What’s happening in West Virginia shouldn’t be a surprise. After a hepatitis C and H.I.V. outbreak in Scott County, Ind., in 2014 and 2015 that was fueled by deindustrialization and opioids, the C.D.C. released a list of 220 counties similarly vulnerable to such outbreaks among people who use intravenous drugs. The densest concentration of those counties is along the Appalachian Trail, with 28 of them in West Virginia — more than half of the state’s 55 counties.

“There is no way that doesn’t wind up as an H.I.V. outbreak in the state,” Ms. Young says. Yet unlike in places like New York — with its comprehensive sex education; efforts at queer- and trans-specific public health; embrace of public syringe exchanges; and what its health commissioner, Oxiris Barbot, describes as a “sex positive approach” — when it comes to confronting its H.I.V. epidemic, rural America is ill-prepared at best and antagonistic at worst.

For instance, despite research showing that syringe programs are effective at limiting transmission of H.I.V. and encouraging people to enter drug treatment, two cities in West Virginia — Clarksburg and Charleston — have recently moved to close or limit their needle-exchange programs. Negative press, business worries and conservative approaches are among the reasons the programs have been reduced when they urgently need to be expanded (along with statewide testing and education about preventive H.I.V. medication).