
==== Front
Hum Vaccin Immunother
Hum Vaccin Immunother
Human Vaccines & Immunotherapeutics
2164-5515
2164-554X
Taylor & Francis

39286864
10.1080/21645515.2024.2389576
2389576
Version of Record
Research Article
Coronavirus
Uptake, adverse effect, and associated factors of COVID-19 vaccine among those living with human immunodeficiency virus, at Bole sub-city health facility Addis Ababa, Ethiopia
S. SEID AND T. GEBRU GEBREMESKEL
HUMAN VACCINES & IMMUNOTHERAPEUTICS
Seid Sendu a
https://orcid.org/0000-0002-8276-5685
Gebru Gebremeskel Teferi b
a Public Health Department, Addis Ababa Medical and Business College , Adis Abeba, Ethiopia
b Flinders Health and Medical Research institute, Collage of medicine and Public Health, Flinders University , Adelaide, Australia
CONTACT Sendu Seid sina2230seid@gmail.com Public Health Department, Addis Ababa Medical and Business College, Adis Abeba, Ethiopia.
Teferi Gebru Gebremeskel teferigebru12@gmail.com Flinders Health and Medical Research institute (FHMRI), College of Medicine and Public Health, Flinders University , Bedford Park, P.O. Box 2100, Adelaide, SA 5001, Australia.
17 9 2024
2024
17 9 2024
20 1 2389576Integra16 9 2024
Integra16 9 2024
10 4 2024
23 7 2024
03 8 2024
© 2024 The Author(s). Published with license by Taylor & Francis Group, LLC.
2024
The Author(s)
https://creativecommons.org/licenses/by-nc/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent.

ABSTRACT

COVID-19 vaccination in African people living with human immunodeficiency virus remains understudied, with limited research in Ethiopia that fails to consider contextual differences. To assess uptake, adverse effects, and associated factors of COVID-19 vaccine among PLWHA in Addis Ababa, Ethiopia, 2022. An institutional cross-sectional study design was employed among 404 participants. Sample selected by systematic random sampling technique. Descriptive and inferential statistical analyses were carried out. Finally, results were presented using Crude Odd Ratio, Adjusted Odd Ratio, and 95% Confidence Interval. Result: Out of all participants, 79% (314) received at least one dose of any type of COVID-19 vaccine, with varying percentages taking one (29.3%), two (50.3%), and three (20.4%) doses of the vaccine. Being knowledgeable (moderate and good) (AOR = 0.06, 95% CI: 0.01, 0.5) and medium attitude (AOR = 1.1, 95% CI: 0.7, 1.3) had a statistically significant association with the uptake of the COVID-19 vaccine. The prevalence of adverse events was 27.8% (110). More than three-quarters of participants were vaccinated for the COVID-19 vaccine. Moderate knowledge and medium attitude have a significant association with the uptake of the COVID-19 vaccine. Nearly a quarter of participants experienced adverse events related to COVID-19. Continued efforts are essential to overcome barriers to achieving full vaccination coverage for the most vulnerable in low-income countries. Addressing hesitancy, monitoring side effects, and implementing effective communication and strategies are crucial for widespread COVID-19 vaccination and public health safety in these regions.

KEYWORDS

Uptake of COVID-19
adverse effect of COVID-19
COVID-19 vaccine among PLWHA
The author(s) reported that there is no funding associated with the work featured in this article.
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pmcIntroduction

Coronavirus disease 2019 (COVID-19) is a pandemic respiratory disease caused by a newly discovered coronavirus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).1 People living with human immunodeficiency virus (PLWHA) had a higher risk of SARS-CoV-2 infection and mortality from COVID-19 than HIV‑negative individuals.2,3

First, people living with the human immunodeficiency virus who are not on antiretroviral therapy, have detectable viral loads, and/or have lower CD4 counts are more likely to experience a dysregulated immune response to SARS-CoV-2 infection.4 Second, more than 43% of the people living with the human immunodeficiency virus in Addis Ababa, capital city of Ethiopia, are over the age of 50.5 Third, people living with human immunodeficiency virus are more likely to experience comorbid medical conditions and experience them at a younger age compared to those without HIV.6

