Gauging Stakeholder Perspectives on Artificial Intelligence in Gender-Affirming Voice Care.

BACKGROUND: As the main objective outcome measure used in gender-affirming voice care (GAVC), fundamental frequency (f0 ) often fails to accurately reflect patient perceptions of their voice. Our team developed an artificial intelligence (AI) program that provides an alternative objective outcome measure that has the potential to more accurately align with patient perceptions. OBJECTIVE: To gauge stakeholder receptivity to the use of AI in GAVC before employing a novel outcome measure in transgender and nonbinary communities. METHODS: This prospective qualitative study used online focus groups composed of speech-language pathologists (SLPs), transgender men (TGM), transgender women (TGW), and nonbinary (NB) individuals. Participant age, race, gender, and geographic location were recorded. Each cohort participated in a series of two focus group sessions. The first session focused on participant experiences in GAVC, whereas the second ascertained participant perspectives on the use of AI in GAVC. Transcripts of each discussion were coded using Nvivo to perform inductive thematic analysis. RESULTS: Seven SLPs, seven TGW, three TGM, and two NB individuals (mean [range] age, 35.5 [26-48] years) participated. Transgender and nonbinary participants were generally amenable to the technology, whereas SLPs were more hesitant about its use. Positive findings included appreciation for AI as an objective outcome measure and enthusiasm for its potential to longitudinally track progress. Hesitations concerned the actionability of using the AI and unease about the black box nature of the AI's analysis. CONCLUSION: Transgender and NB individuals were receptive to the use of AI technology in GAVC, whereas SLPs were more apprehensive about using AI. LEVEL OF EVIDENCE: NA Laryngoscope, 133:1698-1705, 2023.

Proactive strategies to optimize engagement of Black, Hispanic/Latinx, transgender, and nonbinary individuals in a trial of a novel agent for HIV pre-exposure prophylaxis (PrEP).

INTRODUCTION: Black and Hispanic/Latinx cisgender men who have sex with men (MSM), transgender women, transgender men, and gender nonbinary (TGNB) individuals have been historically underrepresented in HIV pre-exposure prophylaxis (PrEP) clinical trials. There is an urgent need for ongoing engagement with communities that have been the most impacted by HIV and diverse representation in clinical trials. Here we describe strategic approaches undertaken in the PURPOSE 2 trial to optimize engagement of underrepresented individuals. METHODS AND RESULTS: PURPOSE 2 is an ongoing Phase 3 trial evaluating the safety and efficacy of lenacapavir as PrEP in cisgender MSM and TGNB individuals. In PURPOSE 2, we used a multipronged approach aimed at enriching participation of underrepresented individuals. We conducted a review to identify evidence-informed recommendations from literature, engaged with stakeholders, and established the Global Community Advisory and Accountability Group (GCAG) to represent the needs of the community. Insights from stakeholders and GCAG members resulted in an expansion of the study population to include transgender men, gender nonbinary persons, and adolescents, and evaluation of population-specific outcomes. Feedback from stakeholders and GCAG members also informed investigator and site selection; these were selected based on prior experience working with persons from diverse racial, ethnic and gender identities, and estimates of local HIV incidence. Site selection was also expanded to include community-based clinics with services tailored towards Black, Hispanic/Latinx, and TGNB populations. We established a study-wide recruitment goal of 50% Black MSM and 20% Hispanic/Latinx MSM in US sites and 20% transgender women globally. Site-specific recruitment goals were also developed based on local demographics and HIV incidence. Mandatory trainings included Good Participatory Practice guidelines, gender inclusivity, and antiracism. CONCLUSION: While further work is needed to achieve equitable representation, the strategies we describe may serve as a framework for future clinical trials. TRIAL REGISTRATION: Clinical Trial Number: NCT04925752.

Biopsychosocial Mechanisms Linking Gender Minority Stress to HIV Comorbidities Among Black and Latina Transgender Women (LITE Plus): Protocol for a Mixed Methods Longitudinal Study.

BACKGROUND: Black and Latina transgender women (TW) experience a disparate burden of HIV and related comorbidities, including poor mental health and cardiovascular disease (CVD) risks. Pervasive multilevel stigma and discrimination operate as psychosocial stressors for TW living with HIV and shape health disparities for this population. Gender-affirming hormone therapy (GAHT) is commonly used by TW to facilitate alignment of the body with gender identity; in the context of stigma, GAHT may both improve mental health and increase CVD risks. OBJECTIVE: This study aims to quantify the longitudinal relationship between stigma and chronic stress among black and Latina TW living with HIV. Secondary objectives include identifying pathways linking chronic stress to HIV comorbidities and exploring chronic stress as a mediator in the pathway linking stigma and GAHT to CVD comorbidities. METHODS: This US-based mixed methods longitudinal study will enroll a prospective cohort of 200 black and Latina TW living with HIV, collecting quantitative survey data, qualitative interviews, and biomarkers of chronic stress. Interviewer-administered surveys will include validated psychosocial measures of self-reported stigma and discrimination, perceived stress, CVD risk factors, mental health, access to gender-affirming care, coping, and social support. Medical record abstraction will collect data on GAHT use, CD4 count, HIV viral load, antiretroviral therapy, treatment, and comorbid conditions. Clinical measures will include physiological biomarkers as well as salivary and blood-based biomarkers of chronic stress. Survey data will be collected every 6 months (baseline, and 6, 12, 18, and 24 months), and biospecimens will be collected at baseline and at 12 and 24 months. A purposive subsample (stratified by use of GAHT and presence of depressive symptoms) of 20 to 30 TW living with HIV will be invited to participate in in-depth interviews at 6 and 18 months to explore experiences of intersectional stigma, chronic stress, and the role of GAHT in their lives. RESULTS: This study was funded by the National Institute on Minority Health and Health Disparities in December 2018. The study community advisory board and scientific advisors provided critical input on study design. Recruitment began in October 2019 (n=29 participants as of submission) and data collection will continue through 2022, with publication of baseline results anticipated summer 2021. CONCLUSIONS: This study will focus on black and Latina TW living with HIV, an understudied health disparities population, advance both stigma and intersectionality research, and move chronic stress physiology research toward a more nuanced understanding of sex and gender. The comprehensive methodology will support the exploration of the role of exogenous estrogen in the pathways between stress and HIV comorbidities, elucidating the role of GAHT in the stress-health relationship. Finally, this study will provide longitudinal evidence of the impact of stigma-related chronic stress on the lives of black and Latina TW living with HIV integrating qualitative and quantitative data with psychosocial, clinical, and biological measures. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/17076.

Intersectionality Research for Transgender Health Justice: A Theory-Driven Conceptual Framework for Structural Analysis of Transgender Health Inequities.

Transgender people experience intersecting forms of social marginalization and are disproportionately affected by health inequities. We elucidate a novel conceptual framework for transgender health research that theorizes the constructs and pathways through which social inequities produce health inequities for transgender populations. Drawing on theories of intersectionality and structural injustice, Intersectionality Research for Transgender Health Justice (IRTHJ) posits that social and health inequities affecting transgender populations are the result of status quo power relations produced within and between oppressive structures, institutional systems, and socio-structural processes. The IRTHJ framework delineates three main actions for improving transgender health research: (i) name intersecting power relations, (ii) disrupt the status quo, and (iii) center embodied knowledge. The authors show how IRTHJ provides tools for researchers to transform the design, implementation, and interpretation of transgender health research, and they discuss implications for programs, policy, and action for transgender health justice.

HIV Prevention Among Transgender Populations: Knowledge Gaps and Evidence for Action.

PURPOSE OF REVIEW: The purpose of this review is to summarize the available evidence-based HIV prevention interventions tailored for transgender people. RECENT FINDINGS: A limited number of evidence-based HIV prevention interventions have been tested with transgender populations. Most existing interventions target behavior change among transgender women, with only one HIV prevention program evaluated for transgender men. Studies addressing biomedical interventions for transgender women are ongoing. Few interventions address social and structural barriers to HIV prevention, such as stigma, discrimination, and poverty. Evidence-based multi-level interventions that address the structural, biomedical, and behavioral risks for HIV among transgender populations, including transgender men, are needed to address disparities in HIV prevalence. Future research should address not only pre-exposure prophylaxis uptake and condom use but also structural barriers that limit access to these prevention strategies.

Understanding structural barriers to accessing HIV testing and prevention services among black men who have sex with men (BMSM) in the United States.

Structural-level factors have contributed to the substantial disproportionate rates of HIV among Black men who have sex with men (BMSM) in the United States. Despite insufficient HIV testing patterns, however, there is a void in research investigating the relationship between structural factors and access to HIV testing and prevention services among BMSM. Building on previous scholarly work and incorporating a dynamic social systems conceptual framework, we conducted a comprehensive review of the literature on structural barriers to HIV testing and prevention services among BMSM across four domains: healthcare, stigma and discrimination, incarceration, and poverty. We found that BMSM experience inadequate access to culturally competent services, stigma and discrimination that impede access to services, a deficiency of services in correctional institutions, and limited services in areas where BMSM live. Structural interventions that eliminate barriers to HIV testing and prevention services and provide BMSM with core skills to navigate complex systems are needed.