In December 2014, an Indiana physician performed a routine HIV test on a pregnant woman that showed she had the virus. The expecting mother was one of the first in a cluster of new HIV cases in southern Indiana that would quickly grow in a tight-knit community of drug users who shared needles.
At its peak of 22 new people diagnosed each week, up from just three new cases between 2009 and 2013, the Indiana epidemic was the worst HIV outbreak ever to happen in rural America. And medical professionals say it could be the canary in the coal mine of HIV outbreaks in rural communities across the US.
The cause of the Indiana epidemic — centered around Austin, Indiana, where 10 percent of the 4,200 residents inject opioids — was addiction, and the infection spread through the use of dirty needles. The solution, public health officials say, was a needle exchange, the use of preventative drug Truvada, and a successful HIV-prevention strategy first implemented on Vancouver's addiction-afflicted Downtown Eastside.
That Canadian strategy garnered headlines this week after the British Columbia Centre for Excellence in HIV/AIDS announced it had secured funding to continue the program in Indiana.
It was back in March 2014 when acclaimed HIV researcher Dr. Julio Montaner got the call from Indiana. Health practitioners urgently needed to implement the successful strategy he had tested in Vancouver.
In the late '80s and early '90s, HIV/AIDS was predominantly a concern for men who had sex with men. Early interventions weren't working, and there was an urgent need for effective treatment.
In 1996, the same year an estimated 23 million people worldwide were living with HIV, a drug trial Montaner was involved with gave his team a huge surprise. The University of British Columbia researchers realized a cocktail of three drugs could suppress the virus and prevent it from reproducing.
The drug cocktail wasn't a cure — there is still no cure for HIV/AIDS — but once perfected, the antiretroviral drug strategy would dramatically increase the lifespan of those who were infected, and decrease the potential for them to transmit the virus.
But the same year his team discovered the triple-drug therapy, Montaner remembers, an HIV outbreak exploded in Vancouver with new cases "going through the roof."
"The heart of the epidemic was the Downtown Eastside," he said.
Vancouver's Downtown Eastside is one of the poorest neighborhoods in Canada — if not the poorest — with mental illness, homelessness, crime and drug dependency mingling together in one place. There, a concentration of people feeding their addictions and sharing needles gave rise to a rapidly-expanding HIV epidemic.
Montaner realized that any intervention had to target the root of the problem.
"We needed to become experts on addiction before we could get the upper hand on HIV," he said.
The strategy, later perfected and exported internationally under the label Treatment as Prevention, provided free and immediate antiretroviral treatment to anyone diagnosed with HIV. The idea was to reduce the risk of transmission by decreasing a patient's viral load. Physicians then mapped and monitored how the virus clustered to manage the outbreak and prevent future cases.
In 2003, Vancouver opened North America's only legal supervised safe-injection site, dubbed Insite, which has been estimated to prevent 35 cases of HIV each year.
As a result of the 1996 program, Montaner said they have seen a greater than 85 percent decrease in AIDS diagnoses, an 85 to 90 percent decrease in deaths from AIDS complications, and new HIV infections overall in the province have plummeted by about 65 percent.
"We have had no single case of a child born with HIV from an infected mother in the last 14 years, and we have had approximately a greater than 90 percent reduction in HIV diagnoses in injection drug users," Montaner said.
In March, Indiana medical practitioners began collaborating with Montaner to implement his model.
In early April, medical professionals began offering a needle exchange program. Any such program was previously banned in the state until the HIV outbreak led Indiana Governor Mike Pence to override existing law to allow a needle-exchange.
The syringe exchange, which provided clean needles to injection drug users, was one effort among many that helped control the outbreak, the Indiana State Department of Health told VICE News.
Health practitioners also offered Truvada, the only FDA-approved drug to prevent HIV, to people who were at high-risk of HIV infection — for instance, from an infected sex partner or from sharing needles with an infected person.
'The problem with these epidemics is that they are never over.'
There was some uptake of Truvada, Indiana University assistant professor of clinical medicine Diane Janowicz said, but it wasn't as widely used as health experts had hoped. The existence of Truvada wasn't widely known, she said, and patients who did know about it but didn't have insurance viewed it as a less affordable option compared to using clean needles.
It was the combination of the Truvada treatment, needle exchange program, and the approach developed by the Canadian doctor that solved the HIV epidemic in Indiana, said Janowicz, who calls it the worst such outbreak to ever hit rural America. And importantly, the expansion of addiction centres and programs across Indiana helped target the original cause of the epidemic.
Last July, state epidemiologist Pam Pontones said the feeling was that the HIV outbreak in Scott County Indiana had peaked. "We are seeing very few new cases," she told the IndyStar. "We might have one, maybe two in a week."
By the end of July, when the outbreak finally subsided, the number of new cases totaled 175. Since then, only nine new cases of HIV have been reported, with three of those cases announced in December after a retesting blitz.
Though the outbreak has abated, it hasn't ended.
"The problem with these epidemics is that they are never over," Montaner said.
He warned that the low number of new cases could lead to a false sense of security. "Unless you address what led to that outbreak, you don't solve the problem," he said.
Montaner and Janowicz agree the root of the problem is addiction — an issue that exists in rural and marginalized communities across America.
"Many of us fear that the HIV outbreak in southern Indiana is a canary in a coal mine of another rural community in the US to have a similar occurrence,"Janowicz said.
Follow Hilary Beaumont on Twitter: @hilarybeaumont