Federica Santoro 0:15

According to the World Health Organization, nearly 38 million people were living with HIV, the human immunodeficiency virus, at the end of 2020. More than two-thirds of those people are in sub-Saharan Africa. Now, the bad news is that there is no cure for HIV infection. But the good news is that with the right treatment and care, it can go from a death sentence to a manageable chronic condition. HIV patients can lead long and healthy lives as long as they keep taking their medicines. But as with any chronic condition where we want people to stick with their therapy for life, we must acknowledge and manage any side effects. My name is Federica Santoro, and this is Drug Safety Matters, a podcast by Uppsala Monitoring Centre, where we explore current issues in pharmacovigilance and patient safety. Joining me today is Henry Zakumumpa, Senior Research Fellow at Makerere University School of Public Health in Uganda. With funding from Uppsala Monitoring Center and Carta, the Consortium for Advanced Research Training in Africa, Henry has been investigating the potential harms of HIV therapies. On a recent visit to Uppsala, he told me all about his work and the broader challenges of pharmacovigilance in Uganda. Hi Henry, welcome to Drug Safety Matters and to UMC actually, because you're visiting our offices in Uppsala this week. How are you finding it so far?

SPEAKER_00 1:59

It's exciting to come to Uppsala Monitoring Center. It's a surreal feeling to be here to meet the people behind the name. So I'm excited to be here.

Federica Santoro 2:08

So today we're talking about a topic that's dear to your heart, and that's the safety of HIV medications, with a particular focus on Uganda, obviously, where you're based. But before we go into the details of your research, let's take a step back so that we make sure everyone's on the same page. What treatments are available for HIV these days?

SPEAKER_00 2:32

So for HIV treatment, they are really good combination therapy. So in Uganda it's called TLD. There are three classes of drugs that are combined. So for every person with HIV in Uganda, actually, they have to take dilutogravia or DTG because it's the first-line and second-line drug. The third line drug is available as an option, but in Uganda it's not very widely because it's very expensive. So in Uganda, there are very few providers who give uh third-line HIV treatment. So for most patients in Uganda, it's dilutography-based HIV treatment.

Federica Santoro 3:05

And WHO's recommendations nowadays are to start treatment as soon as possible once you've been diagnosed with HIV. And that's both so that you can stay healthy and you can avoid infecting others. But starting therapy isn't always easy. The countries that are worse affected by HIV are also among the poorest in the world, unfortunately. And in some communities, there's still a lot of stigma and prejudice about the disease. So let's talk about those barriers a little bit. How easy is it for people to accept, first of all, that they need HIV therapy? And then how easy is it for them to access those medications?

SPEAKER_00 3:47

Well, I think those are good uh observations already, even before I get in here, because we have a huge problem of HIV in Uganda. We have, I think, uh 1.6 million Ugandans who are living with HIV, and uh about 1.4 million of them are actually accessing treatment. Now, there's always a struggle for people who have HIV to first of all accept that they have a condition. There's a lot of psychological denial, stigma, psychosocial acceptance is a challenge for many people because this is uh a lifelong illness. So for someone to come to terms with it, to accept it, uh it really takes a lot of counseling. So counseling number one is very critical. And we have seen people where who get to know that they're HIV positive, but they have no counseling, they kind of overreact. Some even commit suicide. So, in fact, in Uganda now, it's a requirement that before someone is tested for HIV, they are supposed to be cancelled and told that this is not a life sentence, that this is a chronic condition, you can live with it. And you're not the only one with HIV. So canceling is critical. It's maybe the most important intervention before even talk of drugs, actually. And now because we had a high number of Ugandans leaving with HIV, it was a struggle to get drugs for everyone. So actually, uh before 2004, access to HIV treatment was only for the rich top government officials and the wealthy. But in 2004, uh, Uganda was fortunate. We got a US government program called PEPFA to support uh heavily affected countries with HIV with substantial external donor aid so that they would be enabled to provide free to user HIV care services at routine points of care. So Uganda fortunately was one of the recipients of that aid. So beginning 2004, June, HIV treatment in Uganda, as I speak now, is free to user. So if you want to get HIV treatment, you don't have to pay, especially for the drugs. Uh most of the HIV treatment funding is paid for by the donors. However, the Uganda government also has, I think, about uh 35% contribution to the cost of treatment. So uh we have good uh coverage of treatment, but it's not just 100%. But uh we are meeting you need targets for at least 90% access to HIV treatment. So that's a good thing. But also I should mention that uh HIV treatment is not only about drugs, it has a lot of many angles, many things that have to be covered, things like opportunity take infections. When you get HIV, you can get TB, you can get uh skin cancer called carposisar coma. So it presents with many challenges to the patients. So besides the drugs, if you don't adhere very well, you get immunity problems. And when your immunity is low, then you're susceptible to illnesses. So we have issues with some people in Uganda who don't adhere to HIV treatment, so then they need a lot of uh treat management of opportunistic infections because of their weakened immunity. So those ones now need more money, so out of pocket. So if you are a working mother, you are a father, you have to dip in your pocket to get money to pay for your medicine. But overall, uh the most critical parts of antiretroviral drugs are ideally funded 70% by donors and 30% by the Uganda government.

