Shane Avery practices family medicine in Scott County, Ind. In December, a patient came to his office who was pregnant, and an injection drug user.
After running some routine tests, Avery found out that she was positive for HIV. She was the second case he had seen in just a few weeks.
"Right then, I kind of realized, 'Wow, are we on the tip of something?' " Avery says. "But you just put it away. ... It's statistically an oddity when you're just one little doctor, you know?"
It wasn't just a blip. Health officials have identified dozens of new HIV cases in the area since December, and more are expected.
Scott County is one of the poorest and least healthy counties in Indiana. For years, it has struggled with injection drug abuse. Now the drug use in the area has spawned an epidemic of a different kind: HIV.
More than 70 new infections with the AIDS virus have been confirmed in just the last few months, in a place that normally sees a handful of cases in a year. The crisis led Indiana's governor, Mike Pence, to declare a public health emergency Thursday.
It also reignited a debate in the state over the use of needle exchange programs to prevent HIV's spread among users of injected drugs. Such programs have been found to work elsewhere, but the strategy is illegal in Indiana — and in 22 other states.
Many of the outbreak's cases have been linked specifically to oxymorphone, a prescription painkiller commonly known by the brand name Opana. The opioid seems to have become a favorite among drug abusers, who grind up the pills to inject the medication. Sharing needles is common.
"There is a social network that often goes along with this kind of drug use," says Dr. Andy Chambers, a psychiatrist and addiction specialist at the Indiana University School of Medicine. "So it's fairly usual for infectious diseases to spread through through the needles."
Chambers says the HIV outbreak calls attention to the national epidemic of opioid drug abuse.
"I'm actually ... surprised there haven't been other, similar outbreaks in other parts of the country that could be described in the same way as Scott County, Ind.," he says.
The fear of HIV spreading beyond Scott County has reignited debate about whether needle exchanges should be legalized throughout the state.
The strategy encourages drug users to trade their used needles and syringes for free clean ones in order to reduce the spread of infections that occur when the equipment is reused and shared.
The Centers for Disease Control and Prevention convinced Gov. Mike Pence to allow a temporary needle exchange in Scott County as part of the emergency response. But Pence is still against legalizing such exchanges statewide.
"I don't believe that effective anti-drug policy involves handing out paraphernalia to drug users by government officials," he says. "I reject that."
Rep. Ed Clere, a Republican state legislator who represents a nearby county, says needle exchanges shouldn't just be used to manage a crisis — they should be put in place in time to prevent outbreaks from occurring.
"When we smell smoke, we shouldn't wait until the house is engulfed in flames to do something," Clere points out.
Clere has introduced a measure that would legalize needle exchanges across Indiana. When he introduced a similar measure last year, it failed.
"Many of the folks who have contracted HIV in Scott County are going to be receiving treatment at taxpayer expense," Clere says. "Even with the number of cases that have been confirmed so far ... we could be talking about tens of millions or hundreds of millions of dollars."
Lawmakers in neighboring Kentucky approved needle exchanges in that state this week. But Indiana's Pence is still threatening to veto a needle exchange bill if it reaches his desk.