Abstract
Background:
Among communities with elevated HIV burden, increased uptake of PrEP, including long-acting injectable (LAI) PrEP, could lower HIV incidence. Lack of data on LAI PrEP interest among transgender women in the United States has limited scientific understanding of the potential impact of LAI PrEP on new infections within transgender communities. Our objective was to determine the percent of transgender women interested in LAI PrEP and identify correlates of interest.
Methods:
Transgender women enrolled in the LITE Cohort who completed 12-month surveys between March 2019 and September 2021 were asked about interest in using LAI PrEP. Prevalence ratios (PR) estimated with modified Poisson regression models were assessed for predictors of interest in LAI PrEP.
Results:
Among 867 participants, 15% were current users of oral PrEP and 11% were former oral PrEP users. In total, 47% reported interest in LAI PrEP. Interest in LAI PrEP was more common among participants who were Black (PR: 1.28; 95% CI: 1.05 to 1.55), college-educated (PR: 1.28; 95% CI: 1.04 to 1.57), food insecure (PR: 1.19; 95% CI: 1.00 to 1.41), and had PrEP indications (PR: 1.44; 95% CI: 1.21 to 1.71). LAI PrEP interest was also more common among adherent users of oral PrEP and those who had discontinued oral PrEP, compared with PrEP-naïve participants.
Conclusions:
Interest in LAI PrEP among transgender women varied by demographic and clinical characteristics. Increased interest in LAI PrEP among Black transgender women, those with PrEP indications, and those who had previously discontinued oral PrEP underscores the need to increase LAI PrEP access for transgender women who are interested.
Key Words: pre-exposure prophylaxis, transgender women, long-acting PrEP, injectable PrEP, HIV, United States, LITE cohort
INTRODUCTION
Long-acting injectable (LAI) PrEP is a highly efficacious HIV prevention product, including for transgender women.1,2 Modeling studies have suggested that among communities with elevated HIV burden, uptake of and adherence to LAI PrEP could expand PrEP utilization, reduce HIV incidence at the community level, and contribute to Ending the HIV Epidemic efforts in the United States (US).3–5
Transgender women—particularly Black and Latina/x transgender women—experience among the highest HIV incidence rates across priority populations within the US HIV epidemic.6–8 Engagement with daily, oral PrEP among transgender women in the United States has been suboptimal, with sociostructural barriers, stigma, and difficulty taking pills associated with lower adherence to a daily, oral regimen.9–12
If widely available and equitably distributed, LAI PrEP could improve PrEP uptake among transgender women not currently using PrEP and address low adherence among transgender women currently prescribed daily, oral PrEP, thereby improving community-level PrEP coverage. However, a lack of data on LAI PrEP interest among transgender women in the United States has limited the ability to understand the potential impact of LAI PrEP scale-up on HIV acquisition in transgender women.
Our objective was to describe the extent of interest in LAI PrEP in a large, multisite, observational cohort of transgender women and identify correlates of interest in LAI PrEP. We sought to characterize the association between interest in LAI PrEP and sociodemographic characteristics, health care access, PrEP experience and indication, and use of injectable gender-affirming care. These variables were selected based on prior literature or because they have implications for combination interventions such as those combining gender-affirming care with PrEP delivery.10–12
METHODS
Study Population
Data were drawn from the Leading Innovation for Transgender Women's Health and Empowerment (LITE) cohort, which launched in 2018 and prospectively followed transgender women with risk factors for HIV acquisition in the eastern and southern United States. Participants were recruited through a multipronged approach, including community-based organizations, clinical sites, online advertisements on dating apps and social networking sites, and peer referrals. Participants completed a sociobehavioral survey and HIV test to confirm HIV seronegative status at enrolment. Additional surveys and HIV tests were completed at least semiannually. Participants were compensated an average of $50 per visit. All study activities were available in English and Spanish. Complete study protocols have been previously published.13,14
LITE participants who completed 12-month surveys between March 2019 and September 2021 were included in this analysis (before US Food &Drug Administration approval of LAI PrEP15).
Measures
To assess interest in LAI PrEP, participants were shown the following text: “Another form of PrEP that is currently being tested is an injection, or a shot, given by a doctor or nurse every 2 months. Instead of taking a pill by mouth every day, studies are underway to determine if having a shot (an intramuscular injection) every 2 months will offer protection against HIV.” Participants were then asked: “If found to be effective, how interested would you be in taking injectable PrEP?” Response options included the following: very interested, somewhat interested, neutral, somewhat uninterested, very uninterested, and do not know.
