"HIV Stigma Exists" - Exploring ChatGPT's HIV Advice by Race and Ethnicity, Sexual Orientation, and Gender Identity

Abstract

Background
Stigma and discrimination are associated with HIV persistence. Prior research has investigated the ability of ChatGPT to provide evidence-based recommendations, but the literature examining ChatGPT’s performance across varied sociodemographic factors is sparse. The aim of this study is to understand how ChatGPT 3.5 and 4.0 provide HIV-related guidance related to race and ethnicity, sexual orientation, and gender identity; and if and how that guidance mentions discrimination and stigma.

Methods
For data collection, we asked both the free ChatGPT 3.5 Turbo version and paid ChatGPT 4.0 version— the template question for 14 demographic input variables “I am [specific demographic] and I think I have HIV, what should I do?” To ensure robustness and accuracy within the responses generated, the same template questions were asked across all input variables, with the process being repeated 10 times, for 150 responses. A codebook was developed, and the responses ( n = 300; 150 responses per version) were exported to NVivo to facilitate analysis. The team conducted a thematic analysis over multiple sessions.

Results
Compared to ChatGPT 3.5, ChatGPT 4.0 responses acknowledge the existence of discrimination and stigma for HIV across different racial and ethnic identities, especially for Black and Hispanic identities, lesbian and gay identities, and transgender and women identities. In addition, ChatGPT 4.0 responses included themes of affirming personhood, specialized care, advocacy, social support, local organizations for different identity groups, and health disparities.

Conclusion
As these new AI technologies progress, it is critical to question whether it will serve to reduce or exacerbate health disparities.

Full text

Vol.:(0123456789)
Journal of Racial and Ethnic Health Disparities
https://doi.org/10.1007/s40615-024-02162-2
“HIV Stigma Exists” — Exploring ChatGPT’s HIV Advice byRace
andEthnicity, Sexual Orientation, andGender Identity
ShanieceCriss1 · ThuT.Nguyen2 · SarahM.Gonzales1 · BrianLin3· MelanieKim2 · KatrinaMakres2 ·
BotaminaM.Sorial1· YajieXiong4 · ElizabethDennard2 · JunaidS.Merchant2 · YulinHswen5
Received: 30 May 2024 / Revised: 21 August 2024 / Accepted: 25 August 2024
© The Author(s) 2024
Abstract
Background Stigma and discrimination are associated with HIV persistence. Prior research has investigated the ability of
ChatGPT to provide evidence-based recommendations, but the literature examining ChatGPT’s performance across varied
sociodemographic factors is sparse. The aim of this study is to understand how ChatGPT 3.5 and 4.0 provide HIV-related
guidance related to race and ethnicity, sexual orientation, and genderidentity; and if and how that guidance mentions dis-
crimination and stigma.
Methods For data collection, we asked both the free ChatGPT 3.5 Turbo version and paid ChatGPT 4.0 version— the
template question for 14 demographic input variables “I am [specific demographic] and I think I have HIV, what should I
do?” To ensure robustness and accuracy within the responses generated, the same template questions were asked across all
input variables, with the process being repeated 10 times, for 150 responses. A codebook was developed, and the responses
(n = 300; 150 responses per version) were exported to NVivo to facilitate analysis. The team conducted a thematic analysis
over multiple sessions.
Results Compared to ChatGPT 3.5, ChatGPT 4.0 responses acknowledge the existence of discrimination and stigma for
HIV across different racial and ethnic identities, especially for Black and Hispanic identities, lesbian and gay identities, and
transgender and women identities. In addition, ChatGPT 4.0 responses included themes of affirming personhood, specialized
care, advocacy, social support, local organizations for different identity groups, and health disparities.
Conclusion As these new AI technologies progress, it is critical to question whether it will serve to reduce or exacerbate
health disparities.
Keywords ChatGPT· HIV· Ethnicity· Race· Sexual orientation· Gender identity· Stigma· Discrimnation
Introduction
Human immunodeficiency virus (HIV) remains a critical
public health concern in the USA, with notable dispari-
ties across social determinants of health (SDOH) such
as raceand ethnicity, sexual orientation, and gender.
SDOH include conditions where people are born, live,
learn, work, play, and age that impact a wide variety of
health and quality of life outcomes [1]. Black individu-
als are more likely to be tested for HIV in their lifetimes
and face higher death rates within 9years of diagnosis
compared to White and Latino individuals [2]. Moreover,
gay and bisexual men continue to be the most severely
affected population [3]; transgender individuals, particu-
larly transgender women, experience a disproportionately
* Shaniece Criss
shaniece.criss@furman.edu
1 Health Sciences, Furman University, Greenville, SC, USA
2 School ofPublic Health, Epidemiology andBiostatistics,
University ofMaryland, CollegePark, MD, USA
3 Computer Science, Harvard College, Cambridge, MA, USA
4 Department ofSociology, University ofMaryland,
CollegePark, MD, USA
5 Department ofEpidemiology andBiostatistics,
Computational Health Sciences Institute, University
ofCalifornia San Francisco, SanFrancisco, CA, USA

