Sertraline, Sickness, and Stigma: Conducting a Clinical Drug Trial in Uganda
What does Zoloft (Sertraline), a prescription anti-depressant you may have seen commercials for in between Jeopardy rounds, have to do with people suffering from meningitis in Uganda? Much more than you would think.
In collaboration between the University of Minnesota and several Ugandan medical organizations, the clinical drug study dubbed the A.S.T.R.O. study (Adjunctive Sertraline Treatment for Cryptococcal Meningitis) hopes to find new and more accessible means to treat patients with Cryptococcal Meningitis in low income areas. Sertraline is commonly used as an SSRI antidepressant in the United States but is known to have anti-fungal properties, which leads to the study’s hypothesis that adjunctive Sertraline will lead to faster fungal clearance and an improved 18-week survival rate.
Meningitis is a debilitating acute inflammation of the brain and Cryptococcal Meningitis (crypto for short) is a specific type of meningitis caused by the fungus Cryptococcus neoformans. Crypto cripples impoverished Africa as it rivals TB in mortality in the area. To put it in perspective, I see more cases of crypto in a day than 99% of American doctors will see in a lifetime. Well over half of individuals with Cryptococcal Meningitis will die within 10 weeks if not given proper treatment. While the study is certainly combating Meningitis, it remains only a symptom of a much larger and more serious HIV epidemic. Nearly every single patient the study has seen with crypto has been HIV positive. With HIV comes an entirely new set of challenges including stigma, misconception, and a severe lack of education. The ASTRO team fights not only the illness but also the stigmatized mindset behind many of these diseases. Patients attend weekly classes on treatment and receive HIV counseling. Nonetheless, the stigma is still present. Very often, wives who bring in their husbands infected with HIV/crypto ask to be HIV tested. If the discover themselves to be HIV negative, they often abandon their husbands in the hospital mid-treatment never to be seen again.
The day begins with the ASTRO team meeting. Team doctors, nurses, lab scientists, councilors, and everyone else who make the study possible meet every morning to develop a plan for the day and review the patients enrolled in the trial. Fortunately, if an individual is eligible for the ASTRO study, he or she will receive significantly more attention and better care from our team who fully treat the patient’s issues, not just the crypto. This includes paying for additional medications, CT scans, labs, and more. Unfortunately for the patient, to be enrolled in the study, he or she is likely very, very, sick. After the team meeting, we head down to the Ward and doctors treat every patient individually. A central component of treatment in this study is the lumbar puncture, which I am often responsible in aiding the physicians to conduct. High intracranial pressures are a result of the fungal inflammation leading to symptoms such as stiff necks and headaches. To relieve pressure, the ASTRO team conducts lumbar punctures which are spinal taps to remove cerebrospinal fluid. Spinal taps are vital in treatment for crypto but patients often decline, having developed an association between the procedure and death. To combat this negative association, Nathan Yueh, a friend and student formerly involved with the ASTRO study directed the short film Mulalama (Taking Water). The film follows the struggles of Maria, a young woman that consents to a lumbar puncture for her ill mother despite her fears. The film takes place in our very own Mulago Hospital and I highly recommend a watch. View it here: https://www.youtube.com/watch?v=dVqyj4sgDDA.
Following clinical rounds, the second half of my day is spent recording and analyzing patient charts. As an international clinical drug trial, there is a significant amount of communication and paperwork required both within the study team and also to IRBs. Data is key. Collecting hemoglobin information may appear to be irrelevant in a drug trial for Sertraline but it may contain enough information to spark an entirely new study.
The days can be long and the work somehow follows you home. I admire the Americans who brought their entire lives here to study infectious disease just like I admire the Ugandans who work grueling hours when they likely could be making much more practicing in a private hospital. I feel as if everyone on the study team has a reason to be here. This experience is bringing me closer to unraveling why I need to be here, whether “here” is Uganda, Peru, or Crawfordsville.