The coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has escalated into a global pandemic, with over 750 million infections and 6.8 million deaths recorded as of February 1, 2023 (1). The impacts are particularly severe for specific populations, including people living with HIV (PLWH), who have been shown to have a higher risk of SARS-CoV-2 infection, serious illness, hospitalization, and death than the general population (2–6).

COVID-19 vaccines have been recognized as one of the most effective methods for preventing infection with SARS-CoV-2 and its variants (7, 8). Vaccination has significantly reduced the risk of SARS-CoV-2 infection and severe COVID-19 disease outcomes in PLWH (9, 10). However, the rise of new SARS-CoV-2 variants has necessitated booster doses of COVID-19 vaccines in some countries. Initial studies indicated the effectiveness of the first COVID-19 booster dose among PLWH against new variants such as Delta and Omicron (11–13). However, other research suggests that immunogenicity and the effectiveness of preventing severe outcomes with the first COVID-19 booster dose among PLWH may diminish over time, especially concerning the Omicron variant (14).

Given the potential decrease in immunogenicity and effectiveness over time, PLWH should receive a second COVID-19 booster dose at an appropriate time. Further research indicates enhanced immunogenicity and safety with the second COVID-19 booster dose in PLWH (15). In response to these findings, several countries, including China, now recommend a second booster dose for PLWH, along with other key populations such as individuals over the age of 60, high-risk groups, those with underlying health conditions, and particularly immunocompromised individuals (16–18).

In the past, significant hesitancy was observed among PLWH in China regarding full-dose COVID-19 vaccination. The vaccination coverage among this group was significantly lower than the international average for the PLWH population (6.2% vs. 63.5%) (19, 20). With the current promotion of the second COVID-19 booster dose both in China and globally, understanding the vaccination willingness of PLWH and exploring the relevant influencing factors have profound theoretical and practical implications for developing and promoting vaccination strategies.

According to the World Health Organization (WHO), it is still necessary for individuals who have previously been infected with SARS-CoV-2 to receive a second COVID-19 booster dose (21). However, only Uganda has reported vaccination rates and willingness to receive the first COVID-19 booster doses among PLWH (22). Given the significant differences in COVID-19 vaccination types and perceptions across countries, the results from other contexts cannot directly guide COVID-19 vaccination strategies for PLWH in China.

Previous studies have highlighted the concern about vaccine side effects as a significant factor influencing the hesitation of PLWH to receive the COVID-19 vaccine. Whether side effects after the first COVID-19 booster dose influence the willingness to receive the second booster dose remains unclear. Addressing these knowledge gaps would offer valuable insights to guide the administration of the second COVID-19 booster dose among PLWH.

The HBM is one of the most extensively utilized theories for understanding health and illness behaviors. The model is predicated on the understanding that a person’s belief in a personal threat of an illness or disease and belief in the effectiveness of the recommended health behavior or action will predict the likelihood that the person will adopt the behavior. The HBM has been previously employed to analyze COVID-19 complete vaccination willingness and behavior among cancer patients and PLWH, as well as in health education activities related to vaccine promotion (23, 24). Although applying HBM to COVID-19 vaccination could enhance our understanding of this health behavior, there is still a gap in the literature, particularly about COVID-19 booster vaccination among PLWH.

In this study, we developed a questionnaire based on the HBM to conduct an anonymous survey among the PLWH population in mainland China. This study aims to provide a theoretical basis for guiding the effective adjustment and implementation of vaccination strategies in our country and other nations in response to the continuously evolving disease situation.

To our knowledge, this is the first multicenter cross-sectional study to explore the willingness of PLWH to receive a second COVID-19 booster dose and its influencing factors in China. Our findings suggest that PLWH were more hesitant to receive a second COVID-19 booster dose than the healthy population. The reasons for this hesitation appear to be multifactorial, with HIV infection status, more significant than expected adverse effects after the first COVID-19 booster dose, and negative attitudes toward the COVID-19 vaccine booster dose being the main factors contributing to vaccine hesitancy. Our findings provide important insights into the willingness of PLWH in China to receive a second COVID-19 booster dose and the associated factors influencing this decision. Moreover, our results could inform both the theoretical framework and practical measures for institutions aiming to understand and address the vaccination intentions of PLWH and the factors influencing them. This, in turn, may assist in designing more effective public health interventions and educational campaigns for PLWH, aiming to boost vaccination coverage and minimize the risk of co-infection and severe clinical outcomes.

Our study observed a lower willingness among PLWH to receive a second COVID-19 booster dose compared to full immunization and the first COVID-19 booster dose reported in the United States, Italy, and Latin America and the Caribbean (78–86.2%) (29–31). One possible explanation for this disparity might be that over time, China’s measures to control COVID-19 have not diminished, yet the prolonged duration of such controls has engendered a sense of fatigue among the population. Consequently, this has led to PLWH beginning to underestimate the pathogenic potential of SARS-CoV-2 and its variants. At the same time, our study corroborates previous findings in healthy individuals in China indicating a high willingness to receive a second COVID-19 booster dose (81.1% vs. 88.7%) (32). However, our study, after adjusting for potential confounders, revealed a significant association between HIV status and vaccine hesitancy for the second COVID-19 booster dose. This persistent vaccine hesitancy among PLWH in China warrants further investigation, despite demonstrated safety and preventative efficacy of the fourth COVID-19 dose and ongoing promotion by relevant health departments (15). It suggests the need for targeted interventions and education to address the factors contributing to this hesitancy.