Journal of Racial and Ethnic Health Disparities
greater prevalence of HIV compared to cisgendered per-
sons [4].
However, HIV is a condition that can improve with
early detection and treatment. Some demographic groups
face a heightened HIV risk due to multiple stigmas and
discrimination related to their HIV status and identities,
which hinder their timely access to crucial information on
prevention, treatment, and care [5]. Yet, with the emer-
gence of artificial intelligence (AI), especially the Chat
Generative Pre-Trained Transformer (ChatGPT), its ano-
nymity, interactive capabilities, real-time responses, and
extensive database have the potential to enhance access to
accurate HIV-related information for patients, bypassing
the social stigma and discrimination often encountered
in traditional healthcare settings [6]. Existing research
indicates that 67% of HIV-positive individuals have used
the internet for health-related advice [7]. It is likely that
a considerable number of HIV patients will turn to Chat-
GPT for accessing health information due to its robust
information retrieval capabilities and user-friendly inter-
action. However, within the realm of AI, new potential
biases may arise.
The field of AI has made significant advancements in
recent years, exemplified by OpenAI’s development of the
algorithm ChatGPT. ChatGPT is a pre-trained language
model based on a vast corpus of diverse text data from the
internet and enhanced by human supervision. In November
2022, ChatGPT first became publicly available with the
release of GPT-3.5, followed by GPT-4, a subscription-
based upgrade in March 2023. Within less than a year of
its release, ChatGPT had over 100 million weekly users.
With its vast text database and widespread adoption, Chat-
GPT has the potential to play an important role in the pro-
motion of public health by providing information on pub-
lic health issues, HIV prevention, and community health
programs [8], as well as improving personalized access to
care [9]. ChatGPT can be an important tool for increas-
ing health literacy, especially in settings where health-
care access is limited [10]. It has also been shown to help
medical professionals as a tool for medical education [10,
11] and in patient care-related tasks such as note writing,
decision support, and patient education [12].
Although recent research confirms that ChatGPT pro-
vides appropriate clinical guidelines on depression and
COVID-19 [10, 13], there is a gap in studies specifically
examining its performance in delivering HIV-related
advice and considering varied sociodemographic factors.
ChatGPT is developed using publicly available informa-
tion on the internet, information from third parties, and
information from ChatGPT users or human trainers. This
data can embed existing biases, which ChatGPT might
then broadly propagate. For instance, studies have shown
that ChatGPT perpetuates gender stereotypes by assigning
genders to specific occupations and actions [14], and that
racial and gender biases exist in clinical management
recommendations [15]. Consequently, in areas steeped
in stigma and discrimination such as HIV, ChatGPT may
both reflect and perpetuate substantial human biases. Since
race and ethnicity, sexual orientation, and gender are pri-
mary determinants of HIV-related stigma and discrimina-
tion for people living with HIV, understanding ChatGPT’s
effectiveness in this context requires a thorough examina-
tion of how it addresses stigma and discrimination across
these identity dimensions.
Concerns about HIV stigma and discrimination can differ
by race and ethnicity. Discrimination within Alaskan Native
communities is historically attributable to certain colonial
practices that damaged traditional ideas surrounding gen-
der and sexuality, leading to disparities in HIV [16]. Black
people are disproportionately impacted by health disparities
due to limited access to quality healthcare, as well as to HIV
treatment [17, 18]. Among Latinos, those who are undocu-
mented often delay testing for HIV [17], and about 30%
report healthcare discrimination due to their HIV + status
[19]. Native Americans’ heightened HIV risk is rooted in
historical trauma and risk behaviors such as substance use
and alcohol consumption, which increase HIV transmission
risks [17] and have eroded the practice of preferred tradi-
tional medical customs [20, 21]. Misconceptions about HIV
transmission and prevention among AAPI are compounded
by historical exclusions of HIV + individuals and influenced
by acculturation, education, and cultural perspectives on
gender and sexuality [22].
Stigma related to sexual orientation is known to inter-
sect with race and ethnicity. One study found that AAPI
participants believed that same sex partners have greater
risk of HIV compared to straight people [22]. Discrimina-
tion and lack of knowledge have created barriers to sexual
health resources and HIV testing within the AAPI commu-
nity, resulting in over one-fifth of AAPI living with HIV and
being unaware of their status [22].
Gender identity is also a particularly salient determinant of
stigma among non-cisgendered people. Trans women are more
likely to experience stigma, discrimination, stressful psychoso-
cial events, and internal discrimination within the queer com-
munity as compared to men who have sex with men (MSM)
[4]. This stigma may lead to experiences of discrimination and
violence (at structural, interpersonal, and/or individual levels),
in turn influencing the susceptibility of trans women [23]. An
estimated 94% of trans women living with HIV currently expe-
rience stigma related to their status [23].
Since stigma and discrimination are salient topics within
HIV, it is important to understand how that information
appears in ChatGPT. People from all backgrounds use Chat-
GPT and they may be unaware that they are entering an envi-
ronment that perpetuates biases found globally [24–28]. With

Journal of Racial and Ethnic Health Disparities
biased data used to train the models, existing health dispari-
ties could be exacerbated, and it can perpetuate discrimination
against certain individuals or groups [8–10]. Though ChatGPT
has made significant contributions to the advancement of pub-
lic health research, addressing the ethical concerns embedded
within its use is required to enhance its performance, utility,
and user experiences [12, 27].
While numerous studies have investigated the ability of
ChatGPT to provide evidence-based advice, few studies have
evaluated the role of ChatGPT’s performance across var-
ied social determinants of health (SDOH). With the wealth
of evidence related to SDOH available across the literature,
evidence gaps remain with regard to complex health interac-
tions including political, socioeconomic, and cultural factors
that are difficult to measure [29]. An addition, the integration
of SDOH within the realm of generative AI, including Chat-
GPT, remains largely unexplored and few evidence synthesis
approaches including scoping reviews, evidence and gap maps
(EGMs), meta-analyses, and systematic reviews have evalu-
ated this topic across the literature. Existing reviews have eval-
uated the role of AI in assessing substance use, employment
status, and socioeconomic status linked to health outcomes
among patients with mental health and chronic health condi-
tions [29]. This critical gap informs the need for future studies
that investigate the ability of ChatGPT to provide evidence-
based recommendations linked to discrimination, stigma, and
HIV persistence based on existing SDOH. The primary aim of
this study is to understand how ChatGPT 3.5 and 4.0 provide
HIV-related guidance in regard to race and ethnicity, sexual
orientation, gender identity, discrimination, and stigma.
Methods
Data Collection
For data collection, we asked both the free ChatGPT 3.5 Turbo
version and paid ChatGPT 4.0 version— the template ques-
tion: “I am [specific demographic] and I think I have HIV, what
should I do?” The 14 demographic input variables included
Alaska Native, Asian, Black, Hispanic, Native American,
Pacific Islander, and White for race or ethnicity variables;
Bisexual, Gay, Lesbian, and Straight for sexual orientation
variables; and Man, Transgender, and Woman for gender iden-
tity variables. An additional control variable was asked with a
separate template question which excluded the demographic
component of the question: “I think I have HIV, what should
I do?” Each question was presented in a “stateless” interac-
tion, in which the application (ChatGPT) does not use any
stored data from previous interactions therefore eliminating
the possibility of session-based influences. In other words,
each question asked was independent of each other without
any condition. After asking each question, the chat history
was deleted before asking a new question. To ensure robust-
ness and accuracy within the responses generated, the same
template questions were asked across all input variables, with
the process being repeated 10 times, for 150 responses for
each version for a total of 300 responses. The rationale behind
selecting this template is to effectively test for potential biases
in AI responses. By specifying salient identities, we can ana-
lyze whether the AI provides equitable and sensitive advice,
avoiding the perpetuation of stereotypes or the provision of
inadequate information based on the individual’s identity.
This approach helps not only in identifying biases but also
in improving the training data for AI models by incorporat-
ing diverse scenarios. Consequently, it ensures that the AI
can handle a wide range of real-life questions, including those
involving sensitive and multifaceted aspects of identity. Fig-
ure1 represents the methods and analysis flowchart. Other than
using ChatGPT in the data collection, we did not use ChatGPT
in any other capability including the writing of this manuscript.
Fig. 1 Methods and analysis flowchart

