Ten years ago, the Indiana community of Austin made headlines for its historic HIV outbreak brought on by intravenous drug use.
More than 230 people became infected with HIV in the rural town, worsened by delayed action from former Gov. Mike Pence. Experts and locals credit Indiana’s first syringe exchange program for stopping the spread.
While that exchange no longer exists in Austin or the rest of Scott County, it laid the foundation of community-centered HIV and addiction treatment that remains today.
“There were basically two ways to approach the HIV outbreak that got national attention, international attention,” said Dr. William Cooke. “There was treat the HIV, and get people treated. And then the other approach would be to dig down deeper.”
Cooke leads Foundations Family Medicine, owned and operated by Well Care Community Health, a Federally Qualified Health Center.
Often billed as “the only doctor in town,” Cooke said on the surface, Austin is doing better. HIV infection rates have dropped. Addiction support has improved.
But deeply embedded social problems persist — the same problems that caused the outbreak in the first place, Cooke said. Many residents still struggle with opioid abuse, isolation and a lack of basic needs.
“We want every kid born in our communities across this country to have access to everything they need to prosper and do well,” Cooke said. “But the truth is that not every kid born in certain situations has access to those things. The question is, what are we going to do about it?”
‘A public health emergency’
One now-discontinued drug, Opana, was at the heart of the outbreak in Scott County.
Opana was a powerful pain reliever that wore off quickly and left users with extreme withdrawal symptoms. The manufacturer, Endo Pharmaceuticals, eventually hardened the pills, making it more difficult to grind into a fine powder in an effort to curb abuse. It also blocked competitors from creating a generic version, saving Endo hundreds of millions of dollars in revenue.
So, some people turned to needles, liquifying Opana to inject it directly into their veins. Syringes were reused and shared, sometimes filed down and sharpened when they became dull. Medical issues related to injectable drug use — skin abscesses, Hepatitis C, heart infections — increased. At the same time, Indiana banned giving out sterile syringes.
Doctors like Cooke noticed these warning signs in Scott County before the HIV outbreak.
“People can only make choices from options available to them,” Cooke said. “If they have a sterile syringe, they're not going to transmit that virus to other people.”
In 2015, almost 200 people tested positive for HIV in Scott County. About 80 percent lived in Austin, one doctor found, and almost all made less than $10,000 a year.
Suddenly, Austin was on the map, and it wasn’t for something worth celebrating.
“After working in disasters, you realize chaos comes after a crisis,” said Carolyn King, a community advocate.
The Centers for Disease and Control and former U.S. Surgeon General Dr. Jerome Adams stepped up to control the outbreak. Doctors with Indiana University Health and the Indiana State Department of Health set up clinics. Specialists, including the Indiana Recovery Alliance and AIDS Healthcare Foundation, lent their support, supplies and funding.
King and other locals stepped in. She said she worked as a liaison in the county.
“It was just way too much attention for a community, particularly Austin, whose people just want to be left alone,” King said.
That attention was also directed at former governor Pence. While doctors, addiction experts and local officials stressed the effectiveness of syringe exchanges, Pence resisted legalizing them. Many opponents thought the exchanges would enable drug use and other risky behaviors.
Four months after the first HIV diagnosis in Scott County, Pence allowed Indiana’s first sterile syringe exchange.
"I will tell you that I do not support needle exchange as an anti-drug policy," Pence said in 2015. "But this is a public health emergency."
The stigma around treating addiction and HIV lingered. One county official told King — who had recently lost her granddaughter to the opioid epidemic — that they should let drug users die.
“If you're judging someone and calling them low lives and wishing they were dead, you're not going to solve the problem,” King said. “It could happen to any of us.”
‘We met them exactly where they were at’
Scott County’s syringe change continued for six years.
The exchanges did more than replace dirty needles. For Kelly Hans, now executive director of the Holding Space Recovery Project in Austin, the exchange was a way to connect isolated residents with medical care, addiction services and basic necessities.
“Some of them probably wished, ‘Oh, I wish I could just come in and drop them off and then get some and go, but these girls are going to talk my ear off,’” Hans said.
Hans said they always had snacks and asked a variety of questions.
“‘How are you doing? Have you eaten?” Hans would ask. “When's the last time you've had a shower? Do you have somewhere safe to stay? Do you need a tent? When's the last time you've been to a doctor?”
