AUSTIN, Ind. — From the start of the HIV outbreak here, health officials emphasized that nothing set Scott County apart from many other rural communities where opioid drug use had become an epidemic.

This could happen anywhere, people were told.

Many people here had viewed HIV as a big-city disease, something that might afflict people in San Francisco or New York. But Austin is a small city of about 4,000 people 40 miles north of Louisville, Ky.

Then in February 2015, the first 30 cases of HIV were reported. By mid-March, the number had climbed to 55.

State health officials, the governor and the federal Centers for Disease Control and Prevention were looking for answers. Few public health crises have unfolded so rapidly.

Now, a year later, the outbreak is at 190 cases. But the sickness runs deeper.

Poverty envelops this city. Empty storefronts dot the main street. Many homes are boarded up or have makeshift tarps instead of windows. Fewer than 10% of Austin’s residents have earned a college degree.

One out of five residents lives below the poverty level, more than 1.5 times the rate in Indiana.

Drug use here is still rampant. Some users shoot up alongside their children or even their children’s children.

In the winter, as many as 20 users may huddle in a home, gathering in the one building that has heat for the day. The power of addiction is so great that even the sensation of a prick from an empty needle can bring relief.

Yet people have hope.

The response to the HIV crisis has focused attention and brought services to an area long left in the shadows.

“I think we have a lot of really good things that came out of the HIV outbreak,” said Brittany Combs, public health nurse at the Scott County Health Department neighboring Scottsburg, Ind. “We still have a long way to go.”

Substance-abuse experts often describe five stages of recovery, each critical to long-term success. The many users in Austin are not alone in facing the arduous task, person after person here says.

The city itself is in recovery.

Stage 1: Awareness

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