Independent variables included sociodemographic characteristics such as age, race, ethnicity, census region, education, income level, and food insecurity. Health care access indicators included lack of health insurance at any point in the prior 12 months, type of health insurance at the time of the study visit (public, private, or uninsured), having an established primary care provider, unmet need for gender-affirming care, having a health care provider who is knowledgeable about transgender health, and time since last health care encounter.
PrEP indication was a composite measure based on self-reported behavioral indicators associated with HIV acquisition [(1) sexually active, (2) not in a monogamous relationship, and (3) one or more of the following in past 6 months: condomless anal or vaginal sex, STI diagnosis, engagement in sex work, use of postexposure prophylaxis, or needle sharing]. This composite indicator of PrEP indication was based on Centers for Disease Control and Prevention (CDC) guidelines adapted specifically for transgender women.11 PrEP experience was based on self-reported PrEP use and adherence at each study visit. Participants who reported using PrEP were asked “In the past 7 days, how many days have you taken a PrEP pill?” Those who responded 6 or 7 days were coded as adherent. Partner's use of PrEP was assessed with the question “Have any of your sexual partners told you that they are taking PrEP to prevent HIV-infection?”
Information on prior experience with injectable forms of gender-affirming care was ascertained through two survey items. Participants who reported current use of exogenous hormones were asked how they took their hormones (e.g., pill, patch, or injection) in a select-all-that-apply format. Any participants reporting injection as a mode of administration were dichotomized as currently taking hormones using injection vs not. Participants were asked whether they had ever received injections of silicone or other “fillers” to fill out or feminize their face or body and were dichotomized based on the history of fillers.
Statistical Analysis
The dependent variable of interest was interest in LAI PrEP, which was dichotomized as somewhat/very interested in LAI PrEP versus neutral/uninterested/do not know. We then summarized various characteristics, including sociodemographics, indicators of health care access and engagement, PrEP indication and experience, and prior experience with injectable gender-affirming care, which were stratified by LAI PrEP interest. χ2 tests were conducted to assess for statistically significant differences in proportions between the two groups for each independent variable of interest.
We estimated crude and adjusted prevalence ratios for LAI PrEP interest with sociodemographic characteristics, health care access indicators, prior PrEP experience, PrEP indication, and experience with injectable gender-affirming care using Poisson regression with robust variance. All variables that were significant in bivariate analyses (P < 0.05) were included in the multivariable model along with age, race, ethnicity, census region, education, and type of health insurance, which were identified a priori as important factors to include in adjusted models regardless of statistical significance in bivariate analyses.
Finally, we generated a bar chart to demonstrate the extent of interest in LAI PrEP by prior PrEP engagement—restricting this analysis to just those with PrEP indications. Statistical analyses were conducted in Stata 17.
Ethics
All participants provided written consent to participate, and all study procedures were approved by the Johns Hopkins School of Medicine Institutional Review Board, which served as the single IRB for the multisite study.
RESULTS
There were 867 participants who completed a 12-month survey between March 2019 and September 2021. The median age was 28 years (interquartile range: 23–36). Nineteen percent identified as Black, and 15% identified as Latina/x. Nearly half (45%) resided in the South with the remaining participants residing in the Northeast (42%) and Midwest (14%). Socioeconomic hardships were common with 30% experiencing current food insecurity and 14% having been uninsured in the previous 12 months. A majority (75%) were PrEP-naïve, with 15% reporting current use of oral PrEP and 11% reporting former use of oral PrEP. More than one-third of participants (37%) had a PrEP indication based on adapted CDC criteria (Table 1).
TABLE 1.
