A man was lying sedate after injecting drugs. His fellow users, to amuse themselves, threw needles at him like a human dartboard to see if they would stick, according to a recent police report in Wolfe County, Kentucky.

“Back in the day, all we had to worry about was people drinking or smoking weed,” said special deputy Gary Smith, who is entering his 25th year with the Wolfe County sheriff’s department.

But with a growing US opioid epidemic that has escalated the number of injection drug users, the bucolic county has become acutely at risk from another public health problem.

Wolfe County tops the list of places that are most vulnerable to an HIV outbreak.

A new alarm for the HIV epidemic sounded early last year when a small, rural town in Indiana was beset with a staggering 188 cases of the hard-to-control disease – and the sirens have been heard in similar towns across the country.

The threat of another outbreak such as the one in Austin, Indiana, so concerned the Centers for Disease Control and Prevention (CDC) that the federal agency drafted a report showcasing which places in the US are most vulnerable to a similar outbreak.

    

HIV rates among drug users have dropped substantially since they peaked in the 1980s and before Indiana’s outbreak, rural counties had been largely insulated from outbreaks of HIV. But the opioid addiction epidemic has put new communities at risk.

“If we don’t begin to think about how we could prevent this from happening again, it could really erode our success,” said John Brooks, a CDC epidemiologist and the senior author of the vulnerability assessment.

The CDC determined a county’s vulnerability with a sobering recipe: high rates of drug overdose deaths and prescription opioid sales, a high white population, astounding rates of hepatitis C and searing poverty.

“For many years this was an urban issue, an inner-city issue, but what we learned from southern Indiana is that rural parts of our country are now at significant risk,” said Ardis Hoven, an infectious disease specialist with Kentucky’s department for public health. “If you look at these areas, the uniqueness is not only the poverty, not only the issue of unemployment and early teen births and educational issues, but the cultural issues embedded in many of those areas.”

The CDC said the top 20 most vulnerable counties identified in its report are effectively equal in vulnerability because of the analysis’s margin of error, but Wolfe County is ranked first and serves as a model for the places at most risk, 13 of which are in Kentucky.

“Wolfe is one place in a region where there is a problem,” Brooks said. “Dollars to doughnuts what’s going on with Wolfe, whatever vulnerability they have, is probably shared by communities around them.”

The other seven counties are also in the heart of the US opioid epidemic – Appalachia, which is overwhelmed by drug abuse and underresourced in every other way.

But a stroll down main street in Wolfe County’s main city, Campton, would not betray that this county could be the next place to face a crisis like the one in Austin.

The 7,200-person county is quiet, green and quaint. A sign from the freeway welcomes you to the “naturally gorgeous” region, which is frequented by rock climbers because of its landmark Natural Bridges rock formation and beautiful Red River Gorge.

    

But the sheriff’s department parking lot is packed each weekday and on one recent Tuesday, deputies planned to meet and discuss a recent tip about heroin use. “Everybody is using drugs here – end of story,” one captain muttered as the Guardian took photos of the office.

As has happened across the US, drug abuse soared in the county once people started getting more pain pills from their doctors. Now, Smith gets calls at work, on his home phone and at his front door with tips about who is using, making and selling drugs including heroin, meth and the synthetic drug known as bath salts. “Every time you turn around, you hear about a new drug coming out,” Smith said.

The HIV outbreak in Indiana was tied exclusively to abuse of the pain medication Opana. Its users were sharing needles and having sex with each other, leading to the rapid spread of the disease.

The Wolfe County sheriff’s department has seen similar risky behavior. “A lot of them are using needles over and over again,” said Smith, who likened the activity to a more dangerous version of a group of men getting together to share a bottle of whiskey. Instead of swapping saliva on a bottle cap, users are exchanging all types of body fluids and pushing a needle coated with those fluids into their bodies.

While this type of risky behavior has made injection drug users one of the most vulnerable groups to contracting HIV – alongside sex workers, men who have sex with men and transgender people – HIV rates among the injection drug users in the US dropped from a peak of nearly 35,000 infections annually in the late 1980s to just 3,900 new infections in 2010, according to the CDC.

And before the opioid abuse epidemic, those cases had been almost completely confined to urban areas that have since been armed with needle-exchange programs and extensive, affordable testing. But needle exchanges have long been controversial in the US, especially in the conservative states where opioid abuse is most prominent.

In Indiana, Governor Mike Pence, the Republican vice-presidential nominee, scrambled to respond to a crisis experts there had warned was brewing. He made needle exchanges temporarily legal and emergency funds were directed to setting up an HIV response team in Austin, which had one primary care doctor.

Kentucky saw what was happening in Indiana and became the first state in the south to make needle exchanges legal in March 2015. These exchanges offer clean needles to users, and experts say it is one of the most effective public health measures for any disease. Donald Davis, co-founder of Harm Reduction Kentucky, said it is also a scientifically proven pathway to treatment.

But Davis warned that introducing these programs is a slow process, particularly in rural areas. “There are small towns there where everyone knows everybody, everyone is having unprotected sex together, but there are no syringe exchanges, no harm reduction programs, in those particular counties and in a lot of other countries in Kentucky,” Davis said.

Davis opened a needle-exchange site in Louisville last year with a budget for 500 people in the first year. As they approach the first anniversary, more than 3,800 people will have participated in the exchange.

In the wake of the Indiana outbreak, these efforts are enthusiastically supported by the state health department, as are increases in HIV testing.

The clinics in Campton have dramatically increased HIV testing since seeing the CDC report. Lisa Santos, a nurse and clinic manager at St Luke’s clinic, said there have been more than 228 tests since 1 April and there were new HIV positives in that group.

Hoven said surveillance for any significant changes in local HIV rates is ongoing. “Just this past summer, we have seen a few upticks which have been investigated,” Hoven said.

None of these incidents were found to be an official outbreak.

Clinicians in Wolfe County said that funding for education, testing and primary care would go far to alleviating this problem. At St Luke’s clinic, Santos said 52% of the patients are on the government-funded healthcare Medicaid, 35% are on Medicare and a few people are privately insured. “The only way we are going to be able to combat this is with funding,” Santos said.

The Obama administration heard the call for funding to fight the opioid epidemic and responded in March by announcing $116m for treatment and prevention programs. Yet, earlier this month, the Senate passed the Comprehensive Addiction & Recovery Act (Cara) to combat the opioid addiction crisis, legislation that includes no funding.

Dr Adrian Banks, who works at Campton’s only clinic with doctors who can prescribe addiction treatment drugs like suboxone, agreed that the community’s drug users need much more than what these drugs can offer.

    

Primarily, jobs. “The two problems feed off of each other,” he said.

Banks was raised in Campton, left his hometown for college and returned as a doctor to find it overwhelmed by drug use.

Now, he speaks with people who have a history of using hard drugs like hydrocodone at the age of 12 and 13.

“There are people I see who I’ve known my whole life,” Banks said. “I want to help them, I want to help everybody in the community.”

Holly Hagan, co-director of New York University’s Center for Drug Use and HIV Research said there is clearly potential for an outbreak like the one in Indiana to occur in the counties identified as vulnerable by the CDC. “It’s reached into areas where there was really little cause for concern for HIV epidemics in the past,” she said.

Hagan said of the Indiana outbreak: “It was like a community that was poised for the introduction of HIV; once someone entered, there was very little to stop it.”