AUSTIN, Ind. — She became addicted to painkillers over a decade ago, when a car wreck left her with a broken back and doctors prescribed OxyContin during her recovery. Then came a new prescription opiate, Opana, easily obtained on the street and more potent when crushed, dissolved in water and injected. She did just that, many times a day, sometimes sharing needles with other addicts.
印第安纳州奥斯汀——十年前，她开始对镇痛剂上瘾。当时，她在一次车祸中脊柱受伤，医生在她康复期间给她开了奥施康定(OxyContin)。然后，又出现了一种新的处方麻醉剂Opana，这种药在外面很容易买，碾碎后效力更强，可溶于水，还可以用于注射。她就是那样做的，而且每天要用很多次，有时还会与其他上瘾者共用针头。
Last month, the thin, 45-year-old woman learned the unforgiving consequences. She tested positive for H.I.V., one of nearly 150 cases in this socially conservative, largely rural region just north of the Kentucky border. Now a life long hobbled by addiction is, like so many others here, consumed by fear.
上个月，这个瘦削的45岁女人得知，这样做造成了不可挽回的后果。她的艾滋病毒(HIV)检测结果呈阳性，是靠近肯塔基州北部边界这个民风保守、以农业为主的地区的近150例艾滋病毒携带者之一。现在，与这里的许多人一样，因为上瘾而长期受到困扰的生活已经被恐惧吞噬。

She is afraid to start antiretroviral therapy because she does not want to be spotted entering the clinic on Main Street, she says, and afraid to learn her prognosis after hearing a rumor — false, it turns out — that someone else with the virus was given six months to live. Other drug users have refused to be tested at all.
她说，她不敢开始抗逆转录病毒治疗，因为她不想被人看到走进主街那家诊所，在听到有个病毒携带者经诊断只剩六个月时间后（后经证明是谣言），她甚至不敢去了解自己的预后。还有些药物使用者完全拒绝接受测试。
“I thought it was just a homosexual disease,” the woman said one recent evening, twisting a tissue in her manicured hands as tears filled her eyes. She asked that her name not be published out of concerns about being stigmatized. “I didn’t ever think it would be in my small hometown.”
“我还以为这是同性恋才会得的病，”她在近日的一个晚上说，她做过美甲的双手揉捏着一张纸巾，眼中噙满泪水。因为担心被人歧视，她要求对自己的姓名保密。“我从没想过，这种事会发生在我家乡的小镇。”
The crisis would test even a large metropolis; Austin, population 4,200, is overwhelmed despite help from the Centers for Disease Control and Prevention, the state and nonprofit groups like the AIDS Healthcare Foundation. H.I.V. had been all but unknown here, and misinformation is rife. Attempts to halt the outbreak have been hindered by strong but misguided local beliefs about how to address it, according to people involved in the response.
这个危机甚至还会考验一个大都市；尽管有疾病控制与预防中心（Centers for Disease Control and Prevention，简称CDC）、州和艾滋病健康护理基金会(AIDS Healthcare Foundation)等非营利组织的帮助，人口仅4200的奥斯汀还是有些不知所措。这里几乎对HIV一无所知，而且错误信息也很多。相关人士表示，在如何应对它的问题上，当地一些强烈而具有误导性的观念，对阻止HIV蔓延的工作造成了阻碍。
Gov. Mike Pence reluctantly authorized a needle exchange program last month, but local officials are not running it according to best practices, outside experts say. Austin residents still must wait for addiction treatment, even though they have been given priority. And getting those who are H.I.V.-positive on medication, and making sure they adhere to the protocol, has been difficult.
外界有专家称，上个月州长迈克·彭斯(Mike Pence)不情愿地批准了一个针头更换项目，但当地官员的执行不力。本应得到优先待遇的奥斯汀居民仍然必须等待接受药物上瘾治疗。此外，让那些HIV检测呈阳性的人接受药物治疗，并保证他们能遵守规定，也并非易事。
Officials here say the need for education is urgent and deep; even local health workers are learning as they go. Brittany Combs, the public health nurse for Scott County, said she was stunned to discover from talking to addicts that many were using the same needle up to 300 times, until it broke off in their arms. Some were in the habit of using nail polish to mark syringes as their own, but with needles scarce and houses full of people frequently shooting up together, efforts to avoid sharing often failed.