Study Sample Characteristics by Interest in Long-acting Injectable PrEP Among Transgender Women in the LITE Study Who Completed 12-Month Follow-up Between March 2019 and September 2021
| Total N 867 |
Somewhat to Very Interested in LAI PrEP n (%) 406 (46.8%) |
Not Interested in LAI PrEP, Neutral, or Not Sure n (%) 461 (53.2%) |
P (χ2) | Prevalence Ratio PR (95% CI)* | |
| Sociodemographics | |||||
| Age (median and interquartile range) | 28 (23, 36) | 28 (23, 36) | 28 (23, 35) | 0.93† | |
| Age group | 0.70 | ||||
| Young adult (aged 18–24 years at enrolment) | 279 (32.2%) | 128 (31.5%) | 151 (32.8%) | 1.02 (0.85 to 1.22) | |
| Aged 25 years and older at enrolment | 588 (67.8%) | 278 (68.5%) | 310 (67.2%) | Reference | |
| Black race | 0.002 | ||||
| Yes (inclusive of multiracial participants) | 159 (18.5%) | 92 (22.9%) | 67 (14.6%) | 1.28 (1.05 to 1.55) | |
| No | 701 (81.5%) | 309 (77.1%) | 392 (85.4%) | Reference | |
| Latina/x | 0.41 | ||||
| Yes (of any race) | 132 (15.4%) | 66 (16.5%) | 66 (14.4%) | 0.95 (0.77 to 1.18) | |
| No | 726 (84.6%) | 335 (83.5%) | 391 (85.6%) | Reference | |
| Census region | 0.44 | ||||
| Northeast | 361 (41.6%) | 161 (39.7%) | 200 (43.4%) | Reference | |
| Midwest | 120 (13.8%) | 55 (13.5%) | 65 (14.1%) | 1.02 (0.80 to 1.31) | |
| South | 386 (44.5%) | 190 (46.8%) | 196 (42.5%) | 0.97 (0.81 to 1.15) | |
| Education | 0.84 | ||||
| High school diploma/general education diploma or less | 207 (24.0%) | 98 (24.3%) | 109 (23.7%) | Reference | |
| Attended some college or higher | 655 (76.0%) | 305 (75.7%) | 350 (76.3%) | 1.28 (1.04 to 1.57) | |
| Income | 0.10 | ||||
| Above the federal poverty level | 507 (58.5%) | 224 (55.2%) | 283 (61.4%) | ||
| Below the federal poverty level | 246 (28.4%) | 129 (31.8%) | 117 (25.4%) | ||
| Unknown (declined to answer) | 114 (13.1%) | 53 (13.1%) | 61 (13.2%) | ||
| Food insecure | 0.003 | ||||
| Yes | 258 (29.9%) | 141 (34.7%) | 117 (25.6%) | 1.19 (1.00 to 1.41) | |
| No | 605 (70.1%) | 265 (65.3%) | 340 (74.4%) | Reference | |
| Health care access | |||||
| Uninsured (during first 12 months of follow-up) | 0.11 | ||||
| Yes | 118 (13.9%) | 63 (15.9%) | 55 (12.1%) | ||
| No | 731 (86.1%) | 332 (84.1%) | 399 (87.9%) | ||
| Insurance type (at the time of visit) | 0.24 | ||||
| Uninsured | 76 (9.3%) | 42 (11.0%) | 34 (7.8%) | 1.12 (0.86 to 1.46) | |
| Public insurance | 321 (39.2%) | 150 (39.4%) | 171 (39.0%) | 0.87 (0.72 to 1.06) | |
| Private insurance | 422 (51.5%) | 189 (49.6%) | 233 (53.2%) | Reference | |
| Have a primary care provider | 0.58 | ||||
| Yes | 600 (70.0%) | 277 (69.1%) | 323 (70.8%) | ||
| No | 257 (30.0%) | 124 (30.9%) | 133 (29.2%) | ||
| Report unmet need for gender-affirming medical care | 0.42 | ||||
| Yes | 75 (10.9%) | 39 (12.0%) | 36 (10.0%) | ||
| No | 610 (89.1%) | 287 (88.0%) | 323 (90.0%) | ||
| Have a doctor very knowledgeable about trans health | 0.12 | ||||
| Yes | 444 (51.5%) | 219 (54.3%) | 225 (49.0%) | ||
| No | 418 (48.5%) | 184 (45.7%) | 234 (51.0%) | ||
| Last health care encounter | 0.81 | ||||
| Greater than 6 months ago | 127 (14.8%) | 61 (15.1%) | 66 (14.5%) | ||
| Within the last 6 mo | 734 (85.2%) | 344 (84.9%) | 390 (85.5%) | ||
| PrEP experience and indication | |||||
| PrEP indication per revised CDC criteria | <0.001 | ||||
| Yes | 317 (36.6%) | 197 (48.5%) | 120 (26.0%) | 1.44 (1.21 to 1.71) | |
| No | 550 (63.4%) | 209 (51.5%) | 341 (74.0%) | Reference | |
