A combination of misinformation, ignorance and social stigma have led to an HIV outbreak in the U.S. state of Indiana, health workers say.

Local health services have been overwhelmed by the 146 new cases diagnosed in the conservative rural region in 2015, compared to just three new cases between 2009 and 2013.

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The outbreak has led Indiana officials to issue an alert to other U.S. health departments to warn them to set up programs top identify and treat HIV.

According to the state's chief medical consultant, Dr Joan Duwve, the virus has spread through the shared needles of drug-users: four out of five people in the outbreak are users of injectable drugs, predominantly prescription painkillers such as Opana.

In Scott County, the epicenter of the crisis, there are only 4,300 residents, and according to the New York Times, diagnosed sufferers are too embarrassed to go to treatment centers or needle exchanges, which would help control the spread.

Furthermore the lack of knowledge surrounding the illness is preventing treatment and prevention.

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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.

“I thought it was just a homosexual disease,” one recently diagnosed sufferer told New York Times.

“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 HIV patients .