Federica Santoro 6:52

And as you said right at the beginning, the currently recommended treatment for HIV is based on the antiretroviral drug Dolutegravir or DTG. And that was rolled out as recommended by WHO in 2018 in Uganda. You then set out to understand how patients react to this drug compared to previous HIV therapies. What are the most common side effects of anti-retroviral therapies in general, and what did you find out about DTG specifically?

SPEAKER_00 7:26

Actually, thanks to UMC, we were able to get funding to go to the field. There was uh uh a shortage of money for people to do research because we are depending a lot on clinical trials, which were done in European countries mostly. So, but when we went to the field, we were told that uh the most common uh side effects or adverse drug reactions are one is hypoglycemia. Some people call it diabetes. So sometimes it induces uh new onset diabetes in some patients. And they told us about 5-10% may develop this diabetes. And then uh the second, I think, most common uh side effect was insomnia, uh inability to sleep. So some patients uh when they take this drug, they can't sleep at night, they have trouble sleeping. And uh for some people, really it's a huge, huge problem. If you cannot sleep at night, then you can't do your normal work, you can't go to the market in the morning. So it's kind of a disability if you get it. Then also we're told there is also uh a weight gain. So when you take this drug amongst some patients, you really gain weight. And uh we went down to the facilities and actually saw some of them, and they showed us pictures before DTG and after DTG. And some of them really put on a lot of white, actually. They become uh chubby, and you know, uh, if I saw you, Frederica, for example, after uh three weeks, you look different. You put on white. We also saw reduced libido. So this drug, uh, I think without question, also in some patients causes reduction in uh interest in sex. So there are sexual desire disorders, and in both sexes. So we uh we are told in a few weeks of transitioning to this new drug, people lose interest in sex, and ladies actually even lose interest in uh their male partners, their husbands, their long-term girlfriends, your boyfriends. You feel you have no attraction, emotional attraction, psychosocial attraction is diminished completely. We even saw some ladies who moved back to their father's houses. So it's even bringing some marriage breakups. So uh do that some, I think those are the most common side effects we found in our study. There are also many other small uh problems, headaches, dizziness, uh neuropsychotic uh problems. There are really so many of them, but uh, the most common were hyperglycemia, insomnia, weight gain, and reduced libido.

Federica Santoro 9:38

And those are all pretty serious. I mean, they impact a patient's life considerably. So, how are you hoping your findings will benefit patients and maybe the HIV program as a whole?