| Currently using oral PrEP | <0.001 | ||||
| Yes | 115 (15.0%) | 79 (22.3%) | 36 (8.8%) | ||
| No | 650 (85.0%) | 276 (77.7%) | 374 (91.2%) | ||
| PrEP experience | <0.001 | ||||
| Adherent oral PrEP user (≥6 pills/week) | 89 (11.6%) | 62 (17.5%) | 27 (6.6%) | 1.46 (1.17 to 1.81) | |
| Nonadherent oral PrEP user (≤5 pills/week) | 26 (3.4%) | 17 (4.8%) | 9 (2.2%) | 1.32 (0.93 to 1.89) | |
| Former oral PrEP user | 80 (10.5%) | 50 (14.1%) | 30 (7.3%) | 1.43 (1.13 to 1.82) | |
| PrEP-naïve | 570 (74.5%) | 226 (63.7%) | 344 (83.9%) | Reference | |
| Current partner using PrEP (during the first 12 months of follow-up) | <0.001 | ||||
| Yes | 143 (16.7%) | 92 (23.2%) | 51 (11.2%) | 1.12 (0 92 to 1.36) | |
| No | 711 (83.3%) | 305 (76.8%) | 406 (88.8%) | Reference | |
| Injectable gender-affirming care | |||||
| Currently take hormones through injection | 0.13 | ||||
| Yes | 157 (18.1%) | 82 (20.2%) | 75 (16.3%) | ||
| No | 710 (81.9%) | 324 (79.8%) | 386 (83.7%) | ||
| History of silicone injection (“fillers”) | 0.10 | ||||
| Yes | 46 (5.4%) | 27 (6.7%) | 19 (4.2%) | ||
| No | 812 (94.6%) | 376 (93.3%) | 436 (95.8%) |
All variables that were significant in bivariate analyses (P < 0.05) were included in the multivariable model along with age, race, ethnicity, census region, education, and type of health insurance, which were identified a priori as important factors to include in adjusted models regardless of statistical significance in bivariate analyses. Bold indicates statistically significant adjusted prevalence ratio with a P-value<0.05.
Wilcoxon rank-sum test was the statistical test used to assess for difference in age distribution because this was a continuous variable.
Twenty-three percent of participants reported they were very interested in LAI PrEP, 22% somewhat interested, 19% neutral, 7% somewhat uninterested, 12% very uninterested, and 16% unsure. Those who were somewhat or very interested in LAI PrEP more frequently identified as Black (23% vs. 15%; P = 0.002) and experienced food insecurity (35% vs. 26%; P = 0.003; Table 1). Those who had a PrEP indication based on adapted CDC guidelines were more frequently somewhat to very interested in LAI PrEP (49% vs. 26%; P < 0.001), as were current and former users of oral PrEP (22% vs. 9%; P < 0.001 and 14% vs. 7%; P < 0.001, respectively) (Table 1).
In the final adjusted regression model, interest in LAI PrEP (somewhat/very interested) was associated with identifying as Black (PR = 1.28, 95% CI: 1.05 to 1.55), having attended college or higher education (ref: high school education or less; PR = 1.28; 95% CI: 1.04 to 1.57), and having a PrEP indication (PR = 1.44; 95% CI: 1.21 to 1.71). LAI PrEP interest was also associated with current adherence to oral PrEP (PR = 1.46; 95% CI: 1.17 to 1.81) and discontinued use of oral PrEP (PR = 1.43; 95% CI: 1.13 to 1.82), compared with PrEP-naïve participants. Those experiencing food insecurity were 19% more likely to be interested in LAI PrEP (PR: 1.19; 95% CI: 1.00–1.41). There were no statistically significant differences in LAI PrEP interest for young adults ages 18–24 years compared with those 25 years and older, those who identified as Latina/x, and those who were publicly insured or uninsured compared with those privately insured. The adjusted prevalence ratios and 95% confidence intervals for each variable included in the final model are summarized in Table 1.