这里的官员表示，对教育的需求迫切而深刻；连当地的医务人员都摸索着工作。斯科特县(Scott County)的公共卫生护士布里特妮·库姆斯(Brittany Combs)说，她在与上瘾者交谈的过程中发现，很多人会使用同一个针头达300次，直到针头断在胳膊里，她对此感到震惊。有些人还习惯用指甲油标示出自己的注射器，但是由于针头不多，再加上屋子里满是经常一起进行注射的人，所以往往很难避免共用针头的情况。
After the needle exchange program started last month, Ms. Combs also learned that many addicts were uncomfortable visiting a needle distribution center that opened April 4 on the outskirts of town. So she started taking needles directly to users in their neighborhoods.
库姆斯还了解到，上个月针头更换项目开始后，许多上瘾者都不愿意去往针头分发中心。4月4日，该中心在城郊开放。所以，她开始直接把针头拿到社区，给那里的药物使用者。
At the same time, H.I.V. specialists from Indianapolis — who have evaluated about 50 people with the virus here so far and started about 20 of them on antiretroviral drugs — are fighting a barrage of misinformation about the virus in Scott County, where almost all residents are white, few go to college and one in five live in poverty, according to the census.
同时，来自印第安纳波利斯的HIV专家正在与斯科特县大量关于HIV的错误信息作斗争。据调查，这里几乎所有居民都是白人，上过大学的很少，五分之一的人生活在贫困之中。目前，这些专家已经对这里的大约50名病毒携带者进行了检查，并开始对其中20人使用抗逆转录病毒药物。
“There are still a significant proportion of people in Austin who have biases about H.I.V. and are contributing to the stigma and subsequent fear,” said Dr. Diane Janowicz, an infectious disease specialist at Indiana University, who is treating H.I.V. patients here. “I have to reassure them — if your grandkid wants a sip of your drink, you can share it. It’s O.K. to eat at the same table. You can use the same bathroom.’”
“奥斯汀仍然有很多人对HIV存在偏见，而且正在对与之相伴的耻辱感和恐惧起到推波助澜的作用，”在这里治疗HIV患者的印第安纳大学(Indiana University)传染病专家黛安娜·扬诺维茨博士(Dr. Diane Janowicz)说。“我得反复告诉他们——如果你的孙子想喝一口你的饮料，你可以给孩子喝。在同一张桌子上吃饭也没有问题。你们还可以共用一个卫生间。”
Many of the newly diagnosed here have strikingly high amounts of the virus in their blood, Dr. Janowicz said, and in one patient the H.I.V. has progressed to AIDS. Nonetheless, she said, “if they take their medicine for H.I.V., this is a chronic disease, not something they have to die from.”
扬诺维茨说，这里许多近期确诊者的血液病毒含量都高得惊人。还有一位患者的HIV已经发展成了艾滋病(AIDS)。她说，不过，“如果他们使用针对HIV的药物，这就是一种慢性疾病，不见得一定会死于这个病。”
Another complication is that the needle exchange has faced strong local resistance. Mr. Pence, a Republican, generally opposes such programs, saying they perpetuate drug use. Many residents here feel the same.
另一个问题是，针头更换项目在当地遭到了强烈抵制。身为共和党人的彭斯对此类项目基本上持反对态度，说这样会使药物滥用的行为延续下去。这里的许多居民也这样认为。
“If you would have asked me last year if I was for a needle exchange program, I would have said you’re nuts,” Ms. Combs said. “I thought, just like a lot of people do, that it’s enabling — that you’re just giving needles out and assisting them in their drug habit. But then I did the research on it, and there’s 28 years of research to prove that it actually works.”
“如果你去年问我是否支持针头更换项目，我会说你疯了，”库姆斯说。“与许多人一样，我认为这是在给药物使用提供方便——你把针头分发出去，为他们使用药物的习惯提供帮助。但是，我随后我做了一些了解，有28年的研究可以证明这样做真的有用。”
But researchers say that Scott County’s hastily created exchange has several features that could sharply curb its effectiveness. To get clean needles, drug users have to register, using their birth date and a few letters from their name to create an identification number that goes on a laminated card. But the police are arresting anyone found with needles but no card, saying it will prod more people to participate.
