The HIV epidemic that now grips Austin, Ind., seemed to come out of nowhere. Since the first diagnosis in mid-December, the number of infected there and in the surrounding region has skyrocketed — 26 by the beginning of March, 72 as of this Wednesday. It’s the worst HIV outbreak in state history, and has local and federal officials scrambling to stem the spread of the disease.

But to William Cooke, who runs the only doctor’s office in this city of about 4,300, this epidemic has been years in the making.

“We identified long ago there was an undercurrent there that was very unhealthy,” he told NBC. Poverty and drug addiction in Austin created “a recipe for disaster.”

Long before the first HIV diagnosis, the city has been coping with another epidemic: intravenous drug use. Used needles can be found strewn across yards and roadsides, but just as often wind up in the hands of other users, contributing to the spread of infection.

In the 10 years since he established his family practice here, Cooke has watched drugs and disease take hold — first the opiate addiction, driven by the trafficking of painkillers up nearby Interstate 65, then the increased rate of overdoses, then the spread of hepatitis C, another blood-borne disease.

“We knew it was only a matter of time until HIV set in,” he told NBC.

On Monday, investigators from the Centers for Disease Control and Prevention were dispatched to Scott County, where Austin is located, to investigate the outbreak and determine whether the virus is a new strain or one that has been circulating for a while. They agreed with Cooke’s assessment that this epidemic is driven by drug use, epidemiologist Pam Pontones told the Associated Press.

Intravenous drug use has been identified as the mode of infection in nearly all of the 72 confirmed cases, she added — the vast majority of those infected shared a syringe with someone else while injecting a liquid form of a prescription painkiller called Opana. All of those infected either live in Scott County or have ties to the area. Austin is considered the epicenter of the epidemic, but the disease could easily spread.

“With the amount of drug use that’s happening and the intravenous needle-sharing that’s going on, if someone who’s highly infectious becomes part of that sharing network, that infection can transmit very rapidly,” Pontones said.

Indiana Gov. Mike Pence (R), who is set to announce a public health emergency in the community Thursday, said he would consider implementing a targeted needle exchange program to combat the disease’s spread. Such programs, which allow people to trade-in used hypodermic needles for clean ones, are currently illegal in Indiana. Pence, a Republican, has previously opposed them as anti-drug policy.

The plan Pence is expected to announce would last 30 days, according to the Indianapolis Star, and would legalize needle exchanges only in Scott County.

“What we’re considering is a surgical strike for the areas affected,” Jennifer Walthall, deputy state health commissioner, told the Star. Pence “is opposed to it as a systematic 92-county solution.”

But many local doctors said such a limited plan falls short of what’s needed. Scottsburg doctor Shane Avery pointed out that hepatitis C cases, which often precede HIV, are already on the rise regionally.

“This could explode everywhere in Indiana,” he told the Star. “It just started in Scott County.”

Cooke, the Austin doctor, spoke at a hearing of the Indiana legislature’s public health committee Wednesday, advocating for a law that would legalize needle distribution and collection programs statewide.

Republican Rep. Ed Clere of New Albany, who proposed the legislation, said a similar law was considered last year but never made it out of the House.

“Unfortunately we’re back here, not just with needle exchange as a hypothetical theory, but with a real situation where a needle exchange [program] could make a difference,” he told the AP.

But a needle exchange isn’t the only program Scott County needs, Cooke said. He is petitioning for an addiction treatment center — right now, the nearest such facility is in the next county over, and many residents lack the means to get there — and for more infectious-disease experts, addiction councilors, cardiologists and pulmonary doctors. He also wants more funds and training for his staff to serve the growing number of HIV patients.

“We need help. But that costs money,” he told NBC. “My clinic serves the poorest people in Indiana, potentially the poorest in the country. … It’s overwhelming how much pain and suffering is going on here.”

Ultimately, he added, officials will need to address Austin’s poverty as well. The city’s drug addiction — and the resulting epidemic — are really about “hopelessness,” he said.

Residents “think there’s nothing to live for tomorrow. And the drugs are so available. This is what happens — here and in other towns in America. It’s not unique to Austin,” Cooke said. “As far as this HIV outbreak, we are the canary in the coal mine.”