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. Author manuscript; available in PMC: 2025 Apr 1.
Published in final edited form as: J Acquir Immune Defic Syndr. 2024 Apr 1;95(4):329–341. doi: 10.1097/QAI.0000000000003369

Factors Associated with COVID-19 Vaccination among Racial/Ethnic Minority Groups with HIV in South Florida

Daisy Ramírez-Ortiz 1, Michele Jean-Gilles 2, Diana M Sheehan 1,3, Robert Ladner 4, Tan Li 5, Mary Jo Trepka 1,3
PMCID: PMC10922309  NIHMSID: NIHMS1951903  PMID: 38133577

Abstract

Background:

Racial/ethnic minority groups with HIV in the United States are particularly vulnerable to COVID-19 consequences and can significantly benefit from increased uptake of COVID-19 vaccines. This study identified factors associated with full COVID-19 vaccination among people with HIV.

Setting:

Ryan White HIV/AIDS Program (RWP) in Miami-Dade County, Florida.

Methods:

Data were collected from 299 RWP adult clients during January–March 2022 using a cross-sectional phone survey. Multivariable logistic regression was used to estimate adjusted odds ratios (aORs) with 95% confidence intervals (CIs). All analyses were weighted to be representative of the race/ethnicity and sex distribution of clients in the RWP.

Results:

Eighty-four percent of participants were fully vaccinated with a primary vaccine series; stratified by race/ethnicity, the percentages were 88.9% of Hispanic, 72.0% of Black/African American, and 67.5% of Haitian participants. Fully vaccinated participants were less likely to be Black/African American than Hispanic (aOR=0.18; 95% CI=0.05-0.67) and more likely to not endorse any misconceptions about COVID-19 vaccines (aOR=8.26; 95% CI=1.38-49.64), to report encouragement to get vaccinated from sources of information (aOR=20.82; 95% CI=5.84-74.14), and to perceive that more than 50% of their social network was vaccinated (aOR=3.35; 95% CI=1.04-10.71). Experiences of healthcare discrimination, structural barriers to access vaccines, and recommendations from HIV providers were not associated with full vaccination.

Conclusions:

These findings highlight the importance of delivering accurate and positive messages about vaccines and engaging social networks to promote COVID-19 vaccination among PWH. This information can be leveraged to promote uptake of subsequent boosters and other recommended vaccines.

Keywords: HIV, COVID-19, Vaccination

Introduction

Population-based studies have shown that people with HIV (PWH) are at higher risk of severe COVID-19 outcomes, including death, than people without HIV.1–4 This higher risk is related to immunodeficiencies (i.e., low CD4 cell count, unsuppressed viral load) and co-infections (i.e., tuberculosis) associated with HIV as well as high prevalence of medical comorbidities associated with severe COVID-19 disease (e.g., diabetes, obesity, and cardiovascular disease).1,5 Among PWH, Hispanic and non-Hispanic Black people have greater rates of COVID-19-related hospitalizations, admissions to intensive care unit, and deaths compared with non-Hispanic White people.1

Little is known about COVID-19 vaccine uptake among PWH and even less among PWH from racial/ethnic minority groups in the United States (U.S.). The limited data available to date suggest that vaccination rates may be sub-optimal among PWH. A study using New York State surveillance data reported that 68% of PWH had been fully vaccinated (39% of these had been boosted), and 4% had been partially vaccinated as of March 2022.6 Another surveillance study conducted among PWH living in Oregon reported that 61.6% had received at least one COVID-19 vaccine dose and 56.6% had received a complete vaccine series as of June 2021.7 Further, another study conducted in 2021 using a U.S. national sample of PWH reported that 64.3% of participants had received at least one dose of a COVID-19 vaccine.8 In these studies, Hispanic and non-Hispanic Black/African American people had lower uptake of COVID-19 vaccination compared with non-Hispanic White people.6–8

Data from the U.S. National Immunization Survey indicate that disparities in COVID-19 vaccination for some racial/ethnic groups have narrowed over time.9 As of March 2023, an estimated 89.2% of non-Hispanic Black people and 89.1% of Hispanic people (versus 87.0% of non-Hispanic White people) reported having received at least one dose of a COVID-19 vaccine, and 85.1% of non-Hispanic Black people and 84.0% of Hispanic people (versus 84.3% of non-Hispanic White people) reported having received a complete vaccine series.9 However, only 29.3% of non-Hispanic Black people and 25.6% of Hispanic people as compared to 37.5% of non-Hispanic White people reported having received an updated bivalent booster, suggesting that disparities are increasing again.9

To successfully increase vaccine uptake among PWH and guide ongoing vaccination promotion efforts, it is important to understand disparities and determinants of COVID-19 vaccination in this population. Few studies have been conducted to understand determinants of COVID-19 vaccination uptake among PWH in the U.S.; these studies report that younger age, lower education level, Hispanic ethnicity, rural residency, no history of recent influenza vaccination, having a transmission risk of injection drug use, no engagement in HIV care, and unsuppressed viral load negatively influence uptake of COVID-19 vaccination in this population.7,8,10 Our study adds to the limited existing research among PWH by describing COVID-19 vaccine uptake and associated factors as well as common places of vaccination and reasons for no vaccination in a sample of racial/ethnic minority PWH in Miami-Dade County, Florida. Our study focuses on the three predominant racial/ethnic minority groups with HIV in South Florida, Hispanic, Haitian, African American (excluding Haitian) groups,11 and examines COVID-19 vaccine uptake among Haitian PWH as a separate group from African American PWH due to linguistic and other cultural differences.

