For four decades, HIV/AIDS has been one of the world’s most serious public health challenges, with an estimated 36 million AIDS-related deaths worldwide since the start of the pandemic, and nearly 38 million people currently living with HIV.¹ Despite having the lowest estimated HIV prevalence rates in the world (< 0.1%), the Middle East and North Africa (MENA) region is an area of growing concern, with a 47% increase in new infections and a 57% increase in AIDS-related deaths compared to 2010.^2,3 In addition, in this region it is estimated that only 52% of people living with HIV (PLHIV) are aware of their status, and only 43% of all PLHIV are on antiretroviral treatment.^2,4

In the midst of global and regional efforts to control the HIV epidemic, the novel coronavirus disease 2019 (COVID-19) pandemic emerged, continuing to threaten hard-won gains made against HIV through service disruption, COVID-19 myths among PLHIV, and potential unknown implications of Long-COVID and HIV comorbidity.^5,6,7 As of December 2021, more than 17 million cases of COVID-19 and some 312 000 deaths have been reported across the region.⁸

Several MENA countries adopted strict containment measures to decrease the spread of COVID-19, including closing borders, schools, religious sites and public places, and imposing a full lockdown for certain periods of time.⁹ However, some of these measures intensified existing challenges to HIV care by impeding access to prevention, clinical care and treatment services,^5,6 and by generating or exacerbating stress, depression and isolation among PLHIV.¹⁰

Increased risk of COVID-19 mortality among PLHIV, compared to their HIV-negative counterparts, was demonstrated in South Africa and the United Kingdom.^11,12,13 Similarly, a study of over 15 000 cases of COVID-19 in PLHIV from 24 countries conducted by the World Health Organization found that PLHIV were at higher risk of severe or critical illness at the time of hospital admission and in-hospital mortality after controlling for age, gender and comorbidity burden.¹⁴

Vaccination is the most effective intervention to prevent severe illness and death from COVID-19.¹⁵ As of December 2021, over eight billion doses of COVID-19 vaccines have been administered globally, and 56% of the world population has received at least one dose.¹⁶ Despite this global progress, vaccination coverage remains very low in low- and lower-middle income countries, including those in the MENA region.¹⁷

Slow COVID-19 vaccine coverage reflects global supply issues as well as decreased demand due to vaccine hesitancy. Vaccine hesitancy, defined as ‘a delay in acceptance or refusal of vaccination despite availability of vaccination services’, has been a growing concern worldwide,¹⁸ prompting the World Health Organization to name it one of the top 10 global health threats in 2019. This challenge has grown during the COVID-19 pandemic.¹⁹ Existing studies on public perceptions and acceptance of COVID-19 vaccines in the MENA region illustrate that the Middle East is among the regions with the lowest rates of vaccine acceptance globally.^20,21 Vaccine hesitancy could jeopardise the success of COVID-19 vaccination programmes and undermine efforts to ensure high vaccination coverage rates, especially among vulnerable populations, such as PLHIV. The objectives of this study were to evaluate the acceptance of the COVID-19 vaccine and influencing factors among PLHIV in the MENA region.

Our study investigated COVID-19 vaccine acceptance among PLHIV in Egypt, Tunisia and Saudi Arabia, including associated factors such as sociodemographic characteristics, individuals’ HIV-related health, vaccine perceptions and health beliefs. The overall COVID-19 vaccine acceptance rate among PLHIV who participated in this survey is 64.6%, with wide variation between countries (92.0% in Saudi Arabia, 57.0% in Tunisia, and 46.0% in Egypt). These regional differences in vaccine acceptance are reflected by vaccination coverage in Saudi Arabia, where 71.2% of the general population have received at least one dose of a COVID-19 vaccine, compared with Tunisia (52.9%) and Egypt (27.3%), as of 12 December 2021.²³ A previous study conducted in January 2021 in France showed that 71.3% of PLHIV would accept COVID-19 vaccines, while 28.7% demonstrated hesitancy.²⁴ In eight cities in China between January and February 2021, 57.2% of PLHIV reported willingness to be vaccinated against COVID-19.²⁵ Compared to studies conducted in the MENA region, the acceptance of a COVID-19 vaccine among our study participants was higher than the general population in Jordan (28.4%), Egypt (43.0%), Oman (57.0%), Lebanon (58.8%), and Qatar (60.0%); similar to that in Saudi Arabia (64.7%); and lower than in Kuwait (67.0%), Somalia (76.8%) and Iraq (77.6%).^{20,26,27,28,29,30,31,32,33}

Our study is consistent with others regarding weaker COVID-19 vaccine acceptance among those residing in rural areas³⁴ and regarding age and gender among French PLHIV.²⁴ Compared to the general population in MENA region, there was mixed evidence with respect to the relationship between age and COVID-19 vaccine acceptance. Some studies demonstrate higher acceptance of COVID-19 vaccines among younger age groups,^30,32,35 and others report higher acceptance among older age groups.^29,31 Our results demonstrate comparable vaccine acceptance across gender, marital status and education level, differing from studies that demonstrate higher acceptance among male versus female participants, married versus non-married, and higher versus lower education level.^{29,30,31,32,35} The low acceptance rate among rural communities may reflect socio-economic disadvantage, lack of knowledge regarding COVID-19, and less preventive measures against the COVID-19 virus infection, including vaccines.

According to the HBM, feeling less worried about getting COVID-19 post-vaccination and believing it is vaccine-preventable were the most significant predictors of vaccine acceptance, whereas falsely believing HIV medications protect against COVID-19 transmission and having concerns about the vaccines’ effectiveness were stronger predictors for non-acceptance, consistent with similar studies evaluating effectiveness.^35,36 More than half of the participants were concerned about the vaccine side effects and 47% were concerned regarding potential interactions between their HIV treatment and COVID-19 vaccines.

