COVID-19 Vaccine Uptake, Knowledge and Perceptions Among People Living with HIV in Livingstone District, Zambia: A Mixed-Methods Study

Background: People living with HIV (PLWH) are at increased risk of severe COVID-19 outcomes, yet limited evidence exists on their vaccine-related knowledge, attitudes, and uptake in Zambia. This study assessed COVID-19 vaccination prevalence and examined the factors shaping vaccine behaviors among PLWH attending ART services in Livingstone District, Zambia.
Methods: We employed a cross-sectional mixed-methods design at Mahatma Gandhi Clinic from April to June 2022. Systematic random sampling (every third patient) was used to select 384 PLWH aged ≥18 years from a clinic population of 2,197. Quantitative data on vaccine uptake, knowledge, and perceptions were collected via structured interviews. Purposive sampling selected 20 participants for in-depth qualitative interviews exploring attitudes and explanatory narratives. Descriptive statistics and multivariable logistic regression identified predictors of vaccination; qualitative data were analyzed using Braun and Clarke's thematic analysis framework.
Results: Vaccination prevalence was 78.9% (303/384; 95% CI: 74.5%-82.8%). Knowledge and positive perceptions were widespread: 97.1% knew COVID-19 had no cure, 98.2% recognized vaccines as preventive, and 99.5% were aware of vaccine availability. Most perceived vaccines as safe (97.1%), effective (96.4%), beneficial to all (97.9%), and trusted manufacturers (96.6%). Multivariable logistic regression identified significant negative predictors of uptake: perceiving vaccines as not beneficial to all (AOR = 5.41, 95% CI: 1.20-24.32, p=0.028), distrust of manufacturers (AOR = 3.48, 95% CI: 1.43-8.48, p=0.006), belief that vaccination controls human activities (AOR = 2.31, 95% CI: 1.10-4.85, p=0.027), and belief that suppliers act in bad faith (AOR = 2.39, 95% CI: 1.13-5.05, p=0.022). Qualitative analysis revealed three themes: 1) Trust in biomedical authority ("it has been approved medically"); 2) Genocidal conspiracy beliefs ("they have intentions of wiping out the entire Africa"); and 3) Vaccination as social control ("to stop us from going to church").
Conclusions: While COVID-19 vaccine uptake among PLWH in Livingstone is high and grounded in trust in medical approval, a significant minority remain hesitant due to deep-seated conspiracy beliefs framing vaccination as a tool for population control and harm. This dual reality must inform targeted interventions leveraging trusted healthcare relationships within ART programs.

HIV, COVID-19 vaccination, vaccine uptake, vaccine hesitancy, mixed-methods, conspiracy beliefs, Zambia

1. Peng X-L, Cheng J-S-Y, Gong H-L, Yuan M-D, Zhao X-H, Li Z, et al. Advances in the design and development of SARS-CoV-2 vaccines. Mil Med Res. 2021;8: 67. doi:10.1186/s40779-021-00360-1 [Google Scholar] [Crossref]

2. Guo W, Ming F, Dong Y, Zhang Q, Liu L, Gao M, et al. Driving Force of Covid-19 Among People Living With HIV/AIDS in Wuhan, China. Res Sq. 2020; rs.3.rs-53351. doi:10.21203/rs.3.rs-53351/v1 [Google Scholar] [Crossref]

3. Ambrosioni J, Blanco JL, Reyes-Urueña JM, Davies M-A, Sued O, Marcos MA, et al. Overview of SARS-CoV-2 infection in adults living with HIV. Lancet HIV. 2021;8: e294–e305. doi:10.1016/S2352-3018(21)00070-9 [Google Scholar] [Crossref]

4. Edagwa B, McMillan J, Sillman B, Gendelman HE. Long acting slow effective release antiretroviral therapy. Expert Opin Drug Deliv. 2017;14: 1281–1291. doi:10.1080/17425247.2017.1288212 [Google Scholar] [Crossref]

5. Chao Y-K, Chang S-Y, Grimm C. Endo-Lysosomal Cation Channels and Infectious Diseases. In: Pedersen SHF, Barber DL, editors. Organelles in Disease. Cham: Springer International Publishing; 2023. pp. 259–276. doi:10.1007/112_2020_31 [Google Scholar] [Crossref]

6. Mwananyanda L, Gill CJ, MacLeod W, Kwenda G, Pieciak R, Mupila Z, et al. Covid-19 deaths in Africa: prospective systematic postmortem surveillance study. BMJ. 2021;372: n334. doi:10.1136/bmj.n334 [Google Scholar] [Crossref]

7. Kanwugu ON, Adadi P. HIV/SARS‐CoV‐2 coinfection: A global perspective. J Med Virol. 2021;93: 726–732. doi:10.1002/jmv.26321 [Google Scholar] [Crossref]

8. Brown LB, Spinelli MA, Gandhi M. The Interplay between HIV and COVID-19: summary of the data and responses to date. Curr Opin HIV AIDS. 2021;16: 63–73. doi:10.1097/COH.0000000000000659 [Google Scholar] [Crossref]

9. PDF. Available: https://repository.up.ac.za/server/api/core/bitstreams/0f1b978e-d39c-4712-8e7b-b50235effd4a/content [Google Scholar] [Crossref]

10. Mallah SI, Ghorab OK, Al-Salmi S, Abdellatif OS, Tharmaratnam T, Iskandar MA, et al. COVID-19: breaking down a global health crisis. Ann Clin Microbiol Antimicrob. 2021;20: 35. doi:10.1186/s12941-021-00438-7 [Google Scholar] [Crossref]

11. Nomah DK, Reyes-Urueña J, Llibre JM, Ambrosioni J, Ganem FS, Miró JM, et al. HIV and SARS-CoV-2 Co-infection: Epidemiological, Clinical Features, and Future Implications for Clinical Care and Public Health for People Living with HIV (PLWH) and HIV Most-at-Risk Groups. Curr HIV/AIDS Rep. 2021;18: 518–526. doi:10.1007/s11904-021-00579-6 [Google Scholar] [Crossref]

12. Wu S, Ming F, Xing Z, Zhang Z, Zhu S, Guo W, et al. COVID-19 Vaccination Willingness Among People Living With HIV in Wuhan, China. Front Public Health. 2022;10: 883453. doi:10.3389/fpubh.2022.883453 [Google Scholar] [Crossref]

13. Hochman S, Kim K. The Impact of HIV Coinfection on Cerebral Malaria Pathogenesis. J Neuroparasitology. 2012;3: 235547. doi:10.4303/jnp/235547 [Google Scholar] [Crossref]

14. Cele S, Karim F, Lustig G, San JE, Hermanus T, Tegally H, et al. SARS-CoV-2 evolved during advanced HIV disease immunosuppression has Beta-like escape of vaccine and Delta infection elicited immunity. medRxiv. 2021; 2021.09.14.21263564. doi:10.1101/2021.09.14.21263564 [Google Scholar] [Crossref]

15. Patel RH, Acharya A, Chand HS, Mohan M, Byrareddy SN. Human Immunodeficiency Virus and Severe Acute Respiratory Syndrome Coronavirus 2 Coinfection: A Systematic Review of the Literature and Challenges. AIDS Res Hum Retroviruses. 2021;37: 266–282. doi:10.1089/aid.2020.0284 [Google Scholar] [Crossref]

16. Fang E, Liu X, Li M, Zhang Z, Song L, Zhu B, et al. Advances in COVID-19 mRNA vaccine development. Signal Transduct Target Ther. 2022;7: 94. doi:10.1038/s41392-022-00950-y [Google Scholar] [Crossref]

17. Yang Y, Iwasaki A. Impact of Chronic HIV Infection on SARS-CoV-2 Infection, COVID-19 Disease and Vaccines. Curr HIV/AIDS Rep. 2022;19: 5–16. doi:10.1007/s11904-021-00590-x [Google Scholar] [Crossref]

18. Wang H, Yu H, Bai X, Wang X, Shao H, Liao J, et al. Recent advances in hydrogel-based delivery systems for the treatment of pancreatic cancer. Mater Today Bio. 2025;35: 102487. doi:10.1016/j.mtbio.2025.102487 [Google Scholar] [Crossref]

19. Yao Y, Chai R, Yang J, Zhang X, Huang X, Yu M, et al. Reasons for COVID-19 Vaccine Hesitancy Among Chinese People Living With HIV/AIDS: Structural Equation Modeling Analysis. JMIR Public Health Surveill. 2022;8: e33995. doi:10.2196/33995 [Google Scholar] [Crossref]

20. Jones CL, Jensen JD, Scherr CL, Brown NR, Christy K, Weaver J. The Health Belief Model as an Explanatory Framework in Communication Research: Exploring Parallel, Serial, and Moderated Mediation. Health Commun. 2015;30: 566–576. doi:10.1080/10410236.2013.873363 [Google Scholar] [Crossref]

21. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3: 77–101. doi:10.1191/1478088706qp063oa [Google Scholar] [Crossref]

22. Brumbaugh K (Quirk), Gellert F, Mokdad AH. Understanding Vaccine Hesitancy: Insights and Improvement Strategies Drawn from a Multi-Study Review. Vaccines (Basel). 2025;13: 1003. doi:10.3390/vaccines13101003 [Google Scholar] [Crossref]

23. Dubé E, Laberge C, Guay M, Bramadat P, Roy R, Bettinger JA. Vaccine hesitancy. Hum Vaccin Immunother. 2013;9: 1763–1773. doi:10.4161/hv.24657 [Google Scholar] [Crossref]

24. Earnshaw VA, Eaton LA, Kalichman SC, Brousseau NM, Hill EC, Fox AB. COVID-19 conspiracy beliefs, health behaviors, and policy support. Transl Behav Med. 2020; ibaa090. doi:10.1093/tbm/ibaa090 [Google Scholar] [Crossref]

25. Shukla M, Schilt-Solberg M, Gibson-Scipio W. Medical Mistrust: A Concept Analysis. Nurs Rep. 2025;15: 103. doi:10.3390/nursrep15030103 [Google Scholar] [Crossref]

26. Larson HJ, Clarke RM, Jarrett C, Eckersberger E, Levine Z, Schulz WS, et al. Measuring trust in vaccination: A systematic review. Hum Vaccin Immunother. 2018;14: 1599–1609. doi:10.1080/21645515.2018.1459252 [Google Scholar] [Crossref]

27. Jaiswal J, Halkitis PN. Towards a More Inclusive and Dynamic Understanding of Medical Mistrust Informed by Science. Behav Med. 2019;45: 79–85. doi:10.1080/08964289.2019.1619511 [Google Scholar] [Crossref]

28. Kahan DM, Jenkins-Smith H, Braman D. Cultural cognition of scientific consensus. Journal of Risk Research. 2011;14: 147–174. [Google Scholar] [Crossref]