Methods

Participants, Study Design and Procedures

An exploratory cross-sectional phone survey was conducted among a sample of 299 adults who have received medical case management services through the Miami-Dade County Ryan White HIV/AIDS Program (RWP). The RWP is a federally-funded program that provides no-cost HIV medical care, medications, medical case management, and ancillary support services to low-income PWH.12 Participants self-identified as being Haitian, Hispanic/Latino, Black/African American (hereafter African Americans), and non-Hispanic non-Haitian White (hereafter NHNHW). To be eligible for the survey, clients had to 1) have participated in a previous survey conducted in 2021 that assessed COVID-19 burden and its effects on HIV care access, 2) be currently enrolled in the RWP, and 3) have previously agreed to be contacted again for research. For each participant we were unable to enroll or for each one who was no longer a client of the RWP, we attempted to enroll a replacement of the same racial/ethnic and gender group from the list of clients who had been enrolled in the program since at least 2019, had previously provided consent for research, and spoke English, Spanish, or Haitian Creole. Potential participants were contacted through a text message first to introduce the study, and then called up to 5 times. A total of 113 (37.9%) clients who participated in the first survey were reached, and the remaining either were no longer clients of RWP (n=82) or didn’t answer any calls/verbally refused participation (n=103). Participants completed the survey in their preferred language and received a $50 gift card for their time. The survey was conducted between January and March 2022. The study was approved by [blinded institution name] Institutional Review Board, and all participants provided verbal informed consent.

Survey Instrument and Measures

The survey instrument was translated into Spanish and Haitian Creole by a native speaker and was piloted and revised in all three languages. It included questions about COVID-19 vaccine uptake, possible factors influencing vaccine uptake, and the COVID-19 Pandemic burden and its effects on HIV care. The Health Belief Model (HBM)13 and the Social Ecological Model (SEM)14 were used to guide the selection of factors to be measured that could influence COVID-19 vaccine uptake.

Full COVID-19 vaccination status was determined using the question “have you received a COVID-19 vaccine?” (responses: 1=yes, 2=no, and 3=don’t know), and follow-up questions about number of doses, vaccine products received, and dates of vaccination. Those participants who received a primary vaccine series were classified as fully vaccinated, and those that received only one dose of a two-dose vaccine series or did not receive any doses were classified as not fully vaccinated. Participants fully vaccinated were asked where they received the most recent COVID-19 vaccine dose, and those not fully vaccinated were asked why they decided not to get vaccinated and about their intention to get the COVID-19 vaccine.

Sociodemographic questions included age group, gender, sexual orientation, race/ethnicity, and highest level of education. Household income as a percentage of U.S. federal poverty level was obtained from RWP administrative records. To assess HBM domains, participants were asked about perceived susceptibility to severe COVID-19, and perceived benefits and misconceptions about the COVID-19 vaccine (responses: 1=strongly agree to 5=strongly disagree, and 6=don’t know; items used for each domain are listed in Table 1). They were also asked about their perceptions of the vaccine’s trustworthiness with respect to safety (responses: 1=not at all safe to 4=very safe, and 5=don’t know) and effectiveness against COVID-19 (responses: 1=not at all effective to 4=very effective, and 5=don’t know). In terms of cues to action, participants were asked whether they received a recommendation from their HIV doctors and case managers to receive the COVID-19 vaccine (responses: 1=recommended that you get vaccinated, 2=recommended that you not get vaccinated, 3=didn’t make a recommendation, and 4=not sure/don’t know), and whether the information they received encouraged them to get vaccinated (responses: 1=totally encouraged me to get vaccinated to 5=totally discouraged me from getting vaccinated, and 6=don’t know).

Table 1.