SPEAKER_00 9:49

Yeah, so first of all, I think uh our findings are timely. Because uh when uh we started this research, incidentally I was not involved in pharmacovigence, actually, to be honest. You know, I was an HIV services researcher, and I had to work very closely with the head of HIV treatment in the Ministry of Health in Uganda. So it was around this time when they're rolling out DTG. So she kept telling me, Henry, people are calling me or phones are ringing off the hook. There's a problem with this new drug. Some patients are dying, people are getting diabetes. But Henry, we don't have money to do research. So that's when I got interested, actually. And uh, we looked for money, we didn't get money, and the American government was not interested. I mean, because they weren't pushing for DTG. So fortunately, uh UMC put out a call just a year later, I think it was early 2020. So, from that state of ignorance or rumors about this drug, not having any data, all of us who thought this was uh a catastrophic drug. And so what has happened is now we have, I think, had some understanding. And uh what our studies show is that actually the majority of people who take this drug actually they are safe. But however, there is also a significant population, a number which is not negligible that is affected by this drug, who develop hyperglycemia, who develop insomania, and all these other problems. So, what has happened already, first of all, the National Drug Authority of Uganda has been part of our research. So they know our results. They have been part of the actual investigating team. In fact, they were involved with us in data collection across Uganda. So, number one, some things have changed. Fortunately, the national treatment guidelines have changed now. Initially, they were asking people to be enrolled on both DTG and another anti-tuberculosis drug called IPT or isoniazid preventive therapy, which was causing also toxicities, drug toxicity in some patients. The guidelines now say do not initiate people on both these drugs. So, first of all, guidelines are changing, all right? Number two, we are continuing to engage the donors uh through the NDA, the National Drug Authority, to ensure that they are more flexible in their push for DTG and importantly that there are alternative regimens. Actually, as I mentioned earlier, that many people are doing well on uh the older drug, actually, the fiverance-based HIV treatment. So now we are pushing that there are some available stock in health facilities in Uganda. So that people who get problems can then be switched back to the old drug and they'll have no problem. The drug stocking in Uganda has all been DTG because of donor targets. People didn't even have an alternative to go back to. So we are pushing for alternatives to have that. And also, I think with there's also an increased awareness by the Minister of Health that DTG can cause diabetes in some patients. So now health workers or clinicians are more aware that they should do baseline glucose testing. So they now know, which they didn't know uh three years ago, that before you enroll someone on DTG, please take a baseline glucose test, all right? So that they can know that they have underlying diabetic conditions and therefore not switch them on DTG or choose, modify their regimens accordingly. So this research has helped us in many ways. It has one increased awareness, both by the register authorities in the National Drug Authority and Ministry of Health, two, even among the frontline health workers, the clinicians who offer this care to our patients. So they now know that this drug, some patients do react to it, and therefore they should be cautious in whom they enroll it on. So the national guidelines are also changing. And we also were fortunate to be able to get uh additional funding from the WHO through our research team to see how to improve pharmacovigilance among patients, uh, where patients themselves uh can report these side effects on behalf of their colleagues. So we are rolling out already an intervention to increase reporting of this uh HIV medication among fellow patients. Because also we have the problem of under-reporting. People may get a bad reaction but not report it. So there's people don't even know that people are actually having a problem with uh this joint drug. So when they report, then we get sufficient uh data to take action, either to switch them off or to change their treatment guidelines. So I think this study has helped us in multiple ways.

Federica Santoro 13:54

I have lots of follow-up questions, but I'll start with this one about donors. You've said now a couple of times anti-retroviral therapies are expensive and African countries rely heavily on external donors to fund HIV programs. How aware are they of the importance of pharmacovigilance? Because a recurring theme when we discuss pharmacovigilance in public health programs is how detrimental poor safety monitoring can be on such programs. How aware are donors that it's important to recognize and manage side effects?

SPEAKER_00 14:32

Yeah, that's a good question, actually. Uh, how aware are donors about pharmacovigilance? Because one, we find from our research that the donors they kind of relegate matters of pharmacovigilance. They are secondary, they're in the background. Number one is because they set very stringent targets to providers at the facetal level to enroll the majority of their patients on DTG. Of course, we understand their interests around saving costs because DTG is cheaper because it's one pill per day. So if you have been taking six pills and you're taking one pill, that results in savings in terms of procurement of drugs. So we understand where they're coming from, you know, in terms of cost efficiencies, programmatic efficiencies. So uh we feel they have uh relegated matters of patient safety. They have taken on a very ambitious uh programmatic uh agenda of rolling out of a hundred day roll out of this and that, but they are, I think, uh not appreciating pharmacovigence as much as they should. So uh I wouldn't say that uh these people are totally ignorant about pharmacovigence because actually some of the PEPFA country office in Uganda is made up of medical doctors and clinical specialists in HIV, who ideally should know better. But also, as I mentioned earlier, is that sometimes these donor agendas are set globally at a higher level. And sometimes the the national PEPFA team only has to follow uh guidelines from Washington, D.C., for instance. So their decision space is kind of limited. They have to follow an agenda from above there. So uh even when sometimes they want to do the good thing, they are limited by the orders from above, as we call it in Uganda, you know. But uh I think we need to engage them more. We need to invite them to meetings so that they see, for example, this kind of report I've shared with people, the impact with real life people. They see testimonies from people who have been affected, you know, testimonies from clinicians who offer this care. Because you see, when you don't get the data, you don't see the human beings affected, it's like a distant, abstract thing you're talking about. When they see the impact, I think, to make change. So even us as researchers, as the National Drug Authority, as even Minister of Health, we need to do more to engage donors. Because when you sit in the air-conditioned office and you only read these statistics, you don't have a heart for it. You don't feel it. But when someone engages you, you see the human beings who are affected, whose lives have been lost, then I think they would really feel more obliged to make a change in policy because they have the money. So they can put actually money in pharmacovigilance. I'm telling you, because they're the ones who do the budget. They say we shall spend so much on buying drugs, so much on training health workers. So they can even say, okay, in the next year we are going to put 15% of our budget on pharmacovigilance. So they have it in them to even allocate funding for pharmacovigilance, actually. So but the honors is on us as researchers, as government and other bodies to engage them to come to our side to see why we are all for pharmacovigilance. Otherwise, right now we are all in our cocoons, in our small islands, and nobody's talking to the other. So we need to speak one language to engage each other and uh really. And I think once they know the data, they see the people who are affected, then they will come around, I think.

