In HIV-riddled town, addiction 'the lifestyle'

AUSTIN, Ind. – Two miles from a new HIV testing clinic and needle exchange, a 26-year-old woman in dark sunglasses sat in a city park next to a neighborhood of dilapidated homes with peeling paint and boarded-up windows.

Long addicted to crushing and shooting up pain pills — and sometimes trading sex for drugs — she said last week that she'd recently been diagnosed with HIV, part of an epidemic in Scott County that has reached 142 cases.

But she doesn't plan to stop using drugs, she said, flicking a cigarette into the grass with pink-painted fingernails and climbing into an SUV. There, she mixed powdered heroin and water in the bottom of an energy drink can, drawing the brownish liquid into a well-used needle and injecting it into a hand pocked by drug use.

"Anything bad that can happen has already happened. So why stop now?" she said.

To spend time with drug users and those with HIV in this isolated, impoverished town of 4,200, including the 26-year-old who asked not to be named, is to understand the depth of the problem as Austin battles a drug-fueled HIV epidemic unprecedented in rural America in recent years.

Inside Austin's community of drug abuse — concentrated in neighborhoods dotted by sagging wood-frame houses, tiny Pentecostal churches, no trespassing signs and a few Confederate flags — addiction is "just the lifestyle," the woman said.

"It's normal. In such a small town, there's nothing else to do," she said. "All your friends do it. Everybody here does it. I mean, you probably can go to three houses in a row and one of those houses has people getting high in it."

Despite an influx of aid from the Centers for Disease Control, Indiana's Department of Health and groups such as the California-based AIDS Healthcare Foundation — which has brought new testing, treatment and outreach — officials know it won't be easy reversing underlying conditions of poverty, drug abuse and lack of resources that formed the tinder to HIV's match.

"We saw this coming, for sure," said Dr. William Cooke, Austin's only physician. "But I never expected it to be like this. It's spreading and it's going to spread. It's a demonstration of what happens when we ignore a demographic group."

'Recipe for disaster'

Austin sits a half-hour's drive north of Louisville on Interstate 65, past farm fields and woods, just north of the county seat of Scottsburg. Founded in 1853 as a rail stop between Louisville and Indianapolis, it later became home to large food canneries.

Older residents say the Austin they grew up in was a small, close-knit community — a place of modest homes and neat lawns, with several manufacturing plants and restaurants dotting a tiny downtown strip. But over time, Austin increasingly fell on hard times. It lost some businesses, restaurants and jobs, and property values dipped. On some streets, yards became dotted with old cars, broken furniture and trash.

In 2004, when Cooke opened Family Foundations in Medicine to become the town's only doctor, he found a pervasive lack of opportunity, generational poverty and a severe lack of access to health care and substance-abuse treatment.

State figures show about one in five Scott County adults live in poverty, have not completed high school or are on disability. It has disproportionately high teen birth rates, and more than twice the state's rate of cases of child abuse and neglect. It ranks at the bottom of 92 Indiana counties on most health indicators, according to the Robert Wood Johnson Foundation national health rankings.

Cooke said abuse of opiate painkillers such as Oxycontin, made accessible from traffickers moving along I-65 and from doctors outside town, added to the mix. Around 2010, Cooke began to see intravenous use, and "from there it has just gotten worse." Drug overdoses and hepatitis C also began to increase.

Cooke said it was "a recipe for disaster," and he "repeatedly asked for help," including trying to get grants and added services and to organize behavioral health coalitions that never materialized.

"Everybody would agree it's a problem, everybody would agree something needed to be done, but everybody was busy with other priorities," he said, noting that he grew so frustrated he almost left town nearly five years ago.

In the meantime, used needles were turning up in parks and gutters and on ballfields. Austin police Chief Don Spicer has said police did what they could to crack down with a seven-man force, but the problems persisted.

On the town's north side, 67-year-old Don Estep, who has lived there for five decades doing small engine repair, said he has watched prostitutes walk the street, often looking for a single dose of drugs, as he sat on his front porch. "It's unreal," he said. "At one time we had 20 prostitutes walking the street."

Chris Albertson, a Scott County council member, said "a lot has to do with quality of life. There's not a lot of opportunity in Scott County. The poverty, lack of education, jobs — it all ties together. A lot of people think they're sort of stuck here. They feel hopeless."

He also believes some in the city "sort of turned a blind eye to" the community's problems as they built.

All that came to a head this year when the first cases of HIV began mounting with alarming speed. In a county that saw only three new HIV cases between 2009 and 2013, Scott has recorded 142 new cases through April 24 in the recent outbreak, though HIV cases related to intravenous drug use have declined nationally in recent years.

"It's not like it's happened overnight," said David Reed, 34, adding that he has watched as many as 15 people share the same needle. "Drugs have been in this town for years. They just let things go too far. And now the HIV outbreak is here."