Characteristics of sample by COVID-19 vaccination status

COVID-19 Vaccination Statusa
Total survey sample Fully vaccinated Not fully vaccinated
299 234 (83.8) 65 (16.2)
n (weighted %) n (weighted column %) n (weighted column %) p-value
Sociodemographic Characteristics
Age group (years) 24-34 23 (8.9) 14 (7.8) 9 (14.5) 0.0062 #
35-49 80 (24.2) 57 (21.5) 23 (38.3)
50+ 196 (66.9) 163 (70.8) 33 (47.3)
Gender b Cisgender female 147 (19.2) 111 (17.0) 36 (30.8) 0.0261
Cisgender male 147 (80.8) 119 (83.0) 28 (69.2)
Missing 5 4 1
Sexual orientation Lesbian, gay, bisexual or other 107 (63.7) 87 (66.1) 20 (50.8) 0.0506
Heterosexual 185 (36.3) 142 (33.9) 43 (49.2)
Missing 7 5 2
Race/ethnicity Hispanic 128 (62.0) 112 (65.8) 16 (42.4) 0.0004 * #
Haitian 51 (10.0) 33 (8.1) 18 (20.0)
African American 110 (20.0) 81 (17.2) 29 (34.5)
Non-Hispanic non-Haitian White (NHNHW) 10 (8.0) 8 (9.0) 2 (3.1)
Highest level of education Less than high school or high school diploma or GED 156 (60.7) 118 (36.9) 38 (52.2) 0.0455
Some college or college graduate 143 (39.4) 116 (63.1) 27 (47.8)
Federal poverty level ≤100% 139 (38.9) 101 (33.7) 38 (66.0) <0.0001
>100% 160 (61.1) 133 (66.3) 27 (34.0)
Health Belief Model Factors
Perceived susceptibility
Perceived susceptibility to severe COVID-19 People with HIV who are not vaccinated are at risk for serious health consequences from COVID-19. <0.0001
Agree 205 (73.2) 185 (81.7) 20 (29.2)
Neither/Disagree/Don’t know 94 (26.8) 49 (18.3) 45 (70.8)
Perceived benefits
Perceived benefits of COVID-19 vaccine The COVID-19 vaccine can reduce the chance of COVID-19 infection. <0.0001
Agree 199 (70.7) 179 (78.4) 20 (31.0)
Neither/Disagree/Don’t know 100 (29.3) 55 (21.6) 45 (69.0)
The COVID-19 vaccine can decrease the severity of COVID-19 such as prevent hospitalization and death. <0.0001
Agree 235 (84.2) 210 (92.8) 25 (39.9)
Neither/Disagree/Don’t know 64 (15.8) 24 (7.2) 40 (60.1)
The COVID-19 vaccine can help prevent people from spreading the virus to others. <0.0001
Agree 168 (62.5) 150 (69.7) 18 (25.5)
Neither/Disagree/Don’t know 131 (37.5) 84 (30.3) 47 (74.5)
Number of endorsed perceived benefits of COVID-19 vaccinec <0.0001
0 39 (8.6) 8 (1.4) 31 (45.8)
1-2 126 (41.1) 103 (41.7) 23 (37.7)
3 134 (50.4) 123 (57.0) 11 (16.5)
Perceived barriers
Perceived misconceptions about COVID-19 vaccine The COVID-19 vaccine enters your cells and changes your DNA or genetic material. <0.0001
Agree 38 (13.2) 22 (8.0) 16 (41.6)
Neither/Disagree/Don’t know 257 (86.8) 210 (92.0) 47 (58.4)
Missing 4 2 2
The COVID-19 vaccine causes a person to get COVID-19. <0.0001
Agree 37 (11.5) 20 (7.1) 17 (34.4)
Neither/Disagree/Don’t know 255 (88.5) 209 (92.9) 46 (65.6)
Missing 7 5 2
People have serious side effects after getting the COVID-19 vaccine. 0.0006
Agree 109 (32.2) 73 (28.1) 36 (53.2)
Neither/Disagree/Don’t know 190 (67.9) 161 (71.9) 29 (46.8)
The COVID-19 vaccine can affect a person’s fertility. 0.0073
Agree 22 (6.8) 13 (4.9) 9 (16.7)
Neither/Disagree/Don’t know 274 (93.2) 218 (95.1) 56 (83.3)
Missing 3 3
People who already had COVID-19 don’t need to get the COVID-19 vaccine. 0.0002
Agree 37 (10.9) 24 (8.0) 13 (26.8)
Neither/Disagree/Don’t know 261 (89.1) 210 (92.0) 51 (73.2)
Missing 1 1
The development of the COVID-19 vaccine was too rushed, so its effectiveness and safety cannot be trusted. <0.0001
Agree 80 (22.9) 42 (14.3) 38 (67.2)
Neither/Disagree/Don’t know 219 (77.1) 192 (85.7) 27(32.8)
Number of endorsed perceived misconceptions about COVID-19 vaccinec <0.0001
0 137 (49.9) 121 (56.0) 16 (18.2)
1-3 135 (41.8) 101 (39.4) 34 (54.1)
4-6 27 (8.3) 12 (4.6) 15 (27.7)
Perceived trustworthiness (safety and effectiveness) of COVID-19 vaccine [VACCINATED] At the time you got the first dose of the COVID-19 vaccine, how safe did you think the COVID-19 vaccine was for you? / [UNVACCINATED] How safe do you think the COVID-19 vaccine is for you?d <0.0001
Very or moderately safe 241 (83.7) 214 (92.2) 27 (38.9)
A little/Not at all safe/Don’t know 56 (16.3) 20 (7.8) 36 (61.1)
Missing 2 2
[VACCINATED] At the time you got the first dose of the COVID-19 vaccine, how effective did you think the COVID-19 vaccine was in protecting you against COVID-19? / [UNVACCINATED] How effective do you think the COVID-19 vaccine is in protecting you against COVID-19?d <0.0001
Very or moderately effective 245 (85.8) 219 (95.1) 26 (37.7)
A little/Not at all effective/Don’t know 53 (14.2) 15 (4.9) 38 (62.3)
Missing 1 1
Cues to action
Recommendation from HIV providers (doctors and case managers) to receive COVID-19 vaccine What recommendation, if any, did your Ryan White doctor give you about the COVID-19 vaccine? 0.4048
Recommended that you get vaccinated 225 (68.4) 174 (67.4) 51 (73.4)
Recommended that you not get vaccinated/Didn’t make a recommendation/Not sure/Don’t knowe 73 (31.7) 59 (32.6) 14 (26.6)
Missing 1 1
What recommendation, if any, did your Ryan White medical case manager give you about the COVID-19 vaccine? 0.5584
Recommended that you get vaccinated 160 (49.5) 125 (48.8) 35 (53.4)
Recommended that you not get vaccinated/Didn’t make a recommendation/Not sure/Don’t knowf 139 (50.5) 109 (51.2) 30 (46.7)
Encouragement to get COVID-19 vaccine from information received Overall, has the information you have received encouraged you to get vaccinated, or discouraged you from getting vaccinated? <0.0001
Totally or somewhat encouraged me 223 (78.6) 210 (91.1) 13 (14.6)
