AUSTIN, Ind. >> On the evening of March 24, 2015, Sheriff Dan McClain got an unexpected voice mail: “This is Gov. Mike Pence calling. I would welcome the opportunity to get your counsel on what’s going on in Scott County.”

What was going on was unprecedented in Indiana and rare in the United States: HIV was spreading with terrifying speed among intravenous drug users in this rural community near the Kentucky border. Local, state and federal health officials were urging the governor to allow clean needles to be distributed to slow the outbreak.

But Indiana law made it illegal to possess a syringe without a prescription. And Pence, a steadfast conservative, was morally opposed to needle exchanges on the grounds that they supported drug abuse.

As McClain called the governor back, the pressure was mounting. The number of new HIV cases in the county was nearing 90.

“Don’t give me any political views, I want to know your opinion,” the sheriff recalled the governor saying.

The sheriff, who was not a fan of needle exchanges, was quick to reply. “I believe the only thing we can do to stop or slow this thing is to get clean needles out there,” he said.

As the Republican vice presidential candidate, Pence brings a long record of social and fiscal conservatism that serves as a counterweight to Donald Trump’s frequently shifting views. But rarely have the governor’s principles been tested like they were during Indiana’s worst public health crisis in years.

Much as his Democratic counterpart, Tim Kaine, had to wrestle with his deeply felt opposition to capital punishment in a death penalty state, allowing 11 executions when he was Virginia’s governor, the HIV outbreak forced Pence to balance strong beliefs against ground-level reality: an epidemic that was growing more dire by the day.

In recent interviews, local, state and federal health officials said Pence initially held firm. So as they struggled to contain the spread of HIV, the officials embarked on a behind-the-scenes effort over several weeks to persuade him to change his mind, using political pressure, research and pleas for help from this remote, poor community.

On March 23, more than two months after the outbreak was detected, Pence said he was going to go home and pray on it. He spoke to the sheriff the following night.

Two days later, he issued an executive order allowing syringes to be distributed in Scott County.

Tens of thousands of them were handed out over the following months. And the program, along with drug therapy and aggressive outreach, slowed the flood of new HIV cases to a trickle.

State Rep. Ed Clere, a Republican who was among those pushing the governor to approve the needle exchange, said he was relieved when Pence finally did so. He also wished it had been done sooner. “It was disappointing that it took so much effort to bring the governor on board,” he said.

But Jerome Adams, Pence’s health commissioner, said the governor needed certainty that he was doing the right thing.

“The governor wanted to make sure if we went this route it was absolutely necessary,” Adams said. “I believe he was praying on it up until the final decision.”

A MORAL QUANDARY

The debate over needle exchanges, in which clean syringes are given to drug abusers when they turn in a used one, has raged since 1988, when Sen. Jesse Helms, R-N.C., persuaded Congress to ban the use of federal money for such efforts. Pence, who declined to be interviewed for this article, supported the ban during his six terms in the House. And Indiana was among nearly two dozen states to criminalize the distribution or possession of needles without a prescription.

Even when the HIV outbreak hit, it was hard for Pence and other Indiana officials to consider lifting the prohibition.

“There are people who have real moral and ethical concerns about passing out needles to people with substance abuse problems,” Adams said. “To be honest, I shared that sentiment.”

Brittany Combs, the public health nurse in Scott County, had the same initial reaction. “Even I, as a public health person, was like, ‘Aren’t we just enabling people?’”

But the HIV crisis in Scott County was swift, severe and extremely troubling to those who glimpsed it.

High rates of poverty and painkiller prescriptions had ushered in a wave of opiate addiction. When the makers of the drug Opana, a narcotic, reformulated their pills to make them harder to crush and snort, abusers of the drug began injecting it.

“Three or four of us would be using the same needle,” said Melissa Sword, 30, who lives in a neighborhood of sagging homes here known as the North Side. “Someone would pull a needle out of their arm, and I’d take it to the sink, wash it and use it.”

AN UPTICK IN INFECTIONS

Five people tested positive for HIV in the last seven weeks of 2014 in Scott County, which rarely saw a single new case in an entire year. Then in one week in mid-January, eight people did.

“Everyone we grew up with got HIV in a matter of months,” Sword said. Her boyfriend was one of them.