但研究人员称，斯科特县匆忙创建的更换项目有几个地方会严重影响它的效果。要获得干净的针头，药物使用者必须登记，用出生日期和名字中的几个字母来创建一个识别码，这个码会印到一张塑封的卡片上。然而，任何有针头但没有卡片的人，一经发现就会被警察逮捕，理由是这样会促使更多人参与更换项目。
Dr. Don Des Jarlais, the director of research for the chemical dependency institute at Mount Sinai Beth Israel hospital in New York, said the most successful needle exchange programs let participants pass out syringes to peers who remain in the shadows instead of requiring everyone to sign up. Arresting drug users who are not officially enrolled in the program “makes it hard to build trust,” Dr. Des Jarlais said, adding, “You’re not going to be able to get enough syringes out to really stop the epidemic if you have those types of restrictions.”
纽约西奈山以色列堂医院(Mount Sinai Beth Israel)化学品依赖研究所的研究负责人唐·德夏莱(Don Des Jarlais)说，最成功的针头更换项目会让参与者把注射器传递给身边那些仍然躲在暗处的人，而不是要求每个人去登记。逮捕那些没有在这个项目中正式登记的药物使用者，“会导致很难建立起信任”，德夏莱说。他还表示，“如果设定这些限制，你就无法把足够多的注射器分发出去，从而真正阻止病毒的传播。”
Local supporters of the needle exchange say a limited program is better than none, and believe that improvements will come with time. Last week, the state legislature sent a bill to Mr. Pence that would allow communities to create needle exchange programs for up to a year if they are experiencing an epidemic of H.I.V. or hepatitis C because of intravenous drug use. Mr. Pence said he would sign the measure, noting in a statement that it would allow only “limited and accountable” needle exchange programs, and only “where public health emergencies warrant such action.”
当地支持针头更换项目的人表示，有限制的项目总比完全没有这类项目好，而且他们认为随着时间流逝，事情将出现改善。上周，州立法机构向彭斯提交了一个提案。根据该提案，当一个社区因为静脉药物注射而出现HIV或丙型肝炎的广泛传播时，可以创立一个长达一年的针头更换项目。彭斯称，他将签署这一提案，并在一项声明中指出，它将只批准“有限且可问责的”针头更换项目，而且只在“出现公共健康危机的前提下”进行。
For now, the program here is giving out a maximum of 140 clean needles per user per week to whoever comes to the outreach center or accepts them from the roaming minivan. Ms. Combs said some people told her they injected as often as 15 times a day, and the exchange is erring on the side of providing slightly more than people need. She has passed out needles at a house where the owner, an older woman known as Momma, sits on the porch while a steady stream of visitors comes to shoot up inside. She has knocked on the door of a trailer where, she said, “multiple family members live and the daughters all prostitute themselves out and everyone is doing drugs.” One recent afternoon, on a street fragrant with lilacs, a young woman on a bicycle declined Ms. Combs’s offer of clean needles, saying she already had some — and H.I.V.
目前，这里的项目每周最多向每个药物使用者发放140个干净针头，发放对象是每个来到推广中心，或者从流动的小型货车上拿针头的人。库姆斯说，有人告诉她，他们每天会注射多达15次，而这个更换项目宁愿提供略微超出人们需求的数量。她曾去一户人家发放针头，这家的主人是一个年纪稍大的女性，名叫莫玛(Momma)；莫玛坐在门廊上，有人不停地来到这里，到里面进行注射。库姆斯还曾敲过一个拖车式活动房屋的门，她说，“好几个家庭成员都住在里面，家里的女儿都会去卖淫，每个人都在用毒品。”近日的一天下午，在一条弥漫着紫丁香香味的街道上，一名骑自行车的年轻女性拒绝了库姆斯提供的干净针头，她说自己已经有了一些，而且自己已是HIV携带者。
“I know I need the medicine to slow it down,” she murmured.
她低声说道，“我知道我需要药物来延缓病情发展。”
One unexpected benefit of the H.I.V. outbreak, according to the woman who tested positive and fears starting treatment, is that the men who used to stream into town daily, seeking young female addicts who would prostitute themselves in exchange for drug money, have all but disappeared.
这名检测呈阳性，而且害怕开始治疗的女性表示，HIV的蔓延带来了一个意想不到的好处：那些曾经每天涌入城里，寻找年轻的女性用药上瘾者的男性几乎都消失了。他们之所以来这里，是因为上瘾者会用性服务来换取毒品钱。
“It took H.I.V. to change our town,” she said. “Those of us who are affected are devastated, but I’m glad H.I.V. is here.”
“最终HIV改变了我们的城镇，”她说。“我们这些受感染的人被毁了，但我很高兴HIV来到了这里。”