To date, abundant studies investigating COVID-19 vaccine acceptance among PLWH has generated valuable insights into the underlying influencing factors. For instance, a cross-sectional study demonstrated that negative attitudes towards prime vaccines was associated with the diminished likelihood of vaccine acceptance in China (33). Conversely, individuals with positive perceptions of the prime COVID-19 vaccine exhibited higher rates of acceptance. Furthermore, a positive association between the booster vaccine acceptance and beliefs in the safety, benefits, and accessibility of the booster vaccine was also proved in Uganda (22). Our study further demonstrated that negative attitudes towards vaccines and perceived barriers were both associated with reduced acceptance of the second COVID-19 booster Dose. Similar results were found in immunocompromised cancer patients, which strengthened the necessity of vaccination among specific populations (34, 35).

Our study is the first to investigate the relationship between the willingness of PLWH in China to receive the second COVID-19 booster dose and the six main dimensions of the HBM. These dimensions include perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy. Our findings indicate that perceived barriers negatively correlate with vaccine willingness, suggesting fears and misconceptions may dissuade PLWH from receiving the booster dose (36). On the contrary, perceived benefits were positively associated with vaccine willingness, highlighting the potential impact of understanding the benefits of vaccination in promoting vaccine acceptance. Interestingly, we found a positive correlation between perceived susceptibility and vaccine willingness, suggesting that individuals at risk of contracting COVID-19 may be more willing to get vaccinated. However, perceived severity was negatively associated with vaccine willingness, which could indicate that those who perceive COVID-19 as a severe disease may have heightened fears about the safety of vaccines (37). We also noted a positive correlation between self-efficacy and preventive behavior, reinforcing that individual belief in their ability to take preventive measures successfully can influence their willingness to vaccinate (38, 39). Finally, our findings showed a positive correlation between cues to action and vaccine willingness. This implies that support and encouragement from family, friends, and doctors could be critical in promoting vaccination among PLWH (33, 40).

In light of these findings, health departments in China should amplify their efforts to communicate the benefits of the second COVID-19 booster dose. This includes providing clear and reassuring information about the vaccine’s safety, encouraging social support networks to promote vaccination, and fostering a sense of self-efficacy among PLWH. Addressing these factors can reduce vaccine hesitancy and increase the second COVID-19 booster dose uptake among PLWH.

Our multivariable logistic regression analysis revealed that PLWH with a detectable HIV viral load (≥50 copies/mL) demonstrated a higher willingness to receive the second COVID-19 booster dose than those with an undetectable viral load (<50 copies/mL). This result diverges from a US study, which reported a higher willingness to vaccinate among PLWH with an undetectable HIV viral load (29). The discrepancy could be attributed to differences in study design, participant demographics, cultural attitudes towards vaccination, or the methodology of obtaining HIV viral load data. However, the impact of these factors should be further investigated in future studies.

This study has important practical implications, as it found that the willingness of PLWH to receive the second COVID-19 booster dose in China is notably lower than that of the general adult population. It identifies inhibiting factors such as perception barriers and negative attitudes, suggesting a need for targeted educational campaigns to enhance booster vaccine coverage among PLWH.

However, several limitations in our study should be acknowledged: First, as with all cross-sectional studies, establishing causal relationships between independent variables and different outcomes of interest is impossible. Longitudinal studies or randomized controlled trials would be needed to examine causal relationships. Second, subjectively self-administered questionnaires may introduce recall bias, which is difficult to avoid considering the need for anonymity in our study. Future research could consider using alternative methods, such as structured interviews or electronic data collection, to minimize this bias. Third, while most of the items and scales used in this study were self-constructed based on those used in the general population, the external validation of these measures was limited. Further research should seek to validate these measures against established scales or through other external validation methods. Finally, there were variations in the distribution of sociodemographic characteristics between the two groups. Although we adjusted for these characteristics in the multivariable logistic regression model, their potential impact on the study results should be considered. Future studies could explore the potential influence of these characteristics on vaccine willingness more comprehensively and consider other statistical techniques, such as propensity score matching, to address these imbalances.

In conclusion, our study highlights the lower willingness of Chinese PLWH to receive a second COVID-19 booster dose compared to healthy individuals. Concerns about adverse effects and negative attitudes toward the booster dose primarily drive this reluctance. Strengthening and promoting knowledge about HIV and COVID-19 vaccination, including the importance of vaccine protection against SARS-CoV-2, is crucial. Based on the findings of this study, targeted interventions should be implemented to increase the willingness of PLWH to receive the second COVID-19 booster dose. This may include tailored education and communication strategies, providing comprehensive information and support, and engaging community resources to address the specific concerns and needs of PLWH.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

JX was responsible for the conceptualization of the study and funding acquisition. XL was responsible for data curation and analysis. JX, MS, SL, MY, BS, YQ, and LW were responsible for project administration and securing resources. JX and YW were responsible for supervision and reviewing and editing the article. XL and YW were responsible for writing the original draft of the paper. All authors contributed to the article and approved the submitted version.

This work was funded by the Shenzhen Science and Technology Innovation Committee Projects (No. JCYJ20220818102817038) and the Scientific Research Foundation of Peking University Shenzhen Hospital (No. KYQD2022216).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The reviewer XZ declared a past co-authorship with the authors YQ, MY, and JX to the handling editor.

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