Drugs take toll

Not far from Austin's high school, across from a house with rotten siding and a wheelchair sitting out front, Bobbie Jo Spencer sat on her porch near an old mattress. She said she was "trying to get better" from Opana pain pill withdrawal by looking for a dose.

Rubbing the needle tracks on her arms, she had just finished talking with two visibly intoxicated neighbors as they argued about whether they would learn they had both recently tested positive for HIV.

Spencer, 30, tested negative at the new clinic, where she got clean needles. But she was worried, she said. She'd shared needles with a HIV-positive couple, and some who initially tested negative for HIV later were found to be positive.

Story continues below this video "A Voice of an Addict"

With a boyfriend on disability, she said she earns up to $200 a week on odd house-cleaning and yard-cutting jobs, which she spends mostly on pills, purchasing a quarter of an Opana — a powerful painkiller — for $30. With a handful of friends killed as a result of drugs, she said the HIV outbreak renewed her desire — but not her ability — to quit.

"I do it to escape from my reality. I don't like my reality," she said. "I've been wanting to get off this crap. But rehab is so expensive. I wish I had my life back. I wish it was normal. I hate getting up and wondering where I'm going to get my next pill so my body can function right."

While heroin is surging in Kentucky amid a crackdown on pain pills, Austin's drug of choice is oxymorphone, or Opana, which can be crushed up and mixed with water to take advantage of its time-release properties. While a crush-resistant formulation was developed in 2011, it can still be ground up. Traffickers often cut them in quarters to sell.

Jeanni McCarty, a nurse who works for Cooke and has lost five relatives to drug abuse, said along with traffickers, pills are also coming from valid prescriptions filled in Louisville and Indianapolis for often legitimate ailments. But in some cases, "the amount of medication they're being prescribed, it's insane," she said.

Spicer said while there is some heroin in Austin, "due to the poverty levels, more people can get prescriptions (paid for by Medicaid) ... They may make $1,000 a month. Someone says 'Hey, you can get $130 a pill.' And the wheels start turning."

Because the high from a pill doesn't last long, four to 10 injections a day are common, which increases needle sharing, officials said. And the pills don't dissolve as well as heroin, requiring wider-gauge needles — which could spread more HIV during each injection. One drug abuser said there is a home in Austin in which there is a bucket of used, dirty needles for visiting users.

"Many family members will use drugs together," Joan Duwve, chief medical consultant to the Indiana Department of Health, said last week. "There are children, parents and grandparents who live in the same house, who are injecting drugs together, sort of as a community activity."

Yet for years, treatment and testing have been scarce around Austin. There were no drug treatment facilities in the city and no inpatient drug-treatment facilities in Scott County. And many could not make the trips to the Louisville area for methadone clinics or treatment programs, according to Cooke and others.

"There has been so many people who have wanted help for so long," Reed said. "But it was like nobody had time to help them, or couldn't help them because they didn't have insurance."

Needed

wake-up call

At Austin High School, 18-year-old Holli Reynolds, who helped put out a special edition of the school newspaper on the epidemic, said the outbreak has been both a bad rap and necessary wake-up call for Austin. The town isn't made up wholly of drug users, she said, but "we needed this funding to get these people the help they needed."

Indeed, Indiana health Commissioner Jerome Adams praised an "incredible outpouring of support and resources," from the CDC, foundations and universities. Indiana is allocating $2.1 million to fight the outbreak. Officials have set up a one-stop shop for testing, addiction treatment, immunizations and insurance. The AIDS Healthcare Foundation is providing mobile testing units.

Cooke's office is hosting an HIV treatment clinic with the help of Indiana University experts. Testing and treatment have been set up at the county jail. And while a measure allowing the emergency syringe exchange expires May 24, many expect it to be renewed by Gov. Mike Pence even if the state fails to pass a bill allowing them statewide.

There is talk about a behavioral health center being built in Austin, and local churches have taken up the cause — going on weekly walks to raise awareness, helping addicts and conducting needle sweeps.

Billy Snowden, pastor of the Help to Others church, located in a drug-infested neighborhood, said he hopes the outbreak will mean long-festering problems "are finally being addressed."

But reaching out to Austin's addicts has started slowly. As of last week, 95 people had been to the needle exchange. "So many people are not being tested that need to be tested," McCarty said.

Public health officials are working to quell fears about HIV, educating people about how it's spread. One man, for example, said last week he was nervous about exchanging money at a grocery out of misplaced fear that he could be infected.

Despite the challenges, public health officials hope to turn the response into a model that could be used for other parts of rural America to prevent a similar outbreak. That's critical, because federal AIDS/HIV attention and resources have previously been centered on urban areas, said Garith Fulham, Midwest director of policy and advocacy for the AIDS Healthcare Foundation.

"We've neglected rural America," he said.

As for the 26-year-old addict? "The future? I don't really think about it," she said. "I just go day to day."

Reporter Chris Kenning can be reached at (502) 582-4697. Follow him on Twitter at @ckenning_cj.