Mass vaccination provides hope for ending the global pandemic caused by SARS-CoV-2 by reducing the spread.7 Research shows that in low- and middle-income countries, there is a higher willingness to receive the vaccine due to the interest in personal protection against COVID-19, whereas concerns about side effects are the main reason for hesitancy, despite higher vaccination rates in developed nations.8

Evidence shows that among people living with HIV, 79.7% were on antiretroviral therapy, with a vaccination intention of 65.2% compared to 79.6% among those without HIV.9 This difference may be linked to vaccine confidence, positive attitudes toward the COVID-19 vaccine, and social norms favoring vaccination.

In British Columbia and Canada, people living with HIV have a lower vaccination intention compared to those without HIV. Globally, HIV-positive individuals face a higher risk of SARS-CoV-2 infection and COVID-19 mortality.9 Age below 40 was identified as a risk factor for adverse reactions to the COVID-19 vaccine in Afghanistan, with common symptoms including muscle pain, local pain at the injection site, fever, and fatigue.10 Among people living with HIV, 22.8% experienced adverse reactions after the first dose of the COVID-19 vaccine, higher than after the second dose, with fatigue, drowsiness, and dizziness being the most common severe symptoms.11

People living with HIV (PLWH) face increased vulnerability to COVID-19 due to complex biological and structural factors, leading to a higher risk of severe illness. Ensuring access to and uptake of COVID-19 vaccination is crucial for PLWH. However, in Ethiopia, studies on vaccination uptake and adverse effects among PLWH are limited, with most research focusing on healthy individuals in specific regions. Given the high-risk status of PLWH for COVID-19, it is essential to prioritize their vaccination uptake. Previous studies mainly examined vaccination willingness and influencing factors, with limited focus on vaccination behavior, especially since initial vaccination rates were low, particularly among PLWH.12–14

In this study, we aimed to investigate the uptake rate and adverse effects of COVID-19 vaccination and associated factors among people living with the human immunodeficiency virus in Addis Ababa, Ethiopia.

Method

Study area, period, and population

The Cross-Sectional study design was applied to the Addis Ababa Bole sub-city administration, which comprises 11 woreda structures. The estimated population size of Bole Sub City (catchment population) by the year 2021/22 was 221,006. Within Bole Sub City, there were 7 private general hospitals, 12 medical centers, 84 specialty centers, 58 medium clinics, 18 primary clinics, and 5 government health centers. This study specifically focuses on health centers and ART clinics within the health centers of Bole Sub City. There were 3711 ART clients currently on follow-up with 2424 being female and the remaining 1287 being male. The study was conducted from August 15 to September 15, 2022. All selected adults aged 15 and above on ART follow-up visiting a selected governmental health facility under the Bole Sub City administration during the study period were included. However, ART clients of HC in the Bole Sub-city administration who were in a coma, unable to speak, or missing refill within the study period were excluded. Additionally, individuals below the age of 15 years who were on ART were also excluded from the study.

Sample size determination

The sample size for this study was calculated using a single population proportion formula, considering a 50% prevalence of uptake (no previous study found in Ethiopia), a 95% confidence interval, and a 5% margin of error. After accounting for a 5% non-response rate (NRR), the final sample size of the study was 404 ART patients who met the eligibility criteria.

Sampling procedures

Systematic random sampling was used to select the study participants. All health centers in Bole Sub-city, Addis Ababa, were included by the researcher. The calculated sample size was 404 proportionally allocated to each health center based on the number of adults living with HIV registered in the health centers, obtained by referring to client registration logbooks. Subsequently, data collection was conducted using a systematic random sampling technique. The interval of the interviewee (Kth) was determined for each HC based on their number of ART clients. Every Kth interval was interviewed during their follow-up visit to the ART clinic. The first interviewee was selected randomly from 1 to the kth interval and continued at every Kth interval unit the required sample size for each HC.

