See editor’s note below

INDIANAPOLIS – The cost of the HIV epidemic in rural Indiana may reach $58 million or more, and experts worry that the outbreak of the AIDS-causing virus may not be over.

The cost to the state of the epidemic, found among drug users and sex workers centered in Scott County, includes long-term healthcare costs picked up by Indiana’s Medicaid program.

Experts say the cost could grow, in part, because so many people who had dangerous contact with HIV-infected individuals have refused to be tested.

“We don’t know yet what we don’t know,” said Beth Meyerson, co-director of the Rural Center for AIDS/STD Prevention at Indiana University.

Meyerson has been working with state and federal health officials to track what the U.S. Centers for Disease Control and Prevention calls the largest HIV outbreak in rural America.

The number of cases, traced back to dirty needles shared among drug users injecting prescription painkillers, has grown to 184 since the virus was detected in rural Scott County a year ago, according to the state Department of Health.

Most of the identified cases are enrolled in the state’s Medicaid program, state public health officials said.

In addition to treatment for drug addictions, they’re receiving HIV treatment at $250,000 to $300,000 for lifetime care.

About 90 percent are also infected with Hepatitis C – a potentially lethal and highly infectious disease that’s also costly to treat, at about $85,000 for a 12-week regimen.

But questions remain about the number of cases still out there.

In early December, state health officials revealed that they tracked others at “high risk” of being infected with HIV from sharing dirty needles or having unprotected sex with someone known to be infected.

Of nearly 500 people at risk, nearly all of whom were previously tested, 120 refused to be re-screened for HIV during a two-week testing campaign.

Another 174 people were not tested during that period because they couldn’t be found, didn’t respond to a testing request, were no longer in Indiana, or were incarcerated in jail or prison and had not been screened for HIV.

Of 181 who agreed to be tested, three were HIV-positive.

“How do know if we’re at the end of this? We don’t know,” said Meyerson, who joined a panel of health and state officials at a legislative preview conference Wednesday in Indianapolis. The General Assembly convenes in January for its 2016 session.

Also on the panel was state Attorney General Greg Zoeller, who echoed Meyerson’s concerns that Indiana has yet to understand the full impact of the outbreak.

Zoeller launched a drug abuse task force four years ago, having seen a rise in arrests and deaths of addicts injecting themselves with prescription narcotics and heroin.

Zoeller said Indiana has yet to see the full force of what he called the opioid-addiction crisis.

“The wave has not crested yet,” he said.

Both Zoeller and Meyerson also questioned the adequacy of the state’s current needle-exchange law, passed earlier this year.

The law allows communities, with state permission, to start programs that make clean needles available to IV drug users, along with counseling.

But that comes with multiple conditions. Communities cannot act until they prove they have a drug crisis. And the law forbids state money from being spent on a needle exchange.

Twenty-two counties have moved toward adopting needle exchange programs, but only three have been approved by the state.

Maureen Hayden covers the Indiana Statehouse for CNHI’s newspapers and websites. Reach her at mhayden@cnhi.com

Editor’s Note: An earlier version of this story included incorrect information about screening of people considered at-risk of HIV infection. In a recent campaign to test 476 people – nearly all of whom had been tested previously – 174 couldn’t be found, didn’t respond to messages, weren’t in-state, or were incarcerated during the testing period, according to the State Department of Health. Screening efforts for those individuals are ongoing. In all, 184 people have tested positive for HIV as part of the outbreak. This story is updated to reflect the correct information.