Had no effect on me/Somewhat or totally discouraged me/Don’t know 76 (21.4) 24 (9.0) 52 (85.4)
Social Ecological Model Factors
Intrapersonal-level factors
COVID-19 related medical mistrust The government cannot be trusted to tell the truth about COVID-19. <0.0001
Agree 101 (31.5) 62 (25.1) 39 (64.6)
Neither/Disagree/Don’t know 198 (68.5) 172 (74.9) 26 (35.4)
When it comes to COVID-19, people cannot trust health care providers. 0.0002
Agree 48 (16.2) 31 (12.8) 17 (34.2)
Neither/Disagree/Don’t know 251 (83.8) 203 (87.3) 48 (65.8)
Endorsed COVID-19 related medical mistrustg <0.0001
Yes 115 (35.4) 73 (28.9) 42 (69.3)
No 184 (64.6) 161 (71.2) 23 (30.7)
Interpersonal-level factors
Perceived importance of COVID-19 vaccine by social network How important is COVID-19 vaccination to your family and friends? <0.0001
Extremely or moderately important 229 (77.7) 198 (84.9) 31 (40.3)
Neutral/Slightly important/Not at all important/Don’t know 70 (22.3) 36 (15.1) 34 (59.8)
Perceived percentage of social network vaccinated with COVID-19 vaccine How many of your family and friends have gotten the COVID-19 vaccine? <0.0001
>50% 197 (70.6) 177 (79.1) 20 (26.7)
≤50% 96 (29.4) 53 (20.9) 43 (73.3)
Missing 6 4 2
Institutional- and community-level factors
Personal experiences of healthcare discrimination Have you ever personally experienced discrimination because of your HIV status when going to a doctor or another health care provider? 0.3930
Yes 35 (15.4) 28 (16.2) 7 (11.3)
No or don’t know 263 (84.6) 205 (83.8) 58 (88.7)
Missing 1 1
How about because of your race/ethnicity? 1.0000*
Yes 27 (8.7) 20 (8.8) 7 (8.0)
No or don’t know 271 (91.4) 213 (91.2) 58 (92.0)
Missing 1 1
How about because of your gender or sexual identity? 0.8647
Yes 20 (11.1) 14 (11.0) 6 (11.8)
No or don’t know 278 (88.9) 219 (89.0) 59 (88.2)
Missing 1 1
Reported personal experiences of institutional discriminationg 0.8980
Yes 58 (23.9) 43 (23.8) 15 (24.6)
No 240 (76.1) 190 (76.2) 50 (75.4)
Missing 1 1
Avoidance of healthcare discrimination Have you ever avoided going to a doctor or another health care provider out of concern that you would be discriminated against or treated poorly because of your HIV status? 0.7036
Yes 53 (19.2) 40 (18.8) 13 (21.2)
No or don’t know 246 (80.8) 194 (81.2) 52 (78.8)
How about because of your race/ethnicity? 1.0000
Yes 26 (8.0) 21 (8.0) 5 (7.9)
No 273 (92.1) 213 (92.0) 60 (92.1)
How about because of your gender or sexual identity? 0.5600
Yes 16 (8.0) 11 (7.5) 5 (11.0)
No 283 (92.0) 223 (92.6) 60 (89.0)
Reported avoidance of discriminationg 0.7676
Yes 68 (24.8) 54 (25.1) 14 (23.1)
No 231 (75.2) 180 (74.9) 51 (76.9)
Ease of access to COVID-19 vaccine [VACCINATED] How easy was it for you to get your first COVID-19 vaccine dose? / [UNVACCINATED] How easy do you think it is to get a COVID-19 vaccine dose?d 0.5690*
Very or somewhat easy 231 (83.4) 206 (83.8) 25 (79.7)
Neither/Somewhat or very difficult/Don’t know 40 (16.6) 28 (16.2) 12 (20.4)
Missing 28 28
Perceived barriers to access COVID-19 vaccine
HIV disclosure concerns [VACCINATED] At the time I got the first dose of the COVID-19 vaccine, I was worried that someone would learn that I have HIV if I got vaccinated with the COVID-19 vaccine. / [UNVACCINATED] I worry that someone will learn that I have HIV if I get vaccinated with the COVID-19 vaccine.d 0.7990
Agree 40 (13.3) 30 (13.5) 10 (12.1)
Neither/Disagree/Don’t know 257 (86.7) 202 (86.5) 55 (87.9)
Missing 2 2
Structural access barriers [VACCINATED] At the time I got the first dose of the COVID-19 vaccine, it was difficult to find a place to get vaccinated with the COVID-19 vaccine. / [UNVACCINATED] It is difficult to find a place to get vaccinated with the COVID-19 vaccine.d 0.0551
Agree 39 (17.1) 35 (19.0) 4 (7.6)
Neither/Disagree/Don’t know 260 (82.9) 199 (81.0) 61 (92.4)
[VACCINATED] At the time I got the first dose of the COVID-19 vaccine, vaccination sites for the COVID-19 vaccine were too far away. / [UNVACCINATED] Vaccination sites for the COVID-19 vaccine are too far away.d 0.0744
Agree 28 (13.9) 23 (15.4) 5 (5.8)
Neither/Disagree/Don’t know 271 (86.1) 211 (84.6) 60 (94.2)
[VACCINATED] At the time I got the first dose of the COVID-19 vaccine, I didn’t have transportation to go get vaccinated with the COVID-19 vaccine. / [UNVACCINATED] I don’t have transportation to go get vaccinated with the COVID-19 vaccine.d 1.0000*
Agree 26 (7.2) 20 (7.4) 6 (6.1)
Neither/Disagree/Don’t know 273 (92.8) 214 (92.6) 59 (94.0)
[VACCINATED] At the time I got the first dose of the COVID-19 vaccine, the hours of operation of vaccination sites for the COVID-19 vaccine were inconvenient. / [UNVACCINATED] The hours of operation of vaccination sites for the COVID-19 vaccine are inconvenient.d 0.2348*
Agree 24 (7.5) 17 (6.7) 7 (11.8)
Neither/Disagree/Don’t know 275 (92.5) 217 (93.3) 58 (88.2)
[VACCINATED] At the time I got the first dose of the COVID-19 vaccine, the waiting time to get vaccinated with the COVID-19 vaccine was too long. / [UNVACCINATED] The waiting time to get vaccinated with the COVID-19 vaccine is too long.d 0.0959
Agree 46 (16.4) 27 (14.8) 19 (24.4)
Neither/Disagree/Don’t know 253 (83.7) 207 (85.2) 46 (75.6)
Number of endorsed structural barriers to access COVID-19 vaccinec 0.7380
0 203 (63.5) 165 (63.6) 38 (63.3)
1-2 79 (29.1) 56 (28.6) 23 (31.7)
3-5 17 (7.4) 13 (7.9) 4 (5.0)
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Notes:

