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The region of the Americas is the first in the world to be declared measles-free, after 22 years of work to banish the highly contagious infection that can result in pneumonia, blindness and death (stock photo) Elizabeth Renstrom—TIME

How an HIV Outbreak Hit the Heartland

Updated: Apr 17, 2015 9:21 AM ET | Originally published: Mar 27, 2015
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The number of HIV cases found in a remote Indiana county has grown to 120, according to numbers released Friday by the state's health department, after 79 cases were confirmed there over the last few months. Ten additional cases are awaiting confirmation.

The dozens of cases, described as an epidemic, are centered in Scott County, about a half-hour north of Louisville with a population of about 25,000. Indiana Governor Mike Pence declared a public health emergency there in March after dozens of cases of HIV were discovered.

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An outbreak of HIV may seem odd in such a remote part of the country, but it's been fueled by growing heroin and drug use in rural counties like this one. A number of Midwestern states have struggled with a recent uptick in drug and needle use, and Indiana specifically has seen an increase in the use of a powerful painkiller called Opana, which can be altered and injected. The number of deaths related to opioids like Opana rose from 200 a year in 2002 to 700 in 2012, according to the Indiana State Department of Health.

In this area of the state, there's relatively weak public health infrastructure to prevent the infection from spreading. Scott County is just one of five counties serviced by a single HIV testing clinic, and the county’s relative isolation from a sufficient public health system can help explain the virus's rapid growth, says Beth Meyerson, an Indiana University health professor and co-director of the Rural Center for AIDS/STD Prevention.

“The system isn’t working and isn’t strong enough from a public health perspective,” Meyerson says.

In a 2013 study by the non-partisan organization Trust for America’s Health, Indiana ranked last in federal funding per capita from the Centers for Disease Control. The national average spent per capita was $19.54. In Indiana, $13.72 was spent on each Hoosier.

Indiana has also seen an increase in Hepatitis C in many rural communities, says Meyerson, another warning sign that HIV may be spreading. According to the U.S. Department of Health & Human Services, about 25% of people who have HIV in the U.S. are co-infected with Hepatitis C.

On Thursday, state authorities stepped in. Gov. Pence allowed local officials to start a 30-day needle-exchange program in Scott County as a way to stop the outbreak. "I do not enter this lightly," Pence said, according to the Indianapolis Star. "In response to a public health emergency, I'm prepared to make an exception to my long-standing opposition to needle exchange programs."

MORE This Contraceptive is Linked to a Higher Risk of HIV

While dozens of cases have been reported, it’s likely that there are many more still unconfirmed. “I don’t expect these counties will remain the center of the epidemic,” Meyerson says. “I’m sure it’s going to be in other parts of southern Indiana, wherever our system is the weakest. We don’t know what we don’t know right now.”

Read next: At Least 120 Now Infected In Indiana HIV Outbreak

The Photo That Changed the Face of AIDS

David Kirby on his deathbed, Ohio, 1990.
David Kirby on his deathbed, Ohio, 1990.Therese Frare
David Kirby on his deathbed, Ohio, 1990.
In another of Therese Frare's photos taken in the final moments of David Kirby's life, his caregiver and friend, Peta; David's father; and David's sister, Susan, say goodbye.
Bill Kirby tries to comfort his dying son, David, 1990.
A nurse at Pater Noster House in Ohio holds David Kirby's hands not long before he died, spring 1990.
David Kirby, Ohio, 1990.
David Kirby's mother, Kay, holds a photograph of her son -- taken by Ohio photographer Art Smith -- before AIDS took its toll.
Peta, a volunteer at Pater Noster House in Ohio, cares for a dying David Kirby, 1990.
Peta lies on a couch in a home rented by Pater Noster House, 1991. After the infamous ad ran, Benetton donated money to Pater Noster, some of which was used to furnish the house where Peta and other patients stayed.
Peta on the Pine Ridge Indian Reservation, July 1991. "Peta could be a handful at times," Therese Frare told LIFE.com, "but there was a great deal of joy in our relationship. He wasn't like anyone I'd ever met."
Peta swims in a lake on the Pine Ridge (Lakota) Indian Reservation in South Dakota, during a trip home with photographer Therese Frare in July 1991.
Peta at the Pine Ridge (Lakota) Indian Reservation in South Dakota, during a trip home with Therese Frare in July 1991.
Peta in Ohio, 1991.
Peta in bed at Pater Noster House, 1992.
Scene at Pater Noster House, Ohio, 1991.
Peta at Pater Noster House, 1992.
Peta with Bill and Kay Kirby at Pater Noster House, 1992. "I made up my mind," Kay Kirby said, "when David was dying and Peta was helping to care for him, that when Peta's time came -- and we all knew it would come -- that we would care for him. There was never any question. We were going to take care of Peta. That was that."
Kay Kirby administers medicine to Peta via an IV, 1992.
Peta and Bill Kirby share a quiet moment together in Peta's room, Ohio, 1992.
Peta in hospice, Columbus, Ohio, 1992.
Bill and Kay Kirby, 1992.
David Kirby on his deathbed, Ohio, 1990.
Therese Frare
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