COVID-19 vaccine hesitancy among PLWH in South India: Implications for vaccination campaigns

The global effort to end the Severe Acute Respiratory Syndrome - Coronavirus 2 pandemic has resulted in the development of multiple highly efficacious vaccines1 at an unprecedented speed. Despite an at times rocky roll out, several high-income countries are soon likely to find themselves in a situation in which supply exceeds demand. However, we are also seeing the consequences of vaccine inequities and of the inconsistent use of multiple nonpharmaceutical prevention strategies. Between May and July 2021, India, with a <10% vaccination rate of their population, experienced an enormous second COVID-19 surge, after reopening and allowing large rallies and religious festivals in the presence of the delta variant which is significantly more transmissible than both the wild-type virus and the formerly dominant alpha variant that was responsible for the surge in the United Kingdom and elsewhere during the winter of 2021.2–5 While we must work hard to provide access to those who are willing to get vaccinated with one of the effective and safe COVID-19 vaccines, public health must also turn to the “vaccine hesitant” and address concerns in various subpopulations who are reluctant to get a COVID-19 vaccine. The reasons for vaccine hesitancy with a COVID-19 vaccine might differ from those with past vaccination campaigns6–9 and include the newness of mRNA technology, used in several of the vaccines, and the recent reports of rare blood clots after vaccination with the adenovirus-based vaccines, 2 of which are currently provided by the Indian government. All of these issues have been magnified by social and other media6 and led to an unprecedented politicization of this particular pandemic, not only in the United States but also on social media globally. However, entrenched reasons, such as distrust among marginalized communities of the medical system and a failure to use community partners for community-based messaging,7 may also be playing a role. Given the importance of vaccination to reduce COVID-19–related severe disease, human suffering, hospitalizations and deaths, the risk of further variants, and to protect those not yet eligible for vaccination, it is crucial that we develop evidence-based vaccination uptake campaigns. To accomplish this, we need to better understand the factors that are driving hesitancy in different subpopulations, including people living with HIV (PLWH) who may be vulnerable to severe disease outcomes. PLWH globally, including in India, have been targets of stigma, leading to fear of status disclosure and delays in treatment seeking, with multiple adverse physical and mental health consequences.10–14 Recent research shows that this stigma may also have acted as an additional barrier to HIV management during the COVID-19 pandemic, for example, by forcing them to disclose their HIV status to obtain permission to travel to the clinic despite COVID-related travel restrictions.15–19 PLWH, especially those with multiple comorbidities20 and those with CD4 counts <200 copies/mL,21 are more at risk of severe outcomes with COVID-19 than those living without HIV, making vaccination of this subpopulation even more crucial. India is estimated to have 2,348,000 PLWH,22 with the southern state of Karnataka having the third highest number of cases (269,000). Since the implementation of the government's “test-and-treat” model, it is estimated that 80% of PLWH are linked to care23 and that 75% remain in care after 12 months.24 On March 1, 2021, India's COVID-19 vaccine roll out opened to people aged 45 years and older with underlying medical conditions, which included HIV. On May 1, 2021, vaccinations opened to the whole population, but uptake was initially slow because of a combination of supply and hesitancy. It is now important for vaccine promotion programs to understand the various factors that may be associated with hesitancy in this vulnerable population to help protect its members during the current and future surges.