Federica Santoro 17:39

Let's talk about reporting side effects and the role of healthcare professionals and patients. Let's start with the healthcare professionals and specifically nurses, because in 2020 you published a paper on the role of nurses in HIV management. And you noticed that their responsibilities had basically grown over the years to the point that now they often take on the duties that used to be the prerogative of physicians. How do nurses help out in safety monitoring?

SPEAKER_00 18:09

Oh, that's a great question, actually. Uh, in Uganda, we have uh the WHO says Uganda is among the 20 countries in the world with a what they call a health workforce crisis, shortage of physicians, especially. We actually don't really have a shortage per se, but doctors who complete degrees at Makara University or local universities, the government can't afford to hire them. Because there's competition for doctors by uh private facilities, you know, private uh hospitals, even NGOs, a lot of projects funded by donors which attract medical doctors. So there are few doctors who are in clinical care. They're attracted to where they get better money. So because of that, then we have to rely on non-physicians. So if you are in Uganda and you live in an upcountry town many miles away from the capital, more likely, if you have HIV, you're going to be attended to by a nurse. So nurses are as high as 80% of the Ugandan health workforce. So that's a huge, huge portion of the workforce being nurses. Especially outside the urban centers. And Uganda is predominantly rural. But uh again, coming to your question is nurses, by their training, they are not really deeply trained in pharmacovigilance. So that's the challenge we have actually, because we find that most people who give HIV care in Uganda actually do not have a lot of uh pharmacovigilist training because they're in those roles because of circumstance, you know. You get out of nursing school, you are out there, you are thrust in a role of HIA clinician, you're not trained to be a clinician. So I think what we need to do is to go back to the curriculum of the nursing schools so that they put it in their curriculum and they train them right at the at the stage when they're still in school. So that when the nurses get out, they know what they're talking about, they know the dangers, and they know how to report. And I think would have higher reporting because most workers are actually nurses in Uganda.

Federica Santoro 20:00

How about patients instead? Are they engaged in uh pharmacovigilance activities in Uganda?

SPEAKER_00 20:07

Uh in Uganda, I think what we our study shows actually is that patient rights, patients say, patient voice is not respected, especially in HIV clinics. So even when patients complain or report these adverse drug reactions, they are rarely investigated, they're rarely taken seriously. That's what the patients told us actually, because we conducted research with the patients. They tell the doctors, oh doctor, I I can't sleep because of this drug. I cannot have sex anymore, that the medical workers ignore. They don't empathize with them. So, first of all, empower patients know that they have a right, they say in the decisions around their care to participate in decisions. Two, to sensize health workers know that patients have a right. You have to listen to them. When they complain about something, uh see if it has value, if you can modify. Because, for example, if we learnt that for patients who have sexual adverse reactions after taking DTG, when they revert back to the old drug, a five, that symptom resolves. They regain sexual functioning. So there's a lot that medical workers can do to help alleviate the side effects of patients. But we have a problem of patients not being empowered, not knowing their rights. Because again, you see, the attitude in Uganda is because of the donor culture. It's more like the Americans are paying for your treatment. Why are you complaining? You're getting all these drugs for free. You see, you're taking all these viral tests without paying a coin, you know? There's that uh attitude of health workers. And the patients also tend to buy it. They don't know that they have a right to say, I think I have a problem. Please modify my regiments, please change. So we have uh to empower patients and also to sensitize health workers to know that they have to be more patient centered. They should offer holistic care, not only just dispensing medicines, but also care about the quality of life of patients and make sure the patients are doing well on treatment, not just to viral suppression, viral suppression. But are you happy with your drug? Are you okay? I think we need to uh worry on two fronts, both on the level of the health workers but also on the patient level.

