被艾滋恐懼吞噬的美國小城

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.

印第安納州奧斯汀——十年前，她開始對鎮痛劑上癮。當時，她在一次車禍中脊柱受傷，醫生在她康復期間給她開了奧施康定(OxyContin)。然後，又出現了一種新的處方麻醉劑Opana，這種藥在外面很容易買，碾碎後效力更強，可溶於水，還可以用於注射。她就是那樣做的，而且每天要用很多次，有時還會與其他上癮者共用針頭。

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.

上個月，這個瘦削的45歲女人得知，這樣做造成了不可挽回的後果。她的艾滋病毒(HIV)檢測結果呈陽性，是靠近肯塔基州北部邊界這個民風保守、以農業爲主的地區的近150例艾滋病毒攜帶者之一。現在，與這裏的許多人一樣，因爲上癮而長期受到困擾的生活已經被恐懼吞噬。

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.

她說，她不敢開始抗逆轉錄病毒治療，因爲她不想被人看到走進主街那家診所，在聽到有個病毒攜帶者經診斷只剩六個月時間後（後經證明是謠言），她甚至不敢去了解自己的預後。還有些藥物使用者完全拒絕接受測試。

“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 She asked that her name not be published out of concerns about being stigmatized.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.”

“我還以爲這是同性戀纔會得的病，”她在近日的一個晚上說，她做過美甲的雙手揉捏着一張紙巾，眼中噙滿淚水。因爲擔心被人歧視，她要求對自己的姓名保密。“我從沒想過，這種事會發生在我家鄉的小鎮。”

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.

這個危機甚至還會考驗一個大都市；儘管有疾病控制與預防中心（Centers for Disease Control and Prevention，簡稱CDC）、州和艾滋病健康護理基金會(AIDS Healthcare Foundation)等非營利組織的幫助，人口僅4200的奧斯汀還是有些不知所措。這裏幾乎對HIV一無所知，而且錯誤信息也很多。相關人士表示，在如何應對它的問題上，當地一些強烈而具有誤導性的觀念，對阻止HIV蔓延的工作造成了阻礙。

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.

外界有專家稱，上個月州長邁克·彭斯(Mike Pence)不情願地批准了一個針頭更換項目，但當地官員的執行不力。本應得到優先待遇的奧斯汀居民仍然必須等待接受藥物上癮治療。此外，讓那些HIV檢測呈陽性的人接受藥物治療，並保證他們能遵守規定，也並非易事。

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.

這裏的官員表示，對教育的需求迫切而深刻；連當地的醫務人員都摸索着工作。斯科特縣(Scott County)的公共衛生護士布里特妮·庫姆斯(Brittany Combs)說，她在與上癮者交談的過程中發現，很多人會使用同一個針頭達300次，直到針頭斷在胳膊裏，她對此感到震驚。有些人還習慣用指甲油標示出自己的注射器，但是由於針頭不多，再加上屋子裏滿是經常一起進行注射的人，所以往往很難避免共用針頭的情況。

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.

庫姆斯還了解到，上個月針頭更換項目開始後，許多上癮者都不願意去往針頭分發中心。4月4日，該中心在城郊開放。所以，她開始直接把針頭拿到社區，給那裏的藥物使用者。

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.

同時，來自印第安納波利斯的HIV專家正在與斯科特縣大量關於HIV的錯誤信息作鬥爭。據調查，這裏幾乎所有居民都是白人，上過大學的很少，五分之一的人生活在貧困之中。目前，這些專家已經對這裏的大約50名病毒攜帶者進行了檢查，並開始對其中20人使用抗逆轉錄病毒藥物。

“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.’”

“奧斯汀仍然有很多人對HIV存在偏見，而且正在對與之相伴的恥辱感和恐懼起到推波助瀾的作用，”在這裏治療HIV患者的印第安納大學(Indiana University)傳染病專家黛安娜·揚諾維茨博士(Dr. Diane Janowicz)說。“我得反覆告訴他們——如果你的孫子想喝一口你的飲料，你可以給孩子喝。在同一張桌子上吃飯也沒有問題。你們還可以共用一個衛生間。”

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.”