Health officials quickly traced its spread through networks of IV drug users and began steering those who had been exposed — either through shared needles or sexual encounters — into testing and treatment.

Clere, a Republican known for bucking party leaders, began drafting an amendment to allow the distribution of clean syringes in Indiana.

Studies have shown that needle exchanges do not result in increased drug use among participants or the recruitment of first-time drug users, while they do substantially reduce the risk of HIV infection and other diseases. But Clere could not engage Pence’s staff members on the topic.

“They made it clear that he was categorically opposed to syringe exchange, period,” Clere said.

On March 4, county and state health officials got on a conference call with the New York State Department of Health. The agency explained how the spread of HIV among drug users in New York City had been dramatically reduced years earlier.

“The first thing they said? ‘You need to have a clean needle exchange program,’” Combs, the county nurse, recalled.

But when the topic came up at a community meeting in Scott County the following week, Jennifer Walthall, the deputy state health commissioner, made it sound like an intervention of that kind was not possible, Combs said.

“She said, ‘Let’s focus on the mountains we can climb,’” Combs said.

On March 23, Pence was forced to address the topic head-on at a meeting in the governor’s office with state health officials and doctors from the Centers for Disease Control and Prevention.

“The governor looked to me and he looked to the CDC and said ‘What do we need to do to respond to this outbreak?’” Adams said.

He, for one, was no longer resistant. “The CDC felt strongly, and I agreed, that providing syringes was the appropriate response, that this is an extraordinary situation that requires extraordinary measures.”

Pence found the science convincing, Adams said. But as the meeting concluded, no one was sure what the governor was going to do.

Adams recalled the governor, who is an evangelical Christian, saying, “I’m going to go home and pray on it.”

THE FINAL DELIBERATION

The following evening, Pence and McClain talked for nearly half an hour. “The governor didn’t really give his opinion,” the sheriff said. “He just wanted to listen.”

The next day, Pence traveled to Scott County to hear from other locals, and many of them echoed McClain’s belief that a needle exchange was needed.

While the governor was downstate, Clere was applying pressure back in Indianapolis, holding a hearing with experts who testified about the value of distributing clean needles.

Some legislators were confused as to why the governor was not supporting legislation that would allow for a syringe exchange in Indiana, with one Republican lawmaker asking, “He doesn’t recognize this as a crisis?”

Walthall, the deputy health commissioner, testified that Pence was considering declaring a public health emergency for Scott County and allowing a temporary needle exchange program limited to that jurisdiction.

“This is a heroic moment,” she said. “The quickest way to stop HIV spread that is through needles is to get rid of dirty needles. The only way to do that quickly and effectively is through an emergency needle exchange program.”

The next day, the order came.

“I will tell you, I do not support needle exchange as anti-drug policy but this is a public health emergency,” the governor said at a news conference announcing the order.

Combs was soon traveling the streets of Austin, Indiana, in an SUV, distributing needles to those who did not feel comfortable coming in to get them. At first, the drug users were skeptical. Then, one day, she and a colleague pulled up in front of a house, and a girl rose from her seat on the front porch and walked down to accept a clean syringe.

“When we looked up, there were people coming from every house on the street,” Combs said. “They swarmed the van.”

Since April 2015, more than 270 people have enrolled in the program, and more than 97,000 sterile syringes have been distributed and returned.

Today, the needle exchange program is seen as playing a major role in halting the outbreak. From November 2014 through the following August, 181 people who lived in or used drugs in Scott County tested positive for HIV, according to a study of the outbreak published last month in the New England Journal of Medicine.

In September and October, not a single person tested positive.

Pence signed legislation in May 2015 extending needle exchanges to other counties experiencing an epidemic of HIV or hepatitis C. And this year, Congress lifted most of the ban on federal funding for needle exchanges.

Public health experts in Indiana were relieved by the governor’s change of heart, but some wished he had acted faster and done more. No state funding was made available for needle exchange programs.

“He made it an uphill battle,” said Beth Meyerson, a health science professor at Indiana University and co-director of the school’s Rural Center for AIDS/STD Prevention.

But for those who saw the issue as Pence did, it was a wrenching decision not to be handled lightly.

“Before this I never would have considered needle exchange,” McClain said. “But once this outbreak happened, it became clear it was one of the main ways to stop the spread.”

© 2016 The New York Times Company