Actual frequencies are reported.

All percentages are weighted.

Columns may not add up to 100% due to rounding.

Bold indicates statistically significant difference.

*

Estimated using Fisher’s exact test.

#

Bonferroni correction

Age group: 24-34 vs. 35-49=0.9379; 24-34 vs. 50+=0.0574*; 35-49 vs. 50+=0.0039; Alpha Bonferroni correction (0.05/3=0.017).

Race/ethnicity: Hispanic vs. AA=0.0016; Hispanic vs. Haitian=0.0036*; Hispanic vs. NHNHW=0.4793*; AA vs. Haitian=0.6568; AA vs. NHNHW=0.0296; Haitian vs. NHNHW=0.0149*. Alpha Bonferroni correction (0.05/6=0.008).

a

129 fully vaccinated participants reported receiving an additional primary or booster dose and 9 not fully vaccinated participants received only 1 dose of a two-dose vaccine series.

b

Transgender participants were classified as missing and excluded from the analysis of the gender variable due to small numbers in this category (n=4).

c

Due to the small sample size to run the weighted logistic regression model with all significant variables from the bivariate analyses, variables measuring the number of endorsed perceived benefits of COVID-19 vaccine, perceived misconceptions about COVID-19 vaccine, and perceived structural barriers to access COVID-19 vaccine were created.

d

This question/statement was worded differently depending on the COVID-19 vaccination status of participants.

e

4 (2.4%) participants responded “recommended that you not get vaccinated” and 67 (27.8%) responded “didn’t make a recommendation” in this variable.

f

3 (2.2%) participants responded “recommended that you not get vaccinated” and 130 (46.7%) responded “didn’t make a recommendation” in this variable.

g

Due to the small sample size to run the weighted logistic regression model with all significant variables from the bivariate analyses, variables measuring whether each participant endorsed a COVID-19 related medical mistrust belief, reported a personal experience of healthcare discrimination, and avoidance of healthcare discrimination were created.

To assess intrapersonal level SEM domains, participants were asked about their level of agreement with two COVID-19 medical mistrust beliefs (responses: 1=strongly agree to 5=strongly disagree, and 6=don’t know).15 At the interpersonal level, participants were asked about perceived importance of COVID-19 vaccine by family and friends (responses: 1=not at all important to 5=extremely important, and 6=don’t know), and perceived percentage of family and friends who received the COVID-19 vaccine (1=none to 5=all, and 6=don’t know). To assess institutional and community level SEM domains, participants were asked if they had any personal experiences of discrimination when seeking healthcare or avoided seeking healthcare out of discrimination concerns because of HIV status, race/ethnicity and gender/sexual identity (responses: 1=yes, 2=no, and 3=don’t know).16 They were also asked about their first and second most important sources of information about COVID-19 and vaccination (open-ended question). Additionally, participants were asked about ease of access to COVID-19 vaccine (responses: 1=very easy to 5=very difficult, and 6=don’t know) and their level of agreement with perceived barriers to obtaining the COVID-19 vaccine including worry about disclosure of HIV status when getting vaccinated and structural barriers such as difficulty finding a vaccination place, long distance to vaccination sites, lack of transportation, inconvenient hours of operation, and long waiting times (responses: 1=strongly agree to 5=strongly disagree, and 6=don’t know).

Statistical Analysis

Descriptive analyses using chi-squared tests or Fisher’s exact tests as appropriate were performed to compare sociodemographic characteristics and the domains of the HBM and SEM by full COVID-19 vaccination status. Multiple comparisons between age and race/ethnicity sub-groups were adjusted by using the Bonferroni method. Multivariable logistic regression was used to estimate adjusted odds ratios (ORs) with 95% confidence intervals (CIs). The final adjusted model included all sociodemographic characteristics selected a priori, as well as covariates with a p-value <0.2 in the bivariate analyses. To avoid model convergence failure due to small sample size for the large number of significant independent variables to be included in the full model, we did the following: 1) created variables measuring whether each participant endorsed any items of a measure or the number of endorsed items of a measure (endorsement=strongly agree/agree or yes), 2) responses of questions were aggregated into broader categories (e.g., agree vs. neither/disagree/don’t know), and 3) don’t know responses were included in the analyses (distribution of don’t know responses are in Supplemental Table 1). The new variables created included: number of endorsed perceived benefits of COVID-19 vaccine (3 items [listed on Table 1]; categories: 0, 1-2, 3), number of endorsed perceived misconceptions about COVID-19 vaccine (6 items; categories: 0, 1-3, 4-6), number of endorsed structural barriers to access COVID-19 vaccine (5 items; categories: 0, 1-2, 3-5), endorsed COVID-19 related medical mistrust (2 items; categories: yes, no), reported personal experiences of healthcare discrimination (3 items; categories: yes, no), and reported avoidance of healthcare discrimination (3 items; categories: yes, no). Further, listwise deletion removed participants with missing values on any variable included in the adjusted logistic regression model reducing the sample size from 299 to 280. Four participants who self-identified as transgender were classified as missing and excluded from the analyses due to small number in the gender category. Additionally, we ran an exploratory adjusted model including sociodemographic variables only, to compare fully vaccinated participants who received an additional primary or booster dose with those who didn’t receive an additional primary or booster dose.

Inverse probability weights were calculated based on the race/ethnicity and sex distribution of clients in the Miami-Dade County RWP.17 All analyses were weighted to be representative of the target population. Statistical analyses were performed using SAS 9.4, and p-value <0.05 was used for statistical significance.

Results

Sample Characteristics

The weighted sample was 62.0% Hispanic, 20.0% African American, 10.0% Haitian, and 8.0% NHNHW (n=299; Table 1). Overall, 66.9% of participants were 50 years or older, 80.8% were cisgender male, and 63.7% identified as lesbian, gay, bisexual, or other. In addition, 60.7% had no education beyond high school diploma or GED, and 38.9% were living at or under 100% of the U.S. federal poverty level.

COVID-19 Vaccination Uptake, Places, Reasons and Sources of Information

Regarding COVID-19 vaccine uptake, 83.8% of the weighted sample was fully vaccinated with a primary vaccine series, and 16.2% was not fully vaccinated (Table 1). Ninety-four percent of NHNHW, 88.9% of Hispanic, 72.0% of African American, and 67.5% of Haitian participants were fully vaccinated. Among participants with a complete vaccine series, 65.7% reported having received an additional primary or booster dose. The most frequently reported places where participants received their most recent dose of the vaccine were pharmacy (45.1%), Ryan White agency or doctor’s office (27.8%), and at a public vaccination site (17.5%) (Figure 1).

Figure 1. Place of Most Recent Dose of COVID-19 Vaccine, Percent of Those Fully Vaccinated.

Figure 1.

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*Weighted percentage of participants who were fully vaccinated (n=234)

Among those not fully vaccinated, 85.0% did not receive any dose of the vaccine, and 15.0% received only one dose of a two-dose vaccine series. Seventy-five percent of participants who did not receive any vaccine doses reported no intention to get vaccinated in the next 6 months or ever. The most frequent reasons for not getting vaccinated were “I worry about side effects” (67.2%), “I am concerned about the quality of the vaccine” (55.0%), “I do not think the vaccine will protect me from infection” (40.3%), and “I worry that the vaccine may cause health problems in the future” (38.6%) (Figure 2).

Figure 2. Reasons for Not Getting Vaccinated with COVID-19 Vaccine Percent of People Not Fully Vaccinated Agreeing to Each Reason.

Figure 2.

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* Weighted percentage of participants not fully vaccinated (n=55)

1 missing data on this question

Total do not sum to 100 percent as this question allowed for multiple choices to be selected.

Other reasons mentioned included: it is difficult to get the vaccine, experience with allergic reaction to flu vaccine, worry about vaccine further compromising immune system due to having HIV, uneducated about the vaccine, don’t trust or need the vaccine, blood pressure went high when decided to take the vaccine, don’t want to get the vaccine or not interested in getting the vaccine, hasn’t decided yet, religious reasons, and scared for life due to being a Black person in America.

Overall, the most important sources of information for COVID-19 and vaccination reported by participants were TV/radio/newspapers (39.4%), healthcare providers/medical case managers/case management agencies (23.4%), and online or social media websites/other sources (22.0%) respectively (Supplemental Table 2).

Factors Associated with Full COVID-19 Vaccination

Results from the bivariate analyses showed that participants fully vaccinated were more likely than those not fully vaccinated to be 50 years or older, cisgender male, Hispanic, have at least some college education, and have household incomes over 100% of the U.S. federal poverty line (Bonferroni comparisons are reported in Table 1).

From the bivariate analyses of the HBM factors, participants fully vaccinated were more likely than those not fully vaccinated to agree that PWH who are not vaccinated are at risk for serious health consequences from COVID-19 (81.7% vs. 29.2%, P<0.0001), and to report that the information they received totally or somewhat encourage them to get vaccinated (91.1% vs. 14.6%, P<0.0001). Also, participants fully vaccinated were more likely than those not fully vaccinated to endorse agreement with perceived benefits of the COVID-19 vaccine, 1) “can reduce the chance of COVID-19 infection” (78.4% vs. 31.0%, P<0.0001), 2) “can decrease the severity of COVID-19 such as prevent hospitalization and death” (92.8% vs. 39.9%, P<0.0001), and 3) “can help prevent people from spreading the virus to others” (69.7% vs. 25.5%, P<0.0001). Moreover, participants fully vaccinated were less likely than those not fully vaccinated to endorse agreement with perceived misconceptions about COVID-19 vaccine, 1) “enters your cells and changes your DNA or genetic material” (8.0% vs. 41.6%, P<0.0001), 2) “causes a person to get COVID-19” (7.1% vs. 34.4%, P<0.0001), 3) “people have serious side effects after getting the COVID-19 vaccine” (28.1% vs. 53.2%, P=0.0006), 4) “can affect a person’s fertility” (4.9% vs. 16.7%, P=0.0073), 5) “people who already had COVID-19 don’t need to get the COVID-19 vaccine” (8.0% vs. 26.8%, P=0.0002), and 6) “the development of the COVID-19 vaccine was too rushed, so its effectiveness and safety cannot be trusted” (14.3% vs. 67.2%, P<0.0001). Additionally, participants fully vaccinated were more likely than those not fully vaccinated to report that the vaccine was very or moderately safe for them (92.2% vs. 38.9%, P<0.0001) and effective in protecting them against COVID-19 (95.1% vs. 37.7%, P<0.0001). Receiving a recommendation from HIV doctors or case managers to get vaccinated was not associated with full COVID-19 vaccination.

With respect to the SEM factors, participants fully vaccinated were less likely than those not fully vaccinated to endorse agreement with the two COVID-19 related medical mistrust beliefs, 1) “the government cannot be trusted to tell the truth about COVID-19” (25.1% vs. 64.6%, P<0.0001), and 2) “when it comes to COVID-19, people cannot trust health care providers” (12.8% vs. 34.2%, P=0.0002). In terms of social network norms, participants fully vaccinated were more likely than those not fully vaccinated to report that COVID-19 vaccination is extremely or moderately important for their family and friends (84.9% vs. 40.3%, P<0.0001) and that >50% of their family and friends have gotten the COVID-19 vaccine (79.1% vs. 26.7%, P<0.0001). Experiences of healthcare discrimination and structural barriers to access vaccines were not associated with full COVID-19 vaccination.

Results from the weighted adjusted logistic model showed that fully vaccinated participants were less likely to be African American than Hispanic (aOR=0.18; 95% CI=0.05-0.67) and more likely to endorse 0 misconceptions about COVID-19 vaccines than 4-6 (aOR=8.26; 95% CI=1.38-49.64; Table 2). Also, fully vaccinated participants were more likely to report that the information they received totally or somewhat encouraged them to get vaccinated (aOR=20.82; 95% CI=5.84-74.14) and that more than 50% of their family and friends were vaccinated (aOR=3.35; 95% CI=1.04-10.71).

Table 2.

Adjusted associations with full COVID-19 vaccination status (N=280)

Fully vaccinated
Adjusted OR (95% CI)
Sociodemographic Characteristics
Age group (years) (ref: 24-34)
35-49 1.04 (0.12-8.73)
50+ 1.52 (0.23-10.06)
Gender (ref=cisgender female)
Cisgender male 0.80 (0.20-3.20)
Sexual orientation (ref: heterosexual)
Lesbian, gay, bisexual or other 1.20 (0.30-4.82)
Race/ethnicity (ref: Hispanic)
Haitian 0.34 (0.05-2.07)
African American 0.18 (0.05-0.67)
Non-Hispanic Non-Haitian White (NHNHW) 0.58 (0.13-2.65)
Highest level of education (ref: less than high school or high school diploma or GED)
Some college or college graduate 1.15 (0.31-4.33)
Federal poverty level (ref: ≤100%)
>100% 2.79 (0.80-9.70)
Health Belief Model Factors
Perceived susceptibility to severe COVID-19 (ref: neither/disagree/don’t know)
Agree 3.22 (0.77-13.45)
Number of endorsed perceived benefits of COVID-19 vaccine (ref: 0)
1-2 2.07 (0.32-13.30)
3 1.41 (0.15-13.21)
Number of endorsed perceived misconceptions about COVID-19 vaccine (ref: 4-6)
0 8.26 (1.38-49.64)
1-3 2.34 (0.43-12.82)
Encouragement to get COVID-19 vaccine from information received (ref: had no effect on me/somewhat or totally discouraged me/don’t know)
Totally or somewhat encouraged me 20.82 (5.84-74.14)
Social Ecological Model Factors
Endorsed COVID-19 related medical mistrust (ref: yes)
No 0.73 (0.22-2.41)
Perceived importance of COVID-19 vaccine by social network (ref: neutral/slightly important/not at all important/don’t know)
Extremely or moderately important 0.88 (0.27-2.88)
Perceived percentage of social network vaccinated with COVID-19 vaccine (ref: ≤50%)
>50 3.35 (1.04-10.71)
Perceived safety of COVID-19 vaccine (ref: a little/not at all safe/don’t know)
Very or moderately safe 2.84 (0.75-10.77)
Perceived effectiveness of COVID-19 vaccine (ref: a little/not at all effective/don’t know)
Very or moderately effective 3.08 (0.71-13.29)
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Notes:

OR=odds ratio

95% CI=confidence interval

ref= reference category

Bold indicates statistically significant association.

Only factors with a p<0.20 in the bivariate analyses were entered in the weighted adjusted logistic regression model.

Nineteen participants were not included in the weighted adjusted logistic regression model due to missing values on the following variables: gender, sexual orientation, perceived percentage of social network vaccinated with COVID-19 vaccine, perceived safety of COVID-19 vaccine, perceived effectiveness of COVID-19 vaccine. Listwise deletion reduced the sample from 299 to 280.

In our exploratory analysis, we found that compared to fully vaccinated participants who didn’t receive an additional primary or booster dose, those who received an additional primary or booster dose were more likely to be 50 years or older than 24-34 years (aOR=11.37; 95% CI=2.12-60.86), lesbian, gay, bisexual or other vs heterosexual (aOR=3.15; 95% CI=1.02-9.76) and less likely to be Haitian than Hispanic or NHNHW (aOR=0.09; 95% CI=0.03-0.30; results not shown in table).

Discussion

This study adds to the very limited data about determinants of COVID-19 vaccination among PWH in the U.S. We found that most PWH in our sample (84%) were fully vaccinated with a primary vaccine series, and over half (66%) had received an additional primary or booster dose, which was considerably higher than the national percentages at the time of data collection, and higher than those found in another study conducted among PWH in March 2022.6,9 It is important to note that despite this relative success and the wide availability of COVID-19 vaccines at the time of data collection, 16% of our sample reported not being fully vaccinated, and Haitian participants had the lowest vaccine uptake. In addition, the exploratory analysis indicated that younger, heterosexual, and Haitian PWH were the groups less likely to have received an additional primary or booster dose. Most of the participants who were not fully vaccinated reported no intention to get the COVID-19 vaccine, either in the near future or ever. Their primary reasons for not getting vaccinated were related to concerns about the quality and efficacy of the vaccine, as well as potential short- and long-term side effects from the vaccine, which aligns with results from previous studies among PWH.18 These findings are concerning given the higher risk for severe COVID-19 outcomes among PWH.1–4 However, it is possible that uptake of primary vaccine series and booster shots have increased over time among this population, as has been reported nationally among racial/ethnic minority groups.9

This study also found that African American PWH were less likely to be vaccinated compared to Hispanic PWH, which echoes previous studies showing lower COVID-19 vaccine uptake and higher vaccine hesitancy among Black people.6,19 This finding may reflect a higher mistrust of the vaccine among people of color given their history with medical experimentation and systemic racism and discrimination in the U.S.19–21 Additionally, research shows that collective responsibility plays a role in COVID-19 vaccine acceptance among Hispanic people, and that Hispanic people are more likely than Black people to report having a friend or family member who had or died from COVID-19.19,22,23 Therefore, it could be that a sense of responsibility to protect their families and communities may have motivated Hispanic participants to get vaccinated.

Moreover, this study found that not endorsing any misconceptions about the vaccine and receiving encouragement to get vaccinated from sources of information were the two most important factors from the HBM predicting full vaccination. These findings align with previous studies15,18,24–26 and emphasize the critical role of providing accurate information about vaccine safety and efficacy and delivering positive messages about vaccination to promote uptake among PWH. Previous studies have shown that health care providers are the most trusted sources of vaccine information and are important drivers of vaccination.15,27–30 However, our data did not support that recommendations from HIV providers were related to COVID-19 vaccination. It is likely that other initiatives outside of the healthcare setting are needed to address COVID-19 vaccine mistrust and promote vaccination among PWH. Nevertheless, it is still important that HIV providers dedicate some time during HIV care visits to educate patients, address their specific concerns about the vaccine, offer reliable sources of vaccine information, and recommend COVID-19 vaccination.31 It would also help if screening for COVID-19 vaccination status and administering vaccines becomes a routine part of HIV care visits.31

Other sources of information that may be utilized outside of the healthcare setting to deliver positive and accurate information about vaccines, particularly to people of color with HIV, could be community institutions (e.g., churches, barbershops, beauty salons) and leaders.15,30,32 Community institutions could help disseminate accurate information about vaccines through newsletters, announcements, or events, and leaders could engage in positive conversations about the benefits of getting the COVID-19 vaccine.15,30 Also, given that a significant proportion of participants in our study reported TV, radio or newspapers as their most important sources of information, these avenues could be considered to disseminate accurate and encouraging messaging about COVID-19 vaccines to PWH. Research has shown that delivering health storylines on fictional television programs influence health behaviors.33,34 Therefore, creative ways to incorporate accurate and positive COVID-19 vaccine narratives into TV or radio scripts35,36 should be considered, and its effects on promoting vaccine uptake among PWH should be tested.

Furthermore, perceived social norms was the most important factor from the SEM predicting full COVID-19 vaccination in our study, with participants who reported that more than 50% of their social network was vaccinated being more likely to be fully vaccinated. This finding is supported by previous research showing that having family and friends serving as role models, advocating for vaccination, and sharing their personal experiences can decrease vaccine mistrust and motivate people to get the COVID-19 vaccine.27,30,37–39 Accordingly, social networks could also be engaged to promote vaccination among PWH. Interventions, such as vaccine ambassadors,31 lay health advisors,40 popular opinion leaders,41 role modeling and testimonials42 can be leveraged in social networks to disseminate accurate messages about the vaccine and showcase positive experiences with COVID-19 vaccination.

Interestingly and contrary to previous research showing that structural barriers to vaccine access and discrimination experiences hinder vaccine uptake among racial/ethnic minority groups,43,44 these factors were not found to be associated with full vaccination in this study. It could be that the wide availability of vaccination sites (e.g., HIV clinics, pharmacies, public and mobile vaccination sites, community centers45) and the urban/suburban setting46 of Miami-Dade County may have minimized structural barriers to access the vaccine (e.g., transportation and distance). However, structural barriers need to be evaluated in future studies about COVID-19 vaccine booster uptake as the vaccine is no longer available free of charge to all people as it was at the time of this study. Furthermore, it appears that healthcare discrimination experiences were not common in this sample, and thus were not barriers to vaccine uptake among participants.

It is important to note some limitations of this study. First, we used self-reported data on COVID-19 vaccination as of March 2022 in Miami-Dade County; thus, our data are subject to social desirability bias and are time- and location-specific. Comparability of our results with previously published data may be limited given that studies may have been conducted at different timepoints of COVID-19 vaccine availability and rollout and may have used surveillance data instead of self-report. Second, our convenience sample was drawn from PWH who were engaged in care and interested in participating in research which might lead to selection bias and limit the generalizability of our findings. However, our sample included participants from the three predominant racial/ethnic minority groups in South Florida, and all analyses were weighted to be representative of the target population of clients in the Miami-Dade County RWP.

In conclusion, a high proportion of PWH in this study were fully vaccinated which speaks to the importance of public health efforts targeting highly vulnerable groups to facilitate vaccination. However, many PWH, particularly non-Hispanic Black people, were hesitant to get vaccinated due to mistrust and misinformation about the COVID-19 vaccine. Our findings highlight that vaccine uptake among PWH may be increased by promoting accurate information about vaccine safety and efficacy and delivering encouraging messages about vaccination through sources considered trustworthy. Social networks, in particular, can be leveraged to increase vaccine trust and encourage vaccination in this population. This information can be used to tailor messaging and outreach efforts to increase uptake of COVID-19 primary vaccine series and boosters as well as other recommended vaccines (e.g., mpox) among PWH.

Supplementary Material

Supplemental Digital Content

Acknowledgments

The authors would like to acknowledge the staff of Behavioral Science Research Corporation as well as the Miami-Dade County Ryan White Program for assisting in the implementation of this study.

Conflicts of Interest and Source of Funding:

All authors declare that they have no conflicts of interest and do not have any financial disclosures to report. This work was supported by awards 3R01MD012421-04S1 and U54MD012393 from the National Institute on Minority Health and Health Disparities. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

Conferences: Data presented at IDWeek 2023; October 11-15, 2023; Boston, Massachusetts.

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Supplementary Materials

Supplemental Digital Content
NIHMS1951903-supplement-Supplemental_Digital_Content.docx (98.1KB, docx)

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