Operational definition

Uptake of COVID-19 vaccination: Refer to receive at least one dose of any brand of the COVID-19 vaccine.15

The adverse effect of COVID-19 vaccination: any unwanted medical occurrence following immunization, which may manifest as unfavorable or unintended signs, abnormal laboratory findings, symptoms, or diseases.16

Knowledge: Knowledge-specific questions were utilized to assess knowledge scores. The overall knowledge was categorized, based on Bloom’s cutoff point, with scores between 80 and 100% considered good, scores between 60 and 79% categorized as poor, and scores below 60% classified as low.17

Attitude: The overall attitude was categorized, using Bloom’s cutoff point, with a score between 80 and 100% considered good, a score between 60 and 79% categorized as poor, and scores below 60% classified as low.17

Perception: Refer to the perceived health benefit and perceived ease of obtaining vaccination measured through yes or no questions.18 Scores between 80 and 100% were classified as good, scores between 60 and 79% as poor, and scores below 60% as low.

Data collection tool and procedure

Semi-structured interviewer-administered data collection tool was developed based on a review of the literature. Initially drafted in English, it was then translated into Amharic and back to English to minimize any potential gaps in meaning. Careful attention was given to articulating ion of wording and organizing sentences to prevent challenges related to misunderstanding and social desirability issues. Data collection was conducted by five (5) trained female health professionals recruited from VCT or ART facilities to create a comfortable environment for clients.

Various strategies were implemented to enhance the quality of data for the study. Firstly, the data collection tool was meticulously organized and articulated during development, with variables operationalized as necessary. The tool underwent a pretest at a health center in the Lem Kura sub-city to assess the readability, understandability, and coherence of ideas, and adjustments were made accordingly. Data collectors and health professionals utilized as data collectors received appropriate training on the tool. Supervision of data collection was carried out, and any issues encountered during the process were addressed promptly. Careful attention was given during coding, data entry, and analysis to ensure data integrity. The final report was prepared incorporating texts, graphs, and tables.

Analysis plan

Following the coding of each variable, data were entered into Epi-data version 3.1 and cleaned finally. Then data sets in the Epi-data template were exported to SPSS version 25 for analysis. We employed data imputation methods along with full information maximum likelihood techniques to handle missing data, ensuring reliability and validity.

A descriptive analysis was carried out, and the normality test was checked. Bivariate logistic regression analysis was conducted to see the crude association between the factors and outcome variables and select candidate variables (variables with p-value <.25) for multivariable logistic regression. Adjusted odds ratios (AOR) with corresponding 95% CI were calculated to assess the relationship between the factors and outcome variables. Finally, the Hosmer and Lemshow test used the adequacy of the fitted model. In this study, on the final model, a p-value of < 0.05 was assumed to be a statistically significant value.

Result

Socio-demographic results

The study had a response rate of 98.0% (396 participants). The age range of respondents varied from 18 to 68 years, with a mean age of 34.5 ± 10.2. Among the total respondents, 55.1% (218) were female and 44.9% were male. The average monthly income of the participants was ETB7792.1±ETB 806.5. The housing conditions of study participants included street dwellings, single-room houses, double-room houses, and other housing categories, accounting for 11.9% (47), 40.7% (161), 35.9% (142), and 11.4% (45), respectively. (Table 1)Table 1. Socio-demographic characteristics of study participants in Bole Sub City, Addis Ababa, Ethiopia, 2022.

Variables	frequency	percentage	
Marital status	Single	80	20.2%	
Married	211	53.3%	
separated	24	6.1%	
divorced	59	14.9%	
widowed	22	5.6%	
Religion	orthodox	182	46.0%	
Protestant	94	23.7%	
Islam	45	11.4%	
Catholic	43	10.9%	
Others	32	8.1%	
Educational status	Unable to read and write	28	7.1%	
Can read and write	74	18.7%	
Primary school	71	17.9%	
Secondary school	121	30.6%	
College and above	101	25.5%	
Do you have a job?	Yes	283	71.5%	
No	113	28.5%	
Occupation	CSW	16	4.3%	
Government employee	44	11.9%	
driver	49	13.2%	
Private company employee	124	33.4%	
Daily laborer	43	11.6%	
Student	4	1.1%	
Merchant	27	7.3%	
Housemaid	33	8.9%	
Other	31	8.4%	
Housing conditions	street	47	11.9%	
Single room house	161	40.7%	
Double room house	142	35.9%	
Other houses	45	11.4%	