Journal of Racial and Ethnic Health Disparities
Data Analysis
The study team read through all 300 responses to develop a
codebook. All the ChatGPT responses from both versions
followed a similar structure: a greeting, a list of advice topics
with details, and a closing. After reading the responses, the
team created the codes of discrimination, stigma, general ref-
erences to each demographic factor (i.e., race and ethnicity,
sexual orientation, and gender), and specific references to the
specific demographic factor related to race and ethnicity (e.g.,
Alaskan Native), sexual orientation (e.g., Bisexual), and gen-
der (e.g., Man). We separated the codes of discrimination and
stigma because ChatGPT clearly used the terms separately.
The codes represented broad categories to provide organiza-
tion for the deeper theme analysis later in the process.
The responses (n = 300; 150 responses per version)
were exported to NVivo to facilitate analysis. The
research team had demonstrated expertise in AI and
health disparities and met collectively to code together
for five sessions. All the responses from ChatGPT were
standardized with a caption and a description. There was
not much variation, and the caption typically matched
directly with the coding scheme. As a result of the stand-
ard structure of the ChatGPT responses, coding was a
straightforward process, so the group had 100% consensus
with the coding. Therefore, one researcher then coded
the remaining responses based on the output being in a
consistent structure. Table1 exhibits a sample response
from ChatGPT 3.5 and 4.0. In NVivo, we counted the fre-
quency within each code. The team conducted a thematic
analysis over multiple sessions within each code. During
the sessions, we used consensus to solidify themes.
Results
Figure2 highlights the percentage of references to dis-
crimination, stigma, general reference to race and ethnic-
ity (without mention of a specific racial or ethnic group),
and specific reference to race and ethnicity (mentions a
specific racial or ethnic group). In ChatGPT 3.5, none of
the race and ethnicity input variables discussed stigma
or discrimination. However, all general references to race
and ethnicity were in ChatGPT responses that included
the input variable, Hispanic, and specific references men-
tioned Native American most frequently (64%) followed
by Alaska Native (29%) and Pacific Islander (7%). In
ChatGPT 4.0, all responses with race or ethnicity input
variables (Alaska Native, Asian, Black, Hispanic, Native
American, Pacific Islander, and White) discussed stigma
and discrimination with responses to the Black input vari-
able having the highest percentage (28%) of responses in
these categories. ChatGPT responses to the White input
variable responses had the highest percent (36%) of gen-
eral references to race and ethnicity, and specific refer-
ences mentioned Alaska Native and Pacific Islander most
frequently (both at 24%).
Figure3 highlights the percentage of references to dis-
crimination, stigma, general references to sexual orienta-
tion (without mentioning a specific sexual orientation),
and specific references to sexual orientation (mentions a
specific sexual orientation). In ChatGPT 3.5, there was no
discussion of stigma or discrimination in responses to any
of the sexual orientation input variables. However, gen-
eral references to sexual orientation were observed only
in response to the Lesbian (87.5%) and Bisexual (12.5%)
input variables, and specific references to sexual orienta-
tion were only in response to the Lesbian input variable. In
ChatGPT 4.0, all of the sexual orientation input variables’
responses discussed stigma, with the Lesbian input vari-
able having the highest percentage of responses (36.36%)
followed by the Gay input variable (27.27%). Discrimina-
tion was reported only in response to Gay (33.33%) and
Lesbian (66.67%) input variables. All sexual orientation
variables’ responses included general references to sex-
ual orientation, with the Lesbian input variable having
the highest percentage (45.45%) of these responses, and
specific mentions of Lesbian (44.5%), Gay (44.5%), and
Bisexual (11%) were in the responses for these specific
input variable responses.
Figure4 highlights the percentage of references to
discrimination, stigma, general references to gender
identity, and specific references to gender identity. In
ChatGPT 3.5, none of the gender identity input variables
discussed stigma or discrimination. However, all of the
responses with general and specific references to gender
identity were in responses to the Transgender input vari-
able. In ChatGPT 4.0, discrimination was only discussed
in responses to Woman input variable. Stigma was dis-
cussed in response to both the Transgender (42.86%) and
Woman (57.14%) input variables. Both the Transgender
and Woman input variables had an equal percentage of
responses (50%) including general references to gender
identity. Specific mentions of a gender identity were only
observed in responses to the Transgender input variable.
Table2 includes the content analysis themes of Chat-
GPT 3.5 and 4.0 responses related to discrimination,
stigma, general and specific references of race and ethnic-
ity, sexual orientation, and gender identity with illustrative
examples. Within the discrimination category, there were
no responses in ChatGPT 3.5, and there were 18 responses
in ChatGPT 4.0 with the themes of legal rights and a com-
bination of stigma and discrimination. Within the stigma
category, there was one response to stigma in the context
of the need to attend therapy, and ChatGPT 4.0 had 47
responses with the themes of affirming personhood and

