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.