Knowledge about COVID-19

Almost all, 99% (392) had heard about COVID-19, while only 1% (4) had not. Mainstream media, social media, and health facilities were mentioned as the major sources of information for the study participants (Figure 1). Depending on Bloom’s cutoff point, the aggregated knowledge score of study participants is categorized into three categories. Out of the total participants 38.9% (154), 41.4% (164), and 19.7% (78) had poor, medium, and good knowledge about COVID-19 respectively (Figure 2). Of the total respondents, 99.5% (394) indicated that they are aware of the COVID-19 vaccine, and 64.9% (303) mentioned knowing about the vaccine’s effectiveness. Additionally, 13.6% (54) of participants were aware that the vaccine can lead to increased allergic reactions (Table 2). Figure 1. Source of information for study participants in Bole Sub City, Addis Ababa, Ethiopia, 2022.

Figure 2. Knowledge of participants about COVID-19 and its vaccine, Bole Sub City, Addis Ababa Ethiopia, 2022.

Table 2. Responses of study participants for knowledge measuring items in Bole Sub City, Addis Ababa, Ethiopia, 2022.

Items	Response options	%(n)	
Do you know about the COVID-19 vaccine?	Yes	99.5%(394)	
No	0.3%(1)	
Neutral	0.3%(1)	
Do you know about the effectiveness of the COVID-19 vaccine?	Yes	76.5%(303)	
No	14.9%(59)	
Neutral	6.3%(25)	
Is it dangerous to use overdose vaccines?	Yes	64.9%(257)	
No	17.4%(69)	
Neutral	17.7%(70)	
Does vaccination increase allergic reactions?	Yes	13.6%(54)	
No	60.6%(240)	
Neutral	25.8%(102)	
Does vaccination increase autoimmune diseases?	Yes	15.2%(60)	
No	56.1%(222)	
Neutral	28.8%(114)	

Attitude towards COVID-19

The mean attitude scores for safety, the essentiality of the vaccine, hesitancy to receive the vaccine, encouragement of family members to get vaccinated, belief in the vaccine’s role in reducing incidents, and fairness of vaccine distribution were 1.6, 1.5, 1.5, 1.6, 1.1, and 1.8, respectively. The final aggregate score of attitudes (mean of means) was 0.7. Participants with aggregated attitude scores ≥ 0.7 exhibited a positive attitude toward the COVID-19 vaccine, while those scoring < 0.7 displayed a negative attitude toward COVID-19 vaccination in various aspects (Table 3).Table 3. Responses of study participants for attitude measuring items for the study at Bole Sub-city health centers, Addis Ababa, Ethiopia, 2022.

Items	Response options	%(n)	
The newly discovered COVID-19 vaccine is safe.	Disagree	16.3%(63)	
Not decided	26.7%(103)	
Agree	54.7%(211)	
The COVID-19 vaccine is essential for us.	Disagree	15.8%(61)	
Not decided	14%(54)	
Agree	70.2%(271)	
Do you take the COVID-19 vaccine without any hesitation, if it is available in Addis Ababa?	Disagree	17.2%(68)	
Not decided	15.4%(61)	
Agree	67.4%(267)	
Do you also encourage your family/friends/relatives to get the vaccination?	Disagree	10.1%(40)	
Not decided	22%(87)	
Agree	67.7%(268)	
It is not possible to reduce the incidence of COVID-19 without vaccination?	Disagree	37.1%(147)	
Not decided	18.4%(73)	
Agree	43.4%(172)	
The COVID-19 vaccine should be distributed fairly to all of us?	Disagree	5.1%(20)	
Not decided	13.4%(53)	
Agree	81.3%(322)	

Thought about COVID-19

Among all participants, 54% (214) believed that the COVID-19 vaccine could lead to adverse events in recipients, while 45.2% (179) thought the vaccine would not cause adverse events. Furthermore, 43.7% (173) believed that COVID-19 could be eradicated through standard precautionary measures without vaccine intervention, while 55.8% (221) believed eradication without vaccination is not possible. Regarding affordability, 82.8% (328) of participants felt the vaccine should be provided free of charge, while the remainder disagreed. Only 24.2% (96) stated they could afford to pay for the vaccine if it was not free (Figure 3). Figure 3. Responses of participants for eligibility question of vaccine, Bole sub city Addis Ababa, Ethiopia, 2022.

