needles," said Dave Langdon, a spokesman for the Louisville Department of Public Health and Wellness.
Hepatitis C patterns in the state suggest an HIV infection would spread quickly among drug-using communities. If a similar outbreak of HIV were to make its way to Louisville — with a population of nearly 600,000 — Langdon said the city could see as many as 5,000 cases in the time that it took for Scott County to report 135 new infections. The virus would spread faster in the city because there are more than 10 times as many people living in much closer quarters.
In the last decade, hepatitis C cases have skyrocketed in Appalachia. Kentucky, West Virginia, Tennessee and Virginia collectively saw an increase of 364% in the number of acute hepatitis C cases, according to the U.S. Centers for Disease Control and Prevention.
The proliferation of the liver-killing disease and other blood-borne pathogens coincides with the spread of heroin use beyond the confines of poor urban neighborhoods to mostly white suburban and rural communities.
Most of the heroin users that come to the Jefferson Alcohol and Drug Abuse Center are under 25 years old, and middle- or upper-class, Newton said.
"It's really hard when you see 18- or 19-year-olds on their deathbeds," Newton said. "They don't even know they have their whole lives ahead of them."
Five years ago, the treatment center served mostly prescription-pill addicts. Heroin users were rare, Newton said. But now, 80% of the center's patients seeking addiction therapy are using the drug.
As Kentucky and other states tightened regulations controlling prescriptions for painkillers, heroin replaced pills such as Oxycodone. Heroin found in Louisville today is purer than what was sold in the city during the 1970s and 1980s, Newton said.
The spike in hepatitis C cases is likely the "tip of the iceberg," said Stephanie Mayfield, commissioner of Kentucky's Department of Public Health. The disease typically doesn't cause symptoms for decades, so many of those infected don't get tested until the disease has already damaged their livers.
The CDC issued an advisory on the Indiana HIV outbreak in April reminding health departments and physicians to counsel both HIV- and hepatitis-C-positive patients to avoid sharing needles, and to provide those who are actively using drugs with sterile needles.
Kentucky's Legislature passed an emergency bill permitting local governments to establish needle-exchange programs in March, allowing those governments to provide reliable sources of clean syringes for the first time.
Nearby states experiencing an increase in hepatitis C infections are still debating the value of needle exchanges. Some opponents of the programs say they encourage drug users to continue seeking out highs with fewer worries.
But Dr. Rice Leach, who is advocating for a needle exchange in Lexington, Ky., doesn't believe clean needles would increase the number of drug users.
"People who are going to abuse drugs are going to abuse drugs," he said.
The needle exchange is "just going to make the area safer for both drug users and nonusers," he added.