Our investigation is the first to investigate the acceptance of COVID-19 vaccines and its related factors among HIV/AIDS patients in China. This survey showed a lower rate (72.9%) of COVID-19 vaccination acceptance among HIV-infected patients compared to the general population (91.3%) in China, although it is higher than in other countries such as Russia (54.85%), France (58.89%) and Sweden (65.23%), according to global research. There were many studies showing that HIV/AIDS patients were at high risk of COVID-19 in severe manifestations, hospitalization and hospital mortality relative to HIV-negative persons[12, 14, 21]. Furthermore, many countries reported that the delivery of HIV healthcare services has been disrupted by COVID-19 and the consequences may increase morbidity and mortality in HIV-infected patients[22, 23]. South Africa is bearing the brunt of COVID-19 as it has the highest burden of AIDS and the World Health Organization estimated more than 500,000 extra deaths from HIV in the coming year. Accordingly, many countries have identified HIV-infected patients as their priority vaccination cohort[15, 22]. Investigation into acceptance and the factors influencing vaccination for HIV-infected patients is urgent and essential but it would be more feasible and effective to implement an immunization programme among this unique population in China or even worldwide in the future.
As shown in this research, we found that most patients (68.4%) learned about the COVID-19 epidemic but a substantial proportion of respondents (45.4%) had little knowledge of the vaccine. The WTV group possessed better knowledge about COVID-19 vaccine policy in China, such as the free vaccine policy, compared to the non-WTV group. Furthermore, most participants preferred the inactivated vaccine, mainly because the inactivated vaccine technology is more traditional and mature [25, 26] and many researchers have verified that this vaccine has high efficacy against coronavirus[5, 27]. Moreover, most of the WTV group have enough positive awareness to be willing to pay for the vaccine if it was charged for in the future, which may be due to the strong implementation of policies and services for the promotion of COVID-19 vaccination in China. However, some in the non-WTV group expressed that they would refuse vaccination even if there was free access without epidemic restrictions and also if a vast number of people were vaccinated in the future. Therefore, it is urgent to raise awareness of the relationship between the vaccine and AIDS in order to change their mindset.
The further analysis results revealed that vaccine safety is a strong factor affecting vaccine acceptance, which is in line with previous studies on concerns of the public[29, 30]. Many real-world studies have confirmed that COVID-19 vaccines are safe and effective around the world, including inactivated vaccine and mRNA vaccine[27, 31]. The amount of research above should, in theory, give great confidence to the public on vaccine safety. However, the survey reflected that HIV/AIDS patients are still concerned about the side effects and effectiveness of COVID-19 vaccine on themselves, they should be made aware that none of the COVID-19 vaccines were prepared using an attenuated vaccine strategy, which is designed to lose pathogenicity while retaining antigenicity, and therefore the vaccines may not be suitable for people with an impaired immune system[32, 33]. The effect of vaccines on ART efficacy is a great focus for HIV-infected patients: so far, no specific drug to cure AIDS has been developed and although ART is the most effective treatment available, patients still may be immunocompromised or immunosuppressed. A multicentre study found that HIV/AIDS patients receiving tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) had a lower risk for COVID-19 compared with other ART regimens, and a South African study had similar observations. In contrast, several studies reported no significance in the relationship between ART regimens and COVID-19 severity in HIV-infected patients[37, 38], although the findings are not yet conclusive, and some domestic experts recommended that HIV-infected patients on long-term antiviral therapy with a well-controlled HIV viral load and no vaccination contraindications should receive inactivated vaccine as soon as possible.
In addition, this study showed that the higher the education level, the higher the willingness to vaccinate, which was consistent with previous results among the general population[20, 40]. However, HIV/AIDS patients with lower education accounted for the majority in Guangxi, so it is necessary to strengthen knowledge of the COVID-19 vaccine among this population. Furthermore, a cohort study found that lower CD4+T cell counts were associated with COVID-19 mortality, however, other studies found no correlation between CD4+T cell count or HIV viral load and COVID-19 outcomes[37, 42], and our results also showed that CD4+T cell count was not statistically significant for acceptance of COVID-19 vaccines by stratified and multivariate analysis. From the research, our results showed no significant difference in gender and age among HIV/AIDS related to vaccine acceptance, which is inconsistent with some studies[7, 18] and may be attributed to the sample size of the survey.
Several limitations should be taken into account in this study. First, our survey used convenience sampling, which may lead to selection bias in some results. Second, we found no HIV-infected patients who had received the vaccine before this investigation and we had little knowledge on the side effects of the vaccine or ART efficacy among HIV-infected patients, thus we need to learn more about the post-vaccination status as a next step. We will conduct follow-up research on vaccinated patients, including the side effects of vaccination and alterations in immune function, such as CD4+T cell count and viral load, in order to provide some reference basis for future vaccine strategies.