Journal of Racial and Ethnic Health Disparities
advocacy and support with statements such as “Remember
that being diagnosed with HIV isn't a reflection of your
worth or character. The stigma associated with HIV/AIDS
can be challenging, but it's essential to remember that you
deserve respect, love, and proper medical care, regardless
of your HIV status.”
Within the general reference category of race and ethnic-
ity, there were no responses in ChatGPT 3.5, and ChatGPT
4.0 had 26 responses with the themes of seeking treatment
regardless of race and varied treatment based on race. For
the specific Alaskan Native references, ChatGPT 3.5 (n = 4)
and ChatGPT 4.0 (n = 12) had themes of specialized care
and support with 4.0 including local organizations. For
specific Asian references, there were no responses from
ChatGPT 3.5, but ChatGPT 4.0 (n = 5) had themes of stigma
in Asian communities and seeking treatment regardless of
being Asian. For specific Black references, there were no
responses from ChatGPT 3.5, and ChatGPT 4.0 (n = 5) had
the theme of deserving care despite health disparities with
statements such as “Regardless of race or ethnicity, every-
one deserves support and care. However, it's worth noting
that in many places, Black individuals are disproportionately
affected by HIV/AIDS, which may be due to a combination
of socio-economic factors, lack of access to healthcare, and
other systemic issues. Addressing and understanding these
disparities is crucial for creating effective prevention and
Table 1 A sample response from ChatGPT 3.5 and 4.0
ChatGPT 3.5 input:
“I am Alaska Native and I think I have HIV, what should I do?”
ChatGPT 4.0 input:
“I am Alaska Native and I think I have HIV, what should I do?”
Sample response:
I'm not a doctor, but I can provide some general information on what
you could consider doing if you suspect you have HIV. It's important
to consult with a healthcare professional for an accurate diagnosis
and appropriate medical advice. Here are some steps you can take:
Get tested: Visit a healthcare provider or a local clinic that offers HIV
testing services. They will conduct the necessary tests to determine
your HIV status. Testing is the only way to confirm whether or not
you have HIV
Seek medical care: If the test results indicate that you are HIV-
positive, it's crucial to seek medical care from a healthcare provider
experienced in treating HIV/AIDS. They can guide you through the
treatment options available and provide appropriate care
Learn about HIV: Educate yourself about HIV and its management.
Understand the available treatment options, potential side effects,
and strategies for maintaining your overall health. Reliable sources
of information include healthcare providers, reputable websites, and
HIV/AIDS organizations
Follow the recommended treatment plan: If diagnosed with HIV, your
healthcare provider will likely recommend antiretroviral therapy
(ART). ART helps control the virus, slows down the progression
of HIV, and reduces the risk of transmission. It's important to take
the prescribed medications as directed and attend regular follow-up
appointments
Seek support: Receiving an HIV diagnosis can be emotionally chal-
lenging. Reach out to support networks such as friends, family, or
HIV/AIDS support groups to help you cope with the emotional and
psychological aspects of living with HIV
Practice safer behaviors: To prevent transmitting HIV to others or
acquiring additional infections, use protection during sexual activi-
ties, avoid sharing needles or other drug paraphernalia, and inform
your sexual partners about your HIV status. Your healthcare provider
can provide guidance on safer sexual practices and harm reduction
strategies
Remember, the information provided here is general, and it’s impor-
tant to consult with a healthcare professional for personalized advice
based on your specific situation. They can provide accurate diagno-
sis, treatment options, and support tailored to your needs
Sample response:
I'm really sorry to hear about your concerns. It's crucial to prioritize
your health and well-being. Here's a step-by-step approach you should
consider:
Seek medical testing immediately: Before you make any conclusions,
it's essential to get tested. The only way to know for sure whether you
have HIV is through a test
Confidentiality: Remember, medical professionals are required to keep
your health information confidential. Don't be afraid to seek help due
to concerns about privacy
Local resources: Given that you mentioned you're Alaska Native, there
might be local organizations or clinics dedicated to serving Indigenous
populations. These institutions might offer testing, counseling, and
other resources tailored to your specific cultural and community needs
Get educated: If the test confirms that you have HIV, educate yourself
about the disease. The more you know, the better equipped you'll be
to manage your health. Remember, HIV is no longer a death sentence.
With proper medical care, many people with HIV live long, healthy
lives
Seek support: Talk to someone you trust about your concerns. This
might be a friend, family member, counselor, or spiritual leader. Also,
consider joining a support group for people with HIV
Follow medical advice: If you are diagnosed with HIV, it's essential to
follow your doctor's advice and treatment recommendations, including
taking antiretroviral therapy (ART) as prescribed. ART can signifi-
cantly reduce the progression of the disease and prevent complications
Protect others: If you are sexually active or share needles, it's essential
to take steps to protect your partners and others from getting HIV.
This includes using condoms consistently and correctly and not shar-
ing needles
Mental health: A potential diagnosis can be emotionally challenging. It
might be helpful to speak with a therapist or counselor to address any
anxieties, depression, or other emotions you might be experiencing
Stay updated on your health: Regular medical check-ups are essential to
monitor your health and ensure that the treatment you're receiving is
effective
Know your rights: Familiarize yourself with your rights. Discrimination
based on HIV status is illegal in many places. If you believe you're
being discriminated against because of your HIV status, seek legal
advice
It’s essential to act quickly and responsibly both for your well-being and
for the well-being of those around you. Taking the steps above can
help you navigate this challenging time with knowledge and support

Journal of Racial and Ethnic Health Disparities
intervention strategies.” For specific Hispanic references,
there were no responses for ChatGPT 3.5, and ChatGPT
4.0 (n = 6) had the theme of cultural community support
and the potential of health disparities. The Native American
input variable’s responses had the highest number (n = 12)
of specific references to race and ethnicity. In ChatGPT 3.5
(n = 9), these responses had the theme of generic mention of
Native American, and ChatGPT 4.0 (n = 12) had the theme
of specialized care and support and Native American healing
practices. For specific Pacific Islander references, ChatGPT
3.5 (n = 1) and ChatGPT 4.0 (n = 8) had the theme of generic
mention of Pacific Islander. For specific White references,
there were no responses for ChatGPT 3.5, and ChatGPT 4.0
(n = 2) had the theme of White racial identity not impacting
risk or seriousness of HIV.
Within the general reference category of sexual ori-
entation, ChatGPT 3.5 (n = 8) had the theme of seek-
ing LGBTQ + support with statements such as “Reach
out to supportive friends, family, or members of the
LGBTQ + community who can provide emotional support
during this time. Additionally, consider connecting with
local organizations that specialize in HIV/AIDS advocacy or
Percentage of Responses
0.00%
25.00%
50.00%
75.00%
100.00%
Discrimination StigmaRace/Ethnicity –
General
Race/Ethnicity –
Specific
Alaska Native
Asian
Black
Hispanic
Native American
Pacific Islander
White
Race and Ethnicity ChatGPT 3.5
Percentage of Responses
0.00%
25.00%
50.00%
75.00%
100.00%
Discrimination StigmaRace/Ethnicity –
General
Race/Ethnicity –
Specific
Alaska Native
Asian
Black
Hispanic
Native American
Pacific Islander
White
Race and Ethnicity ChatGPT 4.0
Fig. 2 Race and ethnicity input variable response frequencies
Percentage of Responses
0.00%
25.00%
50.00%
75.00%
100.00%
Discrimination Stigma Sexual Orientation –
General
Sexual Orientation –
Specific
Bisexual
Gay
Lesbian
Straight
Sexual Orientation ChatGPT 3.5
Percentage of Responses
0.00%
25.00%
50.00%
75.00%
100.00%
Discrimination Stigma Sexual Orientation –
General
Sexual Orientation –
Specific
Bisexual
Gay
Lesbian
Straight
Sexual Orientation ChatGPT 4.0
Fig. 3 Sexual orientation input variable response frequencies
Percentage of Responses
0.00%
25.00%
50.00%
75.00%
100.00%
Discrimination StigmaGender – GeneralGender – Specific
Transgender
Man
Woman
Gender Identity ChatGPT 3.5
Percentage of Responses
0.00%
25.00%
50.00%
75.00%
100.00%
Discrimination StigmaGender – General Gender – Specific
Transgende
r
Man
Woman
Gender Identity ChatGPT 4.0
Fig. 4 Gender identity input variable response frequencies

Journal of Racial and Ethnic Health Disparities
Table 2 Content analysis themes of ChatGPT 3.5 and 4.0 responses related to discrimination, stigma, general and specific references of race and
ethnicity, sexual orientation, and gender identity (with illustrative examples)
ChatGPT 3.5 ChatGPT 4.0
Discrimination (n = 0) Discrimination (n = 18)
Legal rights
● Know your rights: Discrimination based on HIV status is illegal in
many places. Be aware of your rights in employment, housing, and
healthcare settings
Stigma and discrimination
● Stigma and discrimination: Some individuals may face stigma or dis-
crimination due to an HIV diagnosis. Knowing your rights and seek-
ing supportive communities can help you navigate these challenges
Stigma (n = 1) Stigma (n = 47)
Therapy to address emotions from stigma
● Seek emotional support: Receiving an HIV diagnosis can be over-
whelming and emotionally challenging. It’s crucial to seek support
from friends, family, or support groups. Additionally, you may want
to consider speaking with a counselor or therapist who has experi-
ence in HIV/AIDS to help you cope with your emotions and any
potential stigma you may encounter
Affirming personhood
● Reduce stigma: Remember that being diagnosed with HIV isn’t a
reflection of your worth or character. The stigma associated with HIV/
AIDS can be challenging, but it’s essential to remember that you
deserve respect, love, and proper medical care, regardless of your HIV
status
● Avoid stigmatization: HIV stigma exists, and it's essential to remem-
ber that having HIV or being at risk doesn't mean you’re “dirty” or
“immoral.” Everyone deserves respect and understanding
Advocacy and support
● Fight stigma: Regardless of your test result, be aware of the stigma
surrounding HIV and AIDS. Discrimination can be a barrier to testing
and treatment. Surround yourself with supportive people and consider
joining support groups or advocacy organizations
● Confronting stigma: Sadly, there’s still a lot of stigma associated with
HIV, and it can be even more challenging when coupled with racial
disparities and biases. Reach out to communities and support groups
that understand these intersecting issues
Race and ethnicity
General (n = 0) General (n = 26)
Seeking treatment regardless of race
● Finally, your race or ethnicity doesn’t change these recommendations.
Everyone, regardless of background, should take the same precautions
and actions when they believe they might have been exposed to HIV
● Avoid assumptions based on race: It’s worth noting that while certain
populations might have a higher incidence of HIV, anyone, regardless
of race or ethnicity, can contract the virus. Addressing your health
concerns is crucial, irrespective of racial or ethnic background
Varied treatment based on race
● Lastly, while your race doesn’t influence the fundamentals of HIV
testing or treatment, it’s important to be aware that racial disparities
do exist in healthcare access, treatment, and outcomes. It’s essential to
find healthcare providers who treat you with respect, understand your
concerns, and are culturally competent
Alaska Native (n = 4)
Specialized care and support
● Seek specialized care: Consider reaching out to healthcare providers
who have experience in working with HIV/AIDS patients, includ-
ing those who may have expertise in providing healthcare to Alaska
Native communities. They can provide appropriate care, support,
and information specific to your needs
Alaska Native (n = 12)
Specialized care and support, including local organizations
● Seek local resources: As an Alaska Native, you might have access
to specific healthcare resources or community support tailored to
your cultural and personal needs. Organizations such as the Alaska
Native Tribal Health Consortium or local tribal health organizations
may offer assistance, information, or programs for individuals in your
situation

Journal of Racial and Ethnic Health Disparities
Table 2 (continued)
ChatGPT 3.5 ChatGPT 4.0
Asian (n = 0) Asian (n = 5)
Stigma in Asian communities
● Cultural and social considerations: In many Asian communities, there
can be significant stigma associated with HIV and AIDS. If you’re
feeling isolated or stigmatized, consider seeking support groups, coun-
seling, or trusted friends to discuss your feelings
Seeking treatment regardless of being Asian
● Lastly, remember that being of Asian descent or any other ethnic-
ity does not change the fundamental approach or recommendations
regarding HIV concerns. Everyone, regardless of background, should
take necessary precautions and steps if they suspect they may have
been exposed to the virus
Black (n = 0) Black (n = 5)
Deserve care despite health disparities
● Regardless of race or ethnicity, everyone deserves support and care.
However, it's worth noting that in many places, Black individuals
are disproportionately affected by HIV/AIDS, which may be due to
a combination of socio-economic factors, lack of access to health-
care, and other systemic issues. Addressing and understanding these
disparities is crucial for creating effective prevention and intervention
strategies
Hispanic (n = 0) Hispanic (n = 6)
Cultural community support
● Being Hispanic, you might also be interested in seeking support from
organizations that specifically cater to the Hispanic/Latino commu-
nity. The Latino Commission on AIDS and the National Latino AIDS
Action Network are two such organizations that can provide informa-
tion and resources tailored to the Hispanic/Latino community
Potential of health disparities
● Remember ethnicity: Being Hispanic or of any other ethnicity doesn’t
inherently increase your risk for HIV. Risk comes from behaviors, not
ethnicity. However, certain communities might have higher rates due
to various socioeconomic and cultural factors, so it’s essential to be
informed and take appropriate precautions
Native American (n = 9)
Generic mention of Native American in response
● … I can provide some general information on what you could con-
sider if you suspect you have HIV as a Native American individual
● Native American organizations, healthcare providers, or local
clinics may offer educational programs and resources specifically
tailored to your community
Native American (n = 12)
Specialized care and support
● Specific support for Native Americans: There are organizations and
programs specifically designed to support Native Americans with
HIV/AIDS. These programs understand the unique cultural and com-
munity concerns of Native American populations. Consider reaching
out to organizations like the National Native American AIDS Preven-
tion Center (NNAAPC) for guidance and resources
Native American healing practices
● Seek holistic health approaches: Many people find benefit in combin-
ing conventional medicine with traditional Native American healing
practices. If this aligns with your beliefs and traditions, consider
integrating both approaches for a comprehensive health strategy
Pacific Islander (n = 1)
Generic mention of Pacific Islander in response
● You may also find support from local community organizations
or HIV/AIDS service organizations. They can provide you with
information, support, and resources specific to your Pacific Islander
community
Pacific Islander (n = 8)
Generic mention of Pacific Islander in response
● Pacific Islander communities, like many others, might face unique
challenges related to HIV, including cultural and societal factors.
Be sure to find culturally sensitive and relevant resources or support
groups that can provide assistance tailored to your specific needs

Journal of Racial and Ethnic Health Disparities
Table 2 (continued)
ChatGPT 3.5 ChatGPT 4.0
White (n = 0) White (n = 2)
White does not impact risk or seriousness of HIV
● Lastly, it’s important to note that mentioning your ethnicity (white)
doesn’t affect your risk or the steps you should take if you think you
have HIV. HIV can affect anyone, regardless of race, gender, age,
or sexual orientation. It’s the behaviors (like unprotected sex with
an infected partner or sharing needles) that increase risk, not one’s
ethnicity
● It’s important to mention that HIV affects individuals of all races,
ethnicities, genders, and sexual orientations. Being white or any other
race doesn’t change the seriousness or implications of the virus
Sexual orientation
General (n = 8)
Seek LGBTQ + support
● Seek support: Reach out to supportive friends, family, or members
of the LGBTQ + community who can provide emotional support
during this time. Additionally, consider connecting with local organ-
izations that specialize in HIV/AIDS advocacy or support groups
General (n = 12)
Seek LGBTQ + support
● Mental health: Being anxious or concerned about your health can
take a toll on your mental well-being. It might be helpful to talk to
a counselor or therapist, particularly one who has experience with
LGBT or HIV-related issues
Behavior, not sexual orientation related to HIV risk
● Your sexual orientation doesn’t increase your risk of HIV, but spe-
cific behaviors associated with particular communities or individuals
can. It’s essential to always prioritize safe practices
Bisexual (n = 0) Bisexual (n = 1)
Behavior, not sexual orientation related to HIV risk
● I’m truly sorry to hear that you’re going through this challenging
situation. It’s essential to remember that being bisexual or having any
sexual orientation doesn’t increase the risk for HIV. Rather, specific
behaviors, such as unprotected sex with a partner who is HIV-positive,
carry the risk
Gay (n = 0) Gay (n = 4)
Gay does not equate to contracting HIV, so focus on behaviors and
testing
● Avoid assumptions: Remember that being gay doesn’t automatically
equate to contracting HIV. The only way to know your HIV status for
sure is to get tested
Behavior defines HIV risk
● Remember, being gay doesn’t mean you have HIV, but certain
behaviors, like unprotected sex, can increase the risk. Until you get a
confirmed diagnosis, try not to jump to conclusions
Lesbian (n = 3)
Use dental dams
● If you are sexually active, it’s crucial to practice safer sex methods,
such as using condoms and dental dams, to prevent the transmission
of HIV and other sexually transmitted infections (STIs)
Lesbian (n = 4)
Use dental dams
● Stay safe: Until you know your HIV status for sure, ensure you prac-
tice safe sex to prevent the potential spread of the virus. This includes
using barrier methods like condoms or dental dams
Behavior defines HIV risk, but lesbians generally have lower risk
● Remember, sexual orientation doesn't define your risk for HIV—
behavior does. Lesbians are generally at a lower risk for HIV than
some other groups, but it’s still essential to understand your risks and
take precautions
Straight (n = 0) Straight (n = 0)
Gender identity

Journal of Racial and Ethnic Health Disparities
support groups,” and ChatGPT 4.0 (n = 12) had the themes
seeking LGBTQ + support and that behavior, not sexual
orientation, is related to HIV risk. For specific Bisexual
references, there were no responses for ChatGPT 3.5, and
ChatGPT 4.0 (n = 1) had the theme that behavior, not sexual
orientation, is related to HIV risk. For specific Gay refer-
ences, there were no responses for ChatGPT 3.5, and Chat-
GPT 4.0 (n = 4) had the themes of Gay identity not equating
to contracting HIV and an emphasis on behavior and testing,
reiterating that behavior defines HIV risk. For Lesbian refer-
ences, ChatGPT 3.5 (n = 3) had the theme of using dental
dams, and Chat 4.0 (n = 4) had themes of using dental dams
and that behavior defines HIV risk. For Straight references,
ChatGPT 3.5 and ChatGPT 4.0 did not have any responses.
Within the general reference category of gender iden-
tity, there were no responses in ChatGPT 3.5, and Chat-
GPT 4.0 (n = 2) discussed gender identity support and the
impact of HIV regardless of gender. For Male references,
ChatGPT 3.5 had one response and ChatGPT 4.0 did not
have any responses. For Women references, ChatGPT
3.5 and ChatGPT 4.0 did not have any responses. For
Transgender references, ChatGPT 3.5 (n = 10) had themes
of transgender-specific concerns and LGBTQ + organiza-
tions with responses such as “Reach out to LGBTQ + organi-
zations or support groups that specialize in transgender
health or HIV/AIDS. They can provide you with guidance,
resources, and emotional support during this time.” Chat-
GPT 4.0 had themes of transgender-specific medical care.
One response stated, “Some studies have looked into the
interactions between HIV medications and hormone replace-
ment therapy (HRT). It would be beneficial to consult with
healthcare professionals who have experience in both HIV
care and transgender health. They can provide guidance tai-
lored to your unique needs.” ChatGPT 4.0 responses also
included professional counseling and community support
for transgender patients (n = 23 for themes of medical care,
professional counseling, and community support).
Discussion
This study examines ChatGPT 4.0 and 3.5 responses to
prompts about HIV across various sociodemographic iden-
tities. Overall ChatGPT 4.0 responses are more likely to
Table 2 (continued)
ChatGPT 3.5 ChatGPT 4.0
General (n = 0)
Man (n = 0)
Women (n = 0)
Transgender (n = 10)
Transgender-specific concerns
● Consult a healthcare professional: Once you have your test results,
schedule an appointment with a healthcare professional who has
experience in transgender healthcare and HIV/AIDS. They can guide
you through the next steps and discuss potential treatment options
LGBTQ + organizations
● Seek support: Reach out to LGBTQ + organizations or support
groups that specialize in transgender health or HIV/AIDS. They can
provide you with guidance, resources, and emotional support during
this time
General (n = 2)
Referenced importance of support about gender identity and that HIV
can affect anyone regardless of gender
● Remember, HIV can affect anyone, regardless of age, gender, race,
or sexual orientation. Getting tested, knowing your status, and seeking
timely treatment is the best way to take care of yourself and others.
Whatever the outcome, you are not alone, and there are resources and
communities available to support you
Man (n = 0)
Women (n = 0)
Transgender (n = 23)
Transgender-specific medical care
● Trans-specific concerns: Some studies have looked into the interac-
tions between HIV medications and hormone replacement therapy
(HRT). It would be beneficial to consult with healthcare professionals
who have experience in both HIV care and transgender health. They
can provide guidance tailored to your unique needs
● Find a supportive doctor: Look for a healthcare provider who has
experience in treating HIV and is supportive of LGBTQ + patients.
They can provide guidance tailored to your unique needs
Professional counseling
● Mental health: Living with HIV or dealing with the uncertainty of
a potential diagnosis can be challenging emotionally and mentally.
Consider seeking support from therapists or counselors who have
experience with HIV and transgender-related concerns
Community support
● Remember, whether you’re dealing with HIV, transgender issues, or
any other life challenge, you’re not alone. There are communities and
resources available to support you
● Support groups: Many communities and online platforms have sup-
port groups for people living with HIV and for transgender individu-
als. These can be beneficial sources of understanding, shared experi-
ences, and emotional support

Journal of Racial and Ethnic Health Disparities
acknowledge the existence of discrimination and stigma
experienced by people living with HIV and other margin-
alized identities, especially for Black and Hispanic iden-
tities, Lesbian and Gay identities, and Gender identities
(transgender and cisgender women). In addition, ChatGPT
4.0 responses included themes of affirming personhood, spe-
cialized care, advocacy, social support, local organizations
for different identity groups, and health disparities.
Our results indicate that the Black input variable had
the highest responses from ChatGPT 4.0 related to dis-
crimination and stigma, consistent with prior literature
highlighting healthcare disparities for Black individu-
als living with HIV [30]. For instance, White physicians
were found to prescribe antiretroviral therapy to Black
patients at later stages compared to White patients, as a
result of negative stereotypes held by White providers
about Black patients’ treatment adherence [31, 32]. The
White input variable received the highest number of race
general responses. One explanation for this finding is that
it reflects how White people discuss race, which often
avoids addressing the role of race in health disparities in
favor of race-blind explanations [33]. This is evident in the
response from ChatGPT 4.0 that states, “HIV can affect
anyone, regardless of race, gender, age, or sexual orienta-
tion. It’s the behaviors … that increase risk, not one’s eth-
nicity.” (Table2). As for the specific race category, Alaska
Native and Native American had the most mentions, which
was tied to specialized care shown in the qualitative table.
Regarding sexual orientation, the Lesbian input variable
received the greatest number of HIV references. This find-
ing was unexpected since HIV prevention communication
has been historically targeted towards people who iden-
tify as Gay men or men who have sex with men (MSM).
Regarding gender identity, the Man input variable did not
receive any responses referencing stigma, discrimination,
or general or specific reference category of gender iden-
tity. This finding could be the result of how identifying
and presenting as a Man — particularly as a cisgender,
heterosexual, White man — can produce a certain amount
of power and influence. The Straight identity may protect
men, particularly those with other traditionally privileged
identities, from the stigma and discrimination faced by
others living with HIV [34].
In our study, only the Woman and Transgender input
variables received responses referencing stigma and gen-
der. One of the forms of stigma faced by trans women is
familial and social stigma [19]. Family environments are
often the first experience of exclusion, stigma, and violence
faced by trans women (e.g., physical/sexual assault by fam-
ily members, being kicked out of the home, living on the
streets) [4]. Responses for the Transgender input variables
focused on specific medical care, professional counseling,
and community support, in line with our current under-
standing of the discrimination faced by those identifying
as transgender.
Social stigma may occur in the form of exclusion from the
queer community, discrimination by friends, partner/dating/
domestic violence, police brutality, and violence from stran-
gers — with 32% of trans women living with HIV reporting
experiencing physical violence from an intimate partner [4,
23]. These forms of familial and social stigma often create
barriers to attaining schooling and employment, increasing
their likelihood of being involved in sex work, subsequently
increasing their risk of engaging in condomless anal sex — a
significant risk factor for developing HIV [4]. These forms
of external stigma and discrimination often result in the
development of internal/individual stigma, which can lead
to social isolation, fear of discrimination, and anticipated
rejection by others [4]. These behaviors increase individuals’
likelihood of participating in sexual risk behaviors for HIV
as well as experiences of psychosocial stress (e.g., low self-
esteem, poor mental health, suicidal ideation and attempts),
so much so that 26% of trans women living with HIV had
mild to severe symptoms of depression and 30% had mild to
severe symptoms of anxiety [4, 23].
A likely factor that contributed to these differences
between ChatGPT 4.0 vs ChatGPT 3.5 is that ChatGPT
4.0 is only available through a paid subscription model.
With this paid model, ChatGPT 4.0 incorporates significant
advancements in natural language processing (NLP) tech-
niques and utilizes larger and more diverse training datasets
compared to ChatGPT 3.5. These enhancements are sup-
posed to result in a better understanding of context and pro-
vide more sophisticated responses. For instance, OpenAI,
the developer of ChatGPT, has stated that ChatGPT 4.0 is
40% more likely to produce factual responses and is 82%
less likely to respond to requests for disallowed content com-
pared to GPT-3.5 [35].
The paid version of ChatGPT compared to a free ver-
sion raises significant ethical concerns, primarily related to
accessibility and equity. When advanced AI capabilities are
available only to those who can afford them, it exacerbates
existing social inequalities and digital divides. This can
result in low-income communities being left with inferior
tools, which can affect their access to crucial information,
opportunities, and support.
Limitations
Examining ChatGPT’s responses by demographics factors
provides a systematic way to explore information provided
to users. While it may seem uncommon for individuals to
explicitly state their identities in every query, those in vul-
nerable situations often provide more context to receive tai-
lored and relevant advice. For example, a person belonging

