Vaccine Hesitancy and Under-Vaccination Among Racialized LGBTQ+ People Living with HIV in North America: A Scoping Review

Background and Purpose: Vaccination is crucial to the health of people living with HIV (PLWH), including Covid-19 vaccines, which have been deemed safe and effective. While the incidence of SARS-CoV-2 infection was similar among PLWH and the general population, PLWH were at greater risk of severe COVID-19 outcomes. Importantly, PLWH are not a monolithic population, with heightened vulnerability among those marginalized by gender identity, sexual orientation, and race/ethnicity. We explored multilevel factors associated with Covid-19 vaccination among PLWH in North America. Our research questions were: 1) “What are the determinants of Covid-19 ‘vaccine hesitancy’ reported among PLWH in the U.S. and Canada?” and 2) “What are the intersectional challenges for Covid-19 vaccination among LGBTQ+ and racialized PLWH?"

Methods: Using the Joanna Briggs Institute scoping review methodology, we designed a search string and explored 7 databases to identify peer-reviewed articles published from 1/1/2020–10/31/2022 that addressed Covid-19 vaccine hesitancy, confidence, refusal, mistrust or barriers among marginalized communities, including PLWH, LGBTQ+ people and racialized people, >=18 years-old in the U.S./Canada. We included quantitative, qualitative, and mixed methods studies. Search results were uploaded into Covidence software and screened by two independent reviewers for inclusion. We reviewed data using quantitative (frequency) and qualitative (thematic) analysis and synthesized evidence on determinants of Covid-19 vaccination.

Results: We identified 5,987 unduplicated sources, with abstracts scoped to 519 full-text articles, and 103 articles included: 4 focused on Covid-19 vaccination among PLWH, 21 on African American/Black people, 8 Latinx people, 5 LGBTQ+ people, 3 people experiencing homelessness, with 34 on multiple racial/ethnic minorities. Structural stigma/racism and institutional mistrust were the most prevalent determinants of Covid-19 vaccination among PLWH, racialized, and LGBTQ+ people, and their intersections, including historical and present-day medical racism and pathologization of sexual/gender minorities. Additional structural determinants of under-vaccination included unemployment, poverty, homelessness (among racialized/LGBTQ+ youth and older adults), and indirect vaccination costs (e.g., transportation, missed workdays). Trans and gender diverse (TGD) people and racialized TGD PLWH reported fears of harassment/violence and being misgendered in unfamiliar vaccination clinics as prominent barriers to vaccination. Some PLWH expressed vaccine hesitancy due to concerns that their health condition might make Covid-19 vaccination unsafe. Facilitators of Covid-19 vaccination included having a trusted/regular healthcare provider, altruism (to protect one’s community) and lessons learned about prevention in response to the HIV epidemic. Across marginalized populations, structural barriers rather than "vaccine hesitancy" were the predominant obstacles to Covid-19 vaccination.

Conclusions and Implications: Multilevel determinants of Covid-19 under-vaccination among racialized LGBTQ+ PLWH underscore intersectional challenges and strengths, and the need for structural interventions. Overall, the unilateral attribution of Covid-19 under-vaccination to “vaccine hesitancy” may serve to elide and reproduce the impacts of structural stigma and racism, in effect locating the onus of structural barriers in individual psychology/decision-making. Interventions to mitigate institutional discrimination in healthcare and economic marginalization due to systemic racism, transphobia and homophobia, in tandem with tailored outreach and education conducted in collaboration with PLWH, LGBTQ+, and racialized communities, may support equity in access to Covid-19 vaccination and community-engaged preparedness for future public health emergencies.