Restricting the analysis to only transwomen with PrEP indication, 61% were somewhat to very interested in LAI PrEP (Fig. 1). The proportion expressing interest in LAI PrEP varied by current experience with PrEP. That is, 78% of daily, oral PrEP users were interested in LAI PrEP while just 53% of PrEP-naïve transgender women were. However, despite having comparatively lower levels of interest in LAI PrEP, the largest group interested in LAI PrEP was PrEP-naïve transwomen (86/290 = 30%).
FIGURE 1.
Interest in LAI PrEP among transgender women with an indication for PrEP in eastern and southern United States March 2019–September 2021 (n = 290).
DISCUSSION
In this large, ethnoracially and geographically diverse sample of transgender women in the eastern and southern United States, approximately half reported interest in LAI PrEP, with interest at 61% among transwomen with PrEP indications. This level of interest is lower than that reported in a recent study among transgender women in the Philippines, which found 73% of the sample were very interested in LAI PrEP16 but higher than the 22% of transgender women who reported interest in LAI PrEP in Brazil.17 This level of interest is also lower than that reported in a recent study in the United States, which found that 72% of transgender and nonbinary participants were willing to use LAI PrEP if available (disaggregated data for transgender women were not reported).18 Efforts to increase interest in LAI PrEP among transgender women who could benefit from this HIV prevention tool are needed.
Interest in LAI PrEP among transgender women in our study varied by several demographic and clinical characteristics. The finding that interest in LAI PrEP did not differ based on experience with gender-affirming hormone injections or silicone injections may suggest that experience with other injections and/or comfort with needles are not key predictors of interest in LAI PrEP. Increased interest among transwomen experiencing food insecurity highlights the potential benefit of LAI PrEP for people experiencing material hardships, which is important given the relationship between PrEP adherence and housing instability.9 Increased interest in LAI PrEP among Black transgender women, those who were PrEP indicated, and those who had previously discontinued oral PrEP underscores the need to increase LAI PrEP awareness and access for transgender women who express interest, particularly Black transgender women who bear a disproportionate burden of HIV in the United States.6–8 Findings reflect the potential of LAI PrEP in expanding coverage of antiretrovirals for prevention among transgender women who are PrEP-naïve and have PrEP indications as well as those who have experience with daily oral PrEP.
This study is subject to some limitations. This was a cross-sectional analysis based on self-reported data and is subject to the limitations and biases inherent in such analyses. Data were collected before FDA approval of LAI PrEP. Thus, participants were responding to a hypothetical scenario given the lack of availability in real-world settings at the time of participation. Therefore, it is not possible to speculate the extent to which interest may or may not translate to uptake given the additional factors that are likely to affecy uptake in real-world settings (e.g., cost and distance to closest provider offering LAI PrEP). It remains important to monitor levels of interest and uptake of LAI PrEP among transgender women in the United States in the post-FDA approval period. Our sample was also highly engaged in health care (70% reported having a primary care provider and 85% had seen a health care provider in the past 6 months). Therefore, it is possible that these findings may not be generalizable to transgender women who are less connected to health care. Finally, our sample included a relatively small number of Black and Latina transgender women. Given the racialized inequities in HIV incidence and PrEP uptake in the United States, additional research with larger samples of Black and Latina transgender women are needed.
CONCLUSIONS
Our analysis found moderate levels of interest in LAI PrEP among transgender women in the United States. Higher levels of interest in LAI PrEP among Black transgender women, those who were PrEP-indicated, and those who had previously discontinued oral PrEP underscores the need to increase access to LAI PrEP for transgender women who could benefit from PrEP and express interest. Furthermore, tailored campaigns and interventions to increase awareness of and interest in LAI PrEP may be necessary to achieve high levels of uptake among transgender women.
ACKNOWLEDGMENTS
The LITE study was jointly supported by the National Institute of Allergy and Infectious Diseases, the National Institute of Mental Health, and the National Institute of Child Health and Human Development of the National Institutes of Health under Award Number UG3/UH3AI133669 (A.L.W. and S.L.R.). The LITE study is also appreciative of support from the CFAR at partner institutions, including JHU (P30AI094189), Emory University (P30AI050409), Harvard University (P30AI060354), DC CFAR (P30AI117970), and the University of Miami (P30AI073961). E.E.C. was supported be a predoctoral fellowship from the National Institute of Mental Health (F31MH124582). This analysis was also supported by ViiV Healthcare. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or ViiV Healthcare.
The authors thank the transgender women who took part in this study. This study would not have been possible without their participation. The authors also acknowledge the work of the entire American Cohort To Study HIV Acquisition Among Transgender Women team: Andrea Wirtz (multiple PI; Johns Hopkins University (JHU)); Sari Reisner (multiple PI; Harvard University); Keri Althoff (JHU); Chris Beyrer (JHU); James Case (JHU); Erin Cooney (JHU); Oliver Laeyendecker (JHU); Megan Stevenson (JHU); Elizabeth Humes (JHU); Jeffrey Herman (JHU); Tonia Poteat (University of North Carolina); Kenneth Mayer (Fenway Health); Asa Radix (Callen-Lorde Community Health Center); Christopher Cannon (Whitman-Walker Institute); Jason S. Schneider (Emory University and Grady Hospital); J. Sonya Haw (Emory University and Grady Hospital); Allan Rodriguez (University of Miami); Andrew J. Wawrzyniak (University of Miami); the incredible research teams at each study site; and the LITE Community Advisory Board, including the following individuals: Sherri Meeks, Flora Marques, Sydney Shackelford, Nala Toussaint, and SaVanna Wanzer and those who have remained anonymous.
Footnotes
The LITE study was jointly supported by the National Institute of Allergy and Infectious Diseases, the National Institute of Mental Health, and the National Institute of Child Health and Human Development of the National Institutes of Health under Award Number UG3/UH3AI133669 (A.L.W. and S.L.R.). The LITE study is also appreciative of support from the CFAR at partner institutions, including JHU (P30AI094189), Emory University (P30AI050409), Harvard University (P30AI060354), DC CFAR (P30AI117970), and the University of Miami (P30AI073961). E.E.C. was supported by a predoctoral fellowship from the National Institute of Mental Health (F31MH124582). E.E.C., A.L.W., and T.C.P. received funding support for this analysis from ViiV Healthcare. V.V., A.R., and L.R. are employed by ViiV Healthcare and C.A.B. was employed by ViiV Healthcare at the time of this analysis. For the remaining authors, none were declared. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or ViiV Healthcare.
The authors have no funding or conflicts of interest to disclose. V.V, A.dR and L.R are employees of ViiV Healthcare and receive stock from GSK
A.L.W. and S.L.R. conceived of the LITE cohort, secured funding, and led the overall project. E.E.C. designed the analysis plan, wrote all statistical analysis code, produced all tables and figures, and wrote the first draft. E.E.C., A.L.W. and S.L.R. had full access to all data in the study, have verified the underlying data, and accept responsibility to submit for publication. All authors reviewed, edited, and approved the final manuscript.
Deidentified individual data, a data dictionary, and code will be made available upon reasonable request after approval of a proposal and signing of a data use agreement. There is a formal process for external users to request access to LITE data, which involves review and approval by Principal Investigators from each study site as well as the Community Advisory Board; further details and forms can be obtained by emailing Dr. Andrea Wirtz (awirtz1@jhu.edu).
Contributor Information
Sari L. Reisner, Email: sreisner@umich.edu.
Tonia C. Poteat, Email: tonia.poteat@duke.edu.
Keri N. Althoff, Email: kalthoff@jhu.edu.
Asa Radix, Email: aradix@callen-lorde.org.
Meg Stevenson, Email: megstevenson@jhmi.edu.
Andrew J. Wawrzyniak, Email: awawrzyniak@med.miami.edu.
Christopher Cannon, Email: cannon.christopher727@gmail.com.
Jason S. Schneider, Email: jsschne@emory.edu.
Kenneth H. Mayer, Email: kmayer@fenwayhealth.org.
Chris Beyrer, Email: chris.beyrer@duke.edu.
Carolyn A. Brown, Email: carolyn.a.brown@viivhealthcare.com.
Vani Vannappagari, Email: vani.x.vannappagari@viivhealthcare.com.
Annemiek de Ruiter, Email: annemiek.x.de-ruiter@viivhealthcare.com.
Leigh Ragone, Email: leigh.x.ragone@viivhealthcare.com.
Andrea L. Wirtz, Email: awirtz1@jhu.edu.
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