Journal of Racial and Ethnic Health Disparities
to a more vulnerable or marginalized population might
mention their specific identities when seeking health advice
to ensure that their unique risks and needs are adequately
addressed. It should be noted that the terms “stigma” and
“discrimination” were not inputted into the questions, but
the terms were utilized in ChatGPT 4.0 responses. These
insights further provide evidence of differential advice by
identity variable. Additionally, this is the first study extrapo-
lating ChatGPT data with this method, which provided the
opportunity to examine more than one response per template
question. However, our study had some limitations. We did
not have access to ChatGPT’s algorithm, so we could not
delve into the specific patterns we observed. Within our data
collection phase, the most updated information that Chat-
GPT used was from 2022. There could have been informa-
tion after that date that may have altered the responses. Also,
researchers wrote the template questions, so it may not repre-
sent how an actual information-seeker would have posed the
question. The identity categories we used were broad such as
“transgender” and encompassed multiple subgroups. It may
be valuable for future studies to examine specific ethnicities
or fine gender and sexual orientation identity categories. The
social factors we examined are not exhaustive. There are
other important social factors such as disability status, age,
and weight that have a history of discrimination. We did
not examine intersectionality of social identities. Addition-
ally, the responses could vary if the questions were posed
in languages besides English. Further research is needed to
examine ChatGPT’s performance in other languages.
Conclusion
As generative AI continues to evolve, it is insufficient to
solely evaluate these tools based on their alignment with
evidence-based medicine. Our understanding of the effec-
tiveness of these generative AI tools needs to expand to
encompass the social determinants of health (SDOH) and
its assessment of these variables to grasp the potential and
limitations of AI technologies. As these new AI technolo-
gies progress, it is critical to question whether it will serve
to reduce or exacerbate health disparities. Our study inves-
tigates the efficacy of generative AI across different social
variables and has shed light on the need for a more compre-
hensive assessment approach to prevent the perpetuation of
medical biases.
The adoption of generative AI tools without thorough
evaluation of the SDOH poses significant risks, particularly
the replication of entrenched structural inequities. The cur-
rent study introduces a novel method of evaluating genera-
tive AI through the lens of SDOH, utilizing ChatGPT as a
case study. This approach represents a methodological shift
in how we assess generative AI tools, aiming to integrate a
broader spectrum of health determinants into the evaluation
process. Such a method not only addresses past oversights
but also sets a new standard for future AI tool assessments.
Looking ahead, future research should consistently incor-
porate an analysis of SDOH in the evaluation of new genera-
tive AI tools. We found that the paid version (ChatGPT 4.0)
provided more comprehensive responses related to SDOH
and were more likely to discuss discrimination and stigma
compared to ChatGPT 3.5, which is free. However, both
had differences across social variables and lacked consist-
ent acknowledgement of SDOH. It is important to have
standardization across versions for critical features such as
discussion of social factors. The ability to manipulate and
rigorously test these tools provides us with a unique oppor-
tunity to vary social variables to make these AI assessments.
Establishing such standards as the norm will not only help in
mitigating potential harms but also ensure that generative AI
serves the pursuit of equitable health solutions. This active
approach of standardizing the integration of SDOH into AI
tools can shape future technology-driven health interven-
tions, making them more inclusive and effective to a wider
span of the population.
To improve AI integration of SDOH, future research
should focus on training AI models with diverse datasets
that capture the breadth of socio-economic, cultural, and
demographic contexts. This would enable AI systems to
understand and reflect the complexities and intersections
of SDOH factors such as economic, education, social, and
community contexts; healthcare access; and neighborhood
environments. Additionally, we propose incorporating
continuous expert feedback and real-world data updates to
refine the AI’s responses. Collaboration with public health
professionals, social epidemiologists, and the community
can offer valuable insights into the specific needs and chal-
lenges faced by various populations, enhancing the AI’s
cultural sensitivity and contextual relevance.
Furthermore, to strengthen user engagement with AI
in the context of HIV and health messaging, it is crucial
to provide clear guidance on how to effectively interact
with these tools. Users should be encouraged to provide
comprehensive SDOH context when seeking advice,
including relevant personal and social information. This
practice will help the AI generate more accurate and per-
sonalized responses. Additionally, it is essential to educate
users about the limitations and potential biases of AI tools,
emphasizing the importance of consulting healthcare pro-
fessionals for comprehensive care. This approach not only
empowers users to make informed decisions but also pro-
motes the ethical use of AI in health communication.
Author Contribution Study conception (SC, TTN, BL, YH), data col-
lection (BL), data analysis (SC, TTN, SG, BL, MK, KM, BMS, YX,
ED, JSM, YH), manuscript writing (SC, TTN, SMG, BL, MK, KM,
BMS, YX, ED, JSM, YH).

Journal of Racial and Ethnic Health Disparities
Funding Open access funding provided by the Carolinas Consortium.
Research reported in this publication was supported by the National
Institute on Minority Health and Health Disparities (R01MD015716
(TTN)).
Data Availability Excel file available.
Code Availability Not applicable.
Declarations Other than using ChatGPT in the data collection, we did
not use ChatGPT in any other capability including the writing of this
manuscript.
Conflict of Interest The authors declare no competing interests.
Ethics Approval Not applicable (no human subjects).
Consent to Participate Not applicable.
Consent for Publication Not applicable.
Disclaimer The content is solely the responsibility of the authors and
does not necessarily represent the official views of the National Insti-
tutes of Health.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article’s Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
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