Yama is typically smoked by putting the drug on creased aluminum foil and then heating the foil until the drug smolders. The resulting smoke is inhaled through a short straw or water pipe. Chewing-gum wrappers, with the paper side burned off, are a popular and inexpensive foil source.

Thether smoked, snorted or injected, amphetamines can do more than rot teeth and

wreck health. Experts fear use of these drugs may soon cause a surge in Cambodia's

declining HIV-infection rate - if it hasn't already.

"I'm positive the AIDS rate is going to rapidly increase if there isn't immediate

[drug] intervention," said Graham Shaw, program officer for the United Nations

Office on Drugs and Crime (UNODC). "But it might be too late."

Though researchers in Cambodia have only recently begun to analyze the link between

HIV and amphetamine users - which make up 78 percent of all the country's drug users

- most say their initial findings are disturbing.

As the use of amphetamine-type stimulants (ATS), such as yama, increases in Cambodia,

several soon-to-be-released studies have found a rise in risky sexual behaviors associated

with ATS drugs, Shaw said. The issue surfaced in research done by the World Health

Organization (WHO), UNODC and the UN Population Fund.

The increase in drug-fuelled sexual risk-taking could have significant implications

for Cambodia, which already reports one of the highest HIV-infection rates in Asia,

said Dr. Massimo Ghidinelli, HIV/AIDS advisor for the WHO.

Mith Samlanh/Friends, an NGO which assists young people who live and work on the

street, compiled recently collected data related to the ATS-HIV link at the Post's

request.

"The results were frightening," said David Harding, who analyzed Mith Samlanh's

statistics. "We had known that there were increasing levels of HIV infection

among ATS users, but we didn't know it was this severe."

A recent sample of 173 street youth using ATS showed that 28.3 percent tested positive

for HIV. When Mith Samlanh conducted similar research last year, the organization

found that around 12 percent of ATS users were HIV-positive.

"This potential jump is something we've been waving the red flag about for awhile,"

Shaw said. "The numbers show what's actually happening."

Mith Samlanh's most recent study also found that the HIV-infection rate for non-ATS

using street youth fell around 11 percent.

"This seems to suggest that people using ATS have almost three times as high

a chance of getting HIV," Harding said.

Street youth are already particularly vulnerable to HIV infection because they often

engage in prostitution, but Harding and Shaw both said the figures were relevant

for the population at large.

"We plan to release a report about these findings next week," Harding said.

"It could create some ripples in international drug work communities."

The viagra effect

In many countries, the connection between drug use and HIV transmission isn't new.

For the last two decades, the international scientific community has acknowledged

that injecting drugs is a highly efficient way to spread the virus.

But in Cambodia, around only two percent of drug users inject. Such a small number

couldn't drastically affect the overall HIV rate of street youth taking ATS, Harding

said.

There's another factor: sex.

Drug users throughout the world have long considered ATS drugs sexual stimulants

and performance enhancers.

"It's known widely as having a 'Viagra Effect', and dealers in Cambodia also

market it that way," Shaw said. "They say, 'it'll make you strong; you'll

be more attractive; you'll have great sex'."

Crystal methamphetamine, a form of ATS found in Cambodian yama pills, has several

effects on male sexuality, said Dr. Steve Shoptaw, a research psychologist at the

University of California, Los Angeles, Integrated Substance Abuse Program. The drug

often stimulates libido, provides focus for sexual activities and offers a stamina

boost, enabling men to maintain erections for hours at a time. But long-term use

can cause impotence, a phenomenon referred to as "crystal dick" in the

United States.

Researchers know less about marketing of ATS to women in Cambodia. While there are

relatively few female drug users - 5 percent of the using population - they tend

to take the drugs more frequently than men do.

"Some women in the sex industry are forced by pimps or brothel owners to use

the drugs," Shaw said. "It keeps them indentured. If nothing else brings

them back, the addiction will."

Others use the drugs willingly, often to disassociate themselves from the sexual

act, or to endure long sessions with clients.

"Girls who have spoken with Mith Samlanh are taking ATS not to aid sex, but

to unfocus it in their mind - it's a blanketing mechanism," Harding said. "Even

if they're not involved in commercial sex work, they use it to distance themselves

from the physical and emotional discomfort."

Though meth also stimulates libido in women, Shoptaw said it was reasonable to assume

Cambodian sex workers generally take the drug for its disassociative qualities. He

said that users in the US often complain it's impossible to make meaningful connections

when having sex on meth.

"The sex that happens is not so much intimate as it is a compulsion," Shoptaw

said.

Potent HIV found in US drug user

Still, attention to the link between HIV and ATS use is relatively new. In mid-February,

reports about a New York man with an unusually virulent form of the virus made international

headlines. The man, who had contracted HIV through unprotected sex with other men,

was a regular meth user.

"This kind of news puts all of us working in developing countries on alert,"

Harding said. "We're dealing with a serious set of challenges."

Even in the United States, the meth-HIV connection has been a low-profile issue.

Though there is little evidence of significant transmission among heterosexual users,

60 percent of homosexual and bisexual men seeking treatment for meth addiction test

HIV-positive, Shoptaw said. Over the last decade, the drug has gained popularity

in gay clubs and bathhouses, fueling high-risk sexual behaviors.

Yet the issue only recently reached the US federal agenda, said Rick Rawson, associate

director of the University of California, Los Angeles, Integrated Substance Abuse

Program. Around three weeks ago, the Centers for Disease Control held its first conference

on meth, gay men and HIV.

Whether or not a comparably dangerous situation will develop - or has already - in

Cambodia is difficult to determine at such an early stage, Shaw said. But he added

that local health and drug experts are "extremely concerned."

For Cambodians using ATS, a combination of risks are in place.

Though not as strong as pure crystal meth, yama, the most popular ATS in Cambodia,

is still a highly addictive drug, said Meas Vyrith, director of the National Authority

for Combating Drugs. One tablet of yama is around 30 percent meth. Cambodian forms

of the drug are derived from the same precursor chemicals as are US versions.

Young Cambodians - many from middle-income families - usually crush and smoke the

pills, Shaw said. Sometimes they mix in other substances, like pure crystal meth,

Vyrith added.

Environmental factors can also be hazardous. Like drinking and karaoke, yama has

been adopted by many youth as a seemingly innocuous weekend activity.

"Groups of young teenagers will meet up in guest houses, buy cheap tablets and

smoke them," Shaw said. "This leads to those kids having sex, with and

without condoms."

Physiological effects of the drug can make users particularly susceptible to HIV

infection. While on meth, people usually have longer and rougher sex, leading to

a greater likelihood of exposure to blood, Shoptaw said. He added that meth also

dehydrates users, which could cause damage and abrasions, especially in women.

Perhaps most alarming of all the potential risks for transmission, local experts

agree, is a general lack of knowledge related to drugs and their effects. Education

about ATS has not kept up with the spread in use of such drugs, Shaw said.

"It's being marketed on the street as a vitamin," he said. "Kids have

no idea what they're getting into."

Such dangerous factors - along with Mith Samlanh's reported increase in HIV cases

- highlight a potentially explosive link between ATS and HIV in Cambodia, Shaw said.

Experts are just starting to take notice.

"My biggest concern is for the massive general population, because groups like

sex workers and street kids already have service providers," Shaw said. "Adding

all the risks together, I wouldn't be surprised to see that downward [HIV-infection]

trend reversed."