AUSTIN, Ind. _ Ethan Howard cradled his prized Martin-brand guitar, strumming gently as he sang of happiness he thought he'd never find.
With support from his family and community, the 26-year-old is making his way as a musician after emerging from the hell of addiction, disease and stigma. The former intravenous drug user was among the first of 235 people in this southern Indiana community to be diagnosed in the worst drug-fueled HIV outbreak ever to hit rural America.
Now, five years after the outbreak, Howard counts himself among the three-quarters of patients here whose HIV is so well controlled it's undetectable, meaning they can't spread it through sex. He's sober in a place that has new addiction treatment centers, a syringe exchange and five times more addiction support groups than before the outbreak.
But as this city of 4,100 recovers, much of the rest of the country fails to apply its lessons. The Centers for Disease Control and Prevention deemed 220 U.S. counties vulnerable to similar outbreaks because of overdose death rates, the volume of prescription opioid sales and other statistics tied to injecting drugs. Yet a Kaiser Health News analysis shows that less than a third of them have working syringe exchanges. Such programs, which make clean needles available to drug users, have been found to reduce the spread of HIV and hepatitis C and are supported in the Trump administration's national effort to end the HIV epidemic within a decade.
Still, local backlash often stymies efforts to start such exchanges, even in Indiana, where only nine of 92 counties have one, and with federal funding up for grabs that could help them expand. And rural places in states such as Missouri, West Virginia and Kentucky are still plagued by the raw ingredients that led to Austin's tragedy: addiction, despair, poverty, doctor shortages and sparse drug treatment.
All this threatens to stall the administration's HIV goals, which are championed by two prominent figures who responded to Austin's outbreak: Indiana's former governor Vice President Mike Pence and the former state health commissioner, Dr. Jerome Adams, now the U.S. surgeon general.
Since Austin's 2015 crisis, drug-fueled outbreaks have occurred in more than a half-dozen other communities, some with syringe exchanges and some without.
"When you have these outbreaks, they affect other states and counties. It's a domino effect," said Dr. Rupa Patel, an HIV prevention researcher at Washington University in St. Louis. "We have to learn from them. Once you fall behind, you can't catch up."