揚諾維茨說，這裏許多近期確診者的血液病毒含量都高得驚人。還有一位患者的HIV已經發展成了艾滋病(AIDS)。她說，不過，“如果他們使用針對HIV的藥物，這就是一種慢性疾病，不見得一定會死於這個病。”

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.

另一個問題是，針頭更換項目在當地遭到了強烈抵制。身爲共和黨人的彭斯對此類項目基本上持反對態度，說這樣會使藥物濫用的行爲延續下去。這裏的許多居民也這樣認爲。

“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.”

“如果你去年問我是否支持針頭更換項目，我會說你瘋了，”庫姆斯說。“與許多人一樣，我認爲這是在給藥物使用提供方便——你把針頭分發出去，爲他們使用藥物的習慣提供幫助。但是，我隨後我做了一些瞭解，有28年的研究可以證明這樣做真的有用。”

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.

但研究人員稱，斯科特縣匆忙創建的更換項目有幾個地方會嚴重影響它的效果。要獲得乾淨的針頭，藥物使用者必須登記，用出生日期和名字中的幾個字母來創建一個識別碼，這個碼會印到一張塑封的卡片上。然而，任何有針頭但沒有卡片的人，一經發現就會被警察逮捕，理由是這樣會促使更多人蔘與更換項目。

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.”

紐約西奈山以色列堂醫院(Mount Sinai Beth Israel)化學品依賴研究所的研究負責人唐·德夏萊(Don Des Jarlais)說，最成功的針頭更換項目會讓參與者把注射器傳遞給身邊那些仍然躲在暗處的人，而不是要求每個人去登記。逮捕那些沒有在這個項目中正式登記的藥物使用者，“會導致很難建立起信任”，德夏萊說。他還表示，“如果設定這些限制，你就無法把足夠多的注射器分發出去，從而真正阻止病毒的傳播。”

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.”

當地支持針頭更換項目的人表示，有限制的項目總比完全沒有這類項目好，而且他們認爲隨着時間流逝，事情將出現改善。上週，州立法機構向彭斯提交了一個提案。根據該提案，當一個社區因爲靜脈藥物注射而出現HIV或丙型肝炎的廣泛傳播時，可以創立一個長達一年的針頭更換項目。彭斯稱，他將簽署這一提案，並在一項聲明中指出，它將只批准“有限且可問責的”針頭更換項目，而且只在“出現公共健康危機的前提下”進行。

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，這裏的項目每週最多向每個藥物使用者發放140個乾淨針頭，發放對象是每個來到推廣中心，或者從流動的小型貨車上拿針頭的人。庫姆斯說，有人告訴她，他們每天會注射多達15次，而這個更換項目寧願提供略微超出人們需求的數量。她曾去一戶人家發放針頭，這家的主人是一個年紀稍大的女性，名叫莫瑪(Momma)；莫瑪坐在門廊上，有人不停地來到這裏，到裏面進行注射。庫姆斯還曾敲過一個拖車式活動房屋的門，她說，“好幾個家庭成員都住在裏面，家裏的女兒都會去賣淫，每個人都在用毒品。”近日的一天下午，在一條瀰漫着紫丁香香味的街道上，一名騎自行車的年輕女性拒絕了庫姆斯提供的乾淨針頭，她說自己已經有了一些，而且自己已是HIV攜帶者。

“I know I need the medicine to slow it down,” she murmured.

她低聲說道，“我知道我需要藥物來延緩病情發展。”

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.

這名檢測呈陽性，而且害怕開始治療的女性表示，HIV的蔓延帶來了一個意想不到的好處：那些曾經每天涌入城裏，尋找年輕的女性用藥上癮者的男性幾乎都消失了。他們之所以來這裏，是因爲上癮者會用性服務來換取毒品錢。

“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.”

“最終HIV改變了我們的城鎮，”她說。“我們這些受感染的人被毀了，但我很高興HIV來到了這裏。”