The exchanges were also an opportunity to educate drug users, Hans said. For example, users were advised on how to administer Naloxone and call 911 in case of an overdose.
Meanwhile, Cooke and other doctors set up HIV clinics in town. Nurses and other staff went out into the community, bringing resources directly to affected people.
Tracking the HIV epidemic became easier, and health officials quickly saw improvements.
“Seeing these horrific situations at the hospital where people were losing limbs, or dying, losing their heart valve, and that all stopped once the syringe service program happened,” Cooke said.
As resources poured in, Cooke said the community tried to convert them into ways to meet basic needs.
“We're digging deeper,” Cooke said. “We're trying to find ways to provide people access to health care that don't have a stable house, that don't have a stable meal, that don't have transportation.”
Then, when a drug user was ready for recovery, advocates such as Hans and Cooke would be there.
“We just celebrated, and loved on them, and did things for them that their family wasn't doing for them at the time,” Hans said. “We met them exactly where they were at, and we didn't try to force them to change.”
By the end of 2015, Scott County saw a 100 percent increase in the number of people in recovery.
By 2021, Scott County had effectively stamped out the epidemic.
‘Do we have more cases of HIV?’
Though the syringe exchange was effective, and HIV cases steadily declined, doubters remained.
When the time came to renew the syringe exchange in 2021, Scott County commissioners declined. Commissioners President Mike Jones said at the time he believed more access to needles led to an increase in overdoses.
"I know people that are alcoholics, and I don't buy him a bottle of whiskey, and ... I have a hard time handing a needle to somebody that I know they're going to hurt theirself with," Jones said in 2021.
The county phased out the exchange that year. Current Scott County commissioners and health officials, did not respond to interview requests.
Indiana’s syringe exchange law will expire next year. Hans said unless legislators extend the law again, it is unlikely Scott County will have another exchange.
Harm reduction tools such as syringe exchanges aren’t always perfect, but they save lives, Cooke said. He compared it to treating a patient with a less stigmatized medical condition.
“They have a heart attack or a sudden cardiac event, and they collapse, and we start to perform CPR on them,” Cooke said. “CPR typically results in cracking ribs. And you don't want to crack their ribs. You don't want to hurt them, but you want to save their life.”
While Scott County has drastically reduced HIV rates, Hans said testing has also dropped after the syringe exchange ended.
“Do we have more cases of HIV?” Hans asked. “We don't know because people aren't getting tested.”
Hans and Lisa Webster, community program manager at Holding Space, used to administer 100 tests a month. They also made sure drug users were retested every three months.
“When you're dealing with a hard-to-reach population, if you don't have something that they need, they're not going to come to you,” Webster said. “So, we're not able to make those connections, and we don't have anything that will bring them in so that we can get the testing numbers up.”
But long after the syringe exchange program ended, Cooke, Hans, King and Webster are still treating HIV and helping drug users.
Holding Space builds on Hans’s and Webster’s work with the exchange under the same roof. Two Holding Space employees were helped by the exchange, and others such as Hans are in long-term recovery from drug use. Staff members help patrons secure food, clothes, birth certificates, medical treatment, addiction services and more.
“They know that they'll come in, and get a Rice Krispie Treat, and they can sit and talk to us, and we don't judge them for anything that they do,” Hans said. “They know that we care.”
Southern Indiana now has multiple HIV treatment centers, King said, and more people understand the complexities of addiction. Cooke said his practice gets people into recovery almost daily.
Today, King volunteers nearby in Clark County, which still allows syringe exchanges. She said she keeps love and kindness at the center of her addiction work with Clark County CARES — values she picked up working alongside Cooke.
“I think that's the only approach we have as a community,” King said. “Our approach always has to be, ‘We can make it better for you.’”
More than 15,000 people live with HIV in Indiana, according to a 2025 CDC report. The report estimates about 70 percent of people are virally suppressed, meaning the disease is basically undetectable in their bodies and they can’t transmit it to others. Cooke said many people with HIV live normally.
“It's easily treated with one pill the size of a tic tac once a day,” Cooke said. “It's so different than it was in the ‘80s and all the stories that we've heard. Remember that day is gone, thank God. We're in a new day for HIV.”