This result is consistent with the findings of Huang et al.,²⁵ which showed that about half of PLHIV respondents in China had concerns related to side effects, and potential interactions between antiretroviral treatment and COVID-19 vaccines. Similarly, Vallée et al.²⁴ found that concerns about the serious side effects of COVID-19 vaccines were independently associated with COVID-19 vaccine hesitancy. Similar to studies conducted among the general population in the MENA region, concerns about COVID-19 vaccine safety and fear of side effects were among the most commonly cited reasons for vaccine hesitancy.^20,32,35

As relatively small numbers of PLHIV have been involved in the phase III COVID-19 vaccine trials, limited data has been available regarding COVID-19 vaccines in this specific population.^37,38,39 However, the World Health Organization, as well as several international health authorities, has released recommendations for PLHIV to receive COVID-19 vaccines and to address their safety and efficacy concerns.^40,41,42 These recommendations emphasise no evidence of safety concerns unique to PLHIV and, as with the general population, the vaccines are considered safe. Moreover, PLHIV have been considered as a priority group for the vaccination. Despite being widely reported by participants in our study, there is no compelling evidence to support the use of HIV medications for treatment or prevention of COVID-19, and no evidence on potential interaction between COVID-19 vaccine and HIV drugs.^40,41,42 These findings are important for PLHIV in this region. Authoritative and trustworthy information sources, such as national AIDS programmes and local health authorities, should engage PLHIV with clear, carefully crafted and consistent messages, communicated in plain, non-stigmatising language and in a way that people of all educational levels can understand, to address their specific concerns and perceived barriers regarding COVID-19 vaccination. Ensuring that PLHIV have adequate access to COVID-19 vaccines, as well as sufficient information to make evidence-based immunisation decisions, should be priorities of national health authorities.

Prior studies among the general population have shown that high perceived susceptibility of getting COVID-19 or perceptions of the severity of COVID-19 were significant predictors for vaccine acceptance.^35,43 In addition, low perceived severity of COVID-19 infection was highly correlated with COVID-19 vaccine refusal among French PLHIV.²⁴ However, among PLHIV in the MENA region, perception of susceptibility and severity of COVID-19 infection were not significant predictors. One explanation for decreased risk perception could be that, because of inadequate testing and underreported incidences of COVID-19 infections and mortalities in countries across the region,⁴⁴ people might consider COVID-19 to be an ordinary seasonal respiratory illness rather than the highly transmissible disease it is. This highlights a need to address risk perception and severity among PLHIV, as high-risk perceptions are important precursors to positive health behaviours, including being a significant predictor of intention to take the COVID-19 vaccine.^45,46 Low perceived risk may be correlated not only with vaccine acceptance, but also to adherence to social distancing measures and other public health countermeasures, in the absence of vaccine access.^45,46

Our finding on vaccine acceptance associated with a doctor recommendation, consistent with other studies, demonstrates that healthcare workers, on the frontline of HIV care, can play an influential role in building vaccination literacy and in improving trust in COVID-19 vaccines among PLHIV.⁴⁷ They should be well trained and equipped with the tools to support PLHIV, including listening to their fears and anxieties, answering their questions, and addressing their concerns towards vaccines, as well as correcting misinformation, and being aware of potential stigma concerns.

HIV is a highly stigmatised condition in the MENA region.⁴⁸ The stigmatising and discriminatory attitudes PLHIV face in healthcare settings could deter populations at high risk from seeking health services.⁴⁹ Many civil society organisations and community-based organisations in the region are led by or involve people most affected by HIV and have become integral to the MENA region’s HIV response. Civil society organisations are often more effective in reaching PLHIV and key populations than health authorities⁵⁰ and can therefore play an essential role in building trust in COVID-19 vaccines among these groups. Peer-support for PLHIV can also fulfill a useful role in promoting COVID-19 vaccination, sharing supportive advice and positive experiences of COVID-19 vaccination.

Those reporting more than one year since their last CD4+ cell count check may be less well engaged with the health system and may, in turn, inadvertently accept higher health risks (e.g., remaining unvaccinated) due to lack of information or access to care than those reporting more engagement. Leveraging lessons learned from models of hepatitis C virus/HIV care⁵¹ may provide practical solutions to make vaccination more convenient for PLHIV without risking disclosure of their HIV status. These include, for example, co-location of vaccination services within HIV clinics, ‘one-stop-shop’ models, and door-to-door administration, and can make vaccines easily accessible in safe, familiar and convenient locations.

Limitations of this study include potential selection bias using web-based survey methods, and the cross-sectional nature, preventing us from drawing any causal conclusions. Although Facebook and WhatsApp platforms were valuable in helping to achieve the minimum sample, selection bias could have been introduced by using these methods of advertisement. Nevertheless, this study is the first to evaluate COVID-19 vaccine acceptance and its associated factors among PLHIV in the MENA region. Such findings should help policymakers planning interventions to improve vaccination coverage among this group.

This study reports overall COVID-19 vaccine acceptance of 64.6% among PLHIV in three countries of the MENA region. Factors for vaccine acceptance included feeling less worried about COVID-19 transmission post-vaccination, believing COVID-19 is vaccine-preventable, and having a doctor recommendation. Factors against getting vaccinated included living in a rural area, having a most recent CD4+ cell count check more than one year ago, having concerns about vaccine effectiveness and believing HIV medications protect against COVID-19 transmission. Effective strategies are needed to guarantee PLHIV access to COVID-19 vaccines as a priority group for vaccination as well as to increase vaccine acceptance among PLHIV through clearly tailored messages, addressing their specific concerns and improving their knowledge and awareness about the safety and benefits of COVID-19 vaccines.