Federica Santoro 22:03

Well obviously one way to learn more about the side effects of medicines that are intended for African populations would be to test them in those populations right from the beginning. But unfortunately that doesn't happen a lot and only very few clinical trials are run in Africa these days. Do you see that changing anytime soon?

SPEAKER_00 22:23

You see I understand pharmaceutical companies are run on economics, on finance, on money. When they are developing a new HIV drug, their primary target Western clients, a patient in Paris, in New York, in London, in Milan, because those ones can pay for their own drugs. Because of course they have to invest money in this drug millions of dollars to come up with a drug. So when they are making clinical trials, they are of course going to try it out in London, in Paris, out of uh 30 people there will be two Africans, you know? And then when the two Africans react they say oh only well 98% of the population is okay with it. So those were just outliers. So I think it's a difficult problem. You really your question is around the political economy. I mean will Africans have enough economic power to have products manufactured for them? Are they able to pay for a product that is originally made for an African patient? So I think the long-term question is we have to grow our economies, improve our per capita income, make sure we produce goods for the world market that can make us fit in the global economy and have a fair share of the world economy so that we can then be able to pay for the things that we need like HIV medicines. But short of that, we're going to still have a problem. However, another approach to do it is uh I saw it from the COVID-19 uh scenario. There was this facet called COVAX where multiple donors put money in a basket fund to support COVID-19 vaccine scale up in the poor world in Africa, in Asia, parts of Latin America. So that's another way we can do it you know if we want to have drugs that are made for Africans then if the Africans don't have the money in the medium term, it is to put up like a basket fund where we can do clinical trials for Africans because I don't see this changing in the next five years, in the next even 10 years. Yeah we shall still have to get the intellectual property for Western pharmaceutical companies and try and get access right through medicine access initiative but not through commercial means until the incomes of Africans do improve.

Federica Santoro 24:32

UMC funded your project on Dolutegrave through CARTA, the Consortium for advanced research training in Africa. How did being part of that network benefit you as a researcher and your work?

SPEAKER_00 24:48

First of all the Consortium for advanced training in Africa is important in my life because I got my PhD funding through CAT as well. The aim of QA is to keep African researchers engaged in research because in Africa we have a problem of uh first of all lack of research funding. So many people get into non-research activities like many lecturers in my career are into consultancies for NGOs for the UN someone's like why should I sit down and write a research grant for six months which I may not even get I can go and write a UNIF report and they get $10,000. So that's a huge problem we have. So what Qata did was trying to change that. And also we found that when many people finish their PhDs, they become heads of departments, they become coordinators of program. And if you look at their publishing record after five years from university, they were publishing when they were doing their PhD after that they're not publishing anymore. So QA's aim was to keep us engaged in research by getting opportunities like this one of UMC where you keep someone really interested in research doing fieldwork engaged. So that has been very important. But also in terms of the network we kind of have multidisciplinary orientation in Qatar. So if you are good at qualitative research good at quantitative research you're a social scientist I am a pharmacist I am a medical doctor I am a clinician I'm an epidemiologist. So you see uh we have all those people in Qatar as long as you're interested in population and public health you get in. So that's a fantastic platform because then you get all these specialities. For example I wanted to do statistical analysis on my data I have a super epidemiologist I have somebody who's very good they are just a phone call away and because we have been trained together because when you do these residential trainings you come together we are normally 25. So you go to Johannesburg for one month you go to Ibada Nigeria for one month you go to Kampala Uganda for one month. So you you kind of develop that bonding you know it's called team building so if I called my friend in Darasalam and say hey John please I have this data run some uh some complicated statistics for me they'll help you. So uh that's the advantage you know having that uh a multidisciplinary team you can lean on now when you need them and uh I mean you really it helps you in data collection in writing papers and interpretation and knowledge translation of your research so really it's a it's a blessing in a way because you can do lots of things which you can do personally but if your friend can do it then you can approach them.

Federica Santoro 27:11

Sounds lovely we're at the end so I have one final question for you what's next so what urgent issues in uh HIV pharmacovigilance would you like to tackle next?

SPEAKER_00 27:26

I knew this was coming what's next after this okay now uh one uh fortunately because of this UMC funding we formed a research cluster at Makara University again multidisciplinary we have pharmacists and people from uh pharmacology and I'm part of it now because when we're applying for this grant they wanted us to get two established uh researchers in pharmacovigilance and so we're able to get these people and we didn't stop at just the UMC grant. In fact as I mentioned earlier we're able to attract another grant from WHO actually because of coming together as a group of people. So what's next first of all is to increase pharmacovigilance reporting there's a real problem there's underreporting CV underreporting so we need interventions around reporting and right there with this WHO grant we're going to try out a PLA'd model where we train patients report side effects on behalf of their colleagues. Because in Uganda we have what we call community based model. So if you are stable on treatment you don't have to come to a facility you can only come only once in six months. So if I get an adverse reaction a drug reaction there may be a delay in reporting so now if I have a colleague he can report on my behalf or he can train me on how to report. So we are implementing this intervention which is exciting and I think the coming two years for this grant so that's exciting for us to see how it's going we have now piloted it in about four regional referred hospitals across Uganda. So we're now going to evaluate this intervention and to see whether we can scale it up and roll it out all over Uganda. So that we hope that's uh an exciting journey to see how to increase patient-led reporting. Because again what we are found is that uh when we talk to the clinicians they told us the side effects that patients suffer. But when you talk the patients they tell you a lot more or something that were underestimated by the clinicians. For example sexual adverse drug reaction we are not told how big a problem it was until we talk the patients. So we're also excited about how we are going to encourage the patients to be involved in reporting. But generally it's really to attract more research funding around interventions. How do we encourage health workers? Health worker says why should I report I reported two years ago nothing happened. What will change if I report every month so you have to say do they need incentives? Do we need to give the best health worker in reporting in this facility every year? So we need to think around interventions, incentives how do we get health workers report more? How do we get patients to report more? How do we get these materials to the facilities? So I think we have to craft very smart, intelligent proposals and approach donors and try and get funding to support us because once there is a we have good proposal we have good interventions I think the donors will come on our side and we shall repilote them. Otherwise there's a need because if you tell me that in Africa the reporting rate for adverse drug reaction is 10% that is catastrophic. I mean people are going to die without people knowing what's killing them. So we have to move up from 10% to something a lot more acceptable. But 10% is not acceptable it's dangerous to the African population we have to scale up reporting.

Federica Santoro 30:24

And I guess that means collaborating closely with the National Pharmacovigilance center in Uganda which you've already been doing for the last few years but what you described will probably mean strengthening those ties then.

SPEAKER_00 30:37

Yes absolutely and I almost forgot actually in Uganda we even have regional pharmacovigilance centers actually and uh we have found some of them are very active some are not active and we found some of them actually just need a little support. Like there's one in the western Uganda in hospital called and I really if I had money I would have put money in those people they're really passionate about pharmacovigilance they actually won an award from the NDA for reporting and they really just want a little support to become active to do more activities to encourage their focus report. So really uh these PV centers are very important because in Uganda we have some centers of excellence in pharmacovigilance at their subnational level. So in the district some districts are better reporters than others. So I think we need to work with them and uh fortunately even the UMC grant I think in the second year where there's a small bit of support of engaging with them. We think we can organize some meetings so we can support them to have meetings and engage them, see what ideas they have and how to support them, whether we can also apply for funding to help them to be more active through exciting projects, innovative projects so that's something again to do after this UMC grant. So it is opening up new channels of work for us hopefully in the coming days.

Federica Santoro 31:47

Lots of challenging but exciting work ahead and we wish you best of luck in your research and thanks a lot for taking the time to talk to us today. Thank you thank you that's all for now but we'll be back soon with more conversations on medicine safety. If you'd like to know more about Henry's research and carta check out the episode show notes for useful links. If you like our podcast subscribe to it in your favorite player so you won't miss an episode and spread the word on social media so other listeners can find us. Apart from these in-depth conversations with experts we host a series called Uppsala Reports Long Reads a selection of audio stories from UMC's Pharmacovigilance magazine so do check that out too Uppsala Monitoring Center is on Facebook, LinkedIn and Twitter and we'd love to hear from you send us comments or suggestions for the show or send in questions for our guests next time we open up for that. For Drug Safety Matters I'm Federica Santoro I'd like to thank Henry Zakumumpa for his time Matthew Barwick for production support and of course you for tuning in till next time