When asked to identify high-risk groups (priority groups) for vaccination, only 48.8% (193) of participants could correctly identify groups such as health professionals, employees, and chronic patients, while 51% (202) could not identify a priority group for COVID-19 vaccination.

Factors associated with the utilization of COVID-19 vaccine utilization

By conducting bivariable logistic regression, fourteen (14) candidate variables were selected by taking p value < 0.25 as the cutoff point. Multi-variable logistic regression was run to determine the independent association of the independent variable and outcome variable (uptake of vaccine). From the 13 variables entered multiple regression models, two independent variables (knowledge and attitude) had a statistically significant association with the uptake of the COVID-19 vaccine (p-value < .05) (Table 4).Table 4. Bivariable and multi-variable logistic regression output for the study at Bole Sub-city, Addis Ababa Ethiopia, 2022.

Predictor variables	Uptake of vaccine	OR (95% CI)	
No	Yes	COR	AOR	
Age	<34.5	54(35.1%)	100(64.9%)	1	1	
≥34.5	27(12.4%)	190(87.6%)	0.26(0.01, 0.44)	0.03(0.01, 1.7)	
Sex	male	24(13.6%)	152(86.4%)	1	 	
Female	66(30.6%)	150(69.4%)	2.8(1.66, 4.68)	1.574(0.24, 10.24)	
Marital status	Single	18(22.5%)	62(77.5%)	1	1	
Married	47(22.4%)	163(77.6%)	0.99(0.54, 1.84)	25.20(0.99, 45.8)	
Separated	6(25%)	18(75%)	1.15(1.04, 3.32)	6.20(0.10, 399.12)	
Divorced	19(24.4%)	59(75.6%)	1.11(0.76, 3.52)	17.44(0.80, 379.20)	
Have a job	Yes	80(28.7%)	199(71.3%)	1	1	
No	10(8.8%)	103(91.2%)	0.24(0.12, 0.49)	1,12(0.01,136.50)	
Income	Below the mean	59(26.8%)	161(73.2%)	1	1	
≥ the mean	16(40%)	24(60%)	1.82(1.09, 3.70)	0.96(0.15, 6.10)	
Source of information	Mainstream media	38(20.4%)	148(79.8%)	1	1	
Social media	21(18.6%)	92(81.4%)	0.89(0.61,1.61)	7.20(0.88, 58.62)	
Health facility	29(31.9%)	62(68.1%)	1.82(1.01, 5.12)	0.12(0.02, 1.1)	
Knowledge	Low	55(36.7%)	95(63.3%)	1	1	
Moderate	35(14.5%)	207(85.5%)	0.29(0.13, 0.67)	0.06(0.01, 0.50)**	
Attitude	Low	85(58.2%)	61(41.8%)	1	1	
Moderate	5(9.8%)	46(90.2%)	0.08(0.01, 0.91)	1.1(0.7, 1.3)*	
Stay on ART	≤5 years	32(24.4%)	99(75.6%)	1	1	
6-10 years	42(25.6%)	122(74.4%)	1.07(1.03, 1.81)	0.02(0.67, 29.84)	
>10 years	16(16.5%)	81(83.5%)	0.61(0.31, 1.19)	0.21(.41, 55.98)	
Adherence	Good	78(23.3%)	257(76.7%)	 	 	
Poor	12(33.3%)	24(66.7%)	1.65(0.79, 3.45)	0.24(0.00, 12.70)	
Recent CD4 level	<500	34(28.8%)	84(71.2%)	1	1	
≥500	51(19.1%)	216(80.9%)	0.58(0.35, 0.96)	0.14(0.02, 1.5)	
T-stage	T-stage I	23(13.1%)	153(86.9%)	1	1	
T-stage II	46(38.3%)	74(61.7%)	4.14(2.33, 7.33)	0.41(0.07, 2.37)	
T-stage III	17(21.2%)	58(78.8%)	1.95(0.45, 5.77)	12.83(0.66, 249.10)	
Presence of OIs	Yes	27(16.6%)	136(83.4%)	1	1	
No	59(26.5%)	164(73.5%)	1.81(1.09, 3.02)	3.88(0.74, 20.42)	
**indicated P-value <.01, OIs stand for Opportunistic infections, ART stands for Anti-retroviral therapy, and CD4 stands for cluster of differentiation 4.

Moderate knowledge had a negative association with COVID-19 vaccine uptake in the bivariable analysis. Similarly, the medium attitude had also a negative association with COVID-19 vaccine uptake in the bivariable. Moderate knowledge (AOR = 0.06, 95% CI: 0.01, 0.50) had a statistically significant strong negative association with vaccine uptake (p-value <.01). And moderate attitude (AOR = 1.1, 95% CI: 0.70, 1.30) had a statistically significant positive association with vaccine uptake (p-value = .03)

Health conditions of participants and vaccine side effects

Among the 384 participants who knew their status before the Ethiopian millennium, 7.3% (28) were aware, while 48.4% (186) became aware within 10 years of the Ethiopian millennium, and 44.3% (170) knew their status since Ethiopian 2010. Of the total, 85.4% (338) adhered well to their ARV drugs, but 9.1% (36) did not. Participants had been on ART for durations ranging from 1 year to 20 years, with 33.8% (134) on ART for ≤5 years, 41.7% (165) for 6 to 10 years, and 24.5% (97) for more than 10 years.

Among all participants, 41.5% (163) had experienced opportunistic infections (OIs), while 57.3% (225) had not.

The study revealed that four types of COVID-19 vaccines were administered in the Bole sub-city, Addis Ababa city administration. The most administered vaccines were J&J and AstraZeneca, while Sinopharm and Pfizer were less commonly administered (Figure 4). Figure 4. Vaccine type study participants had used, Bole Sub-city, Addis Ababa Ethiopia, 2022.

Of the participants, 86.9% (344) reported receiving basic (regular) vaccines, while 13.1% (52) did not. Additionally, 79.3% (314) had received at least one dose of any type of COVID-19 vaccine. Among those who received the COVID-19 vaccine, 29.3% (92) received one dose, 50.3% (158) received two doses, and 20.4% (64) received three doses (Table 5).Table 5. Vaccine type and number of doses participants took in Bole sub-city, Addis Ababa, Ethiopia, 2022.

Vaccine type	How many do you take?	Total	
One-Dose	Two Dose	Three Dose	
J&J	46.4% (70)	53.0% (80)	0	100% (151)	
Pfizer	12.5% (2)	81.3% (13)	6.3%(1)	100% (16)	
AstraZeneca	15% (20)	38.3% (51)	46.6% (62)	100% (133)	
Sinofarm	0	100% (5)	0	100% (5)	
Total	29.3% (92)	50.3% (158)	20.1% (63)	100% (314)	

Of some participants, 27.8% (110) had experienced adverse events related to COVID-19 but 48.5% (192) participants had no experience with adverse events. Malaise/headache/numbness/(34.4%), injection site pain (23.4%), muscle pain (14.1%), loss of appetite (8.6%), body temperature increment (2.3%), injection site swelling (2.3%), and nausea and vomiting (0.8%) were among repeatedly mentioned events. Of those who experienced adverse events, 57.3% reposted their concern to the health bureau but not 42.7% (487) (Figure 5). Figure 5. Adverse events experienced by study participants related to CVOVID-19 vaccine bole sub city Addis Ababa Ethiopia, 2022.

Discussion

The current study revealed that 79.3% (314) of participants had received at least one dