It's been more than a year since the town of Austin was catapulted into the international spotlight. The community was ground zero for an HIV epidemic. Since the outbreak was first reported in February of 2015 the number of HIV cases has swelled to more than 180.
Most cases have been traced to injection drug use and needle sharing.
Indiana lawmakers changed the law last year to allow Scott County to establish a temporary needle exchange. Â But health officials are worried that the programs might not be sustainable.
More Counties Adopting Syringe Exchange Programs
Since Scott County got approval for its needle exchange other communities have been going through the process to start their own programs. About two dozen communities are somewhere in the process.
In very simple terms, needle exchanges allow drug users to turn in old needles for new ones. Chris Abert, founder of the Indiana Recovery Alliance, which runs Monroe County's new needle exchange, explains how the program works.
"So when people come on who actually want access to needles or testing, they'll come here for it first and they put their dirty needles in here. Then we have postcards here that show various techniques of good vein care," he says.
About a half dozen exchanges have gotten state approval since the HIV outbreak in Scott County.
They're all a little bit different. Monroe County's is the only one that contracts with an outside provider. The county health department oversees the program and is responsible to the state. But  Abert  actually provides the services through this mobile unit.
Abert is a former addict and all of his staff are either current or former users. They focus on what Abert calls 'comprehensive harm reduction.'
Access to syringes is actually a relatively small part of what they do.
"So we have basic toiletries here. We have safer use guides, FAQs about the needles exchange. The paperwork we do about how many in and how many out, tampons and condoms and lubrication and then a variety of syringes, individual water packs, cottons, some sterile safety squares, tourniquets, cookers, and a variety of bio hazard containers,"Â he says.
He added that even though the IRA Â runs the needle exchange, it doesn't change the services they already provided.
"We continue to give out blankets and jackets. We're going to do a sock exchange, right now we're just giving out socks. Not asking people for their old socks in exchange yet. Doing HIV and Hepatitis C testing, doing referrals to treatment, mental health referrals, housing referrals, doing lots of education on safer IV drug use, lots of education and working with participants to empower them so they can show up to meetings where their fate is being decided," he says.
Before people exit  the van there's a chance for you to leave ideas for other services or needs you might have.
This comprehensive harm reduction approach is about acknowledging drug users typically have a lot of underlying issues.
It's one of those things with harm reduction it's a matter of we're not going to tell you to just stop using because that in it of itself needs to have a whole variety of services in order for you to do that.
Carrie Lawrence is with the Rural AIDS Center and she says that's been an important takeway from the HIV epidemic.
"It's one of those things with harm reduction it's a matter of we're not going to tell you to just stop using because that in it of itself needs to have a whole variety of services in order for you to do that," she says.
She explains that there are many factors that were in play to cause the outbreak.
"And I think from my perspective, as far as the outbreak, we have seen a lot of social determinants that sort of facilitate some of these health related emergencies, extreme poverty, low socio-economic status, low literacy, you know, not access to public health resources, not even access to mental health or addiction, and that's an ongoing problem, that to me is a huge deficit," she says.
How Effective Are Syringe Exchanges?
Studies show the exchange programs are effective at reducing the spread of diseases such as HIV and Hepatitis C among IV drug users.
But it's too early to say whether the needle exchange programs in Indiana are working. The mobile unit in Monroe County has only been operating about a month. Abert estimates they've probably served about a hundred people, but the health department can't provide specific data yet.
The Program Director of Syringe Exchange Program at the Monroe County  Health Department, Kathy Hewitt says that this first month has been good and she's optimistic for the future of the program.
"I think it's going great so far. We've already got a lot more participants since some of the other counties had when they started. We're getting a lot of new participants which means word of mouth is spreading, people are learning about the service. So you know, it's not, it started slow, but still I think it's really strong," she says.
The way Indiana's law is written, a county has to reapply every year to continue to operate a needle exchange program.
The State Department of Health determines the process for counties to use if they elect to renew their request to operate a Syringe Exchange Program. But those guidelines outlining the process haven't been established. The health department says that's coming soon.
Chris Abert says everybody is making it up as they go because there's no standard in Indiana yet for what needle exchange should look like.
"It was the same for starting the syringe exchange. Again, people don't have answers yet, so it was not only daunting but frustrating," he says.
And there are a lot of other details to work out too. Among them: funding. Monroe County has cobbled together a lot of resources to get its program off the ground, but it's still looking for more money.
Scott County's funding is running out so they're trying to find a new source of money.
The big unanswered question is if the rates of Hepatitis C and HIV improve – will the state renew the needle exchange programs?  One of the criteria counties have to meet to establish an exchange is have an epidemic of hepatitis c of HIV.  And they have to show the primary mode of transmission of the diseases are through intravenous drug use. If the needle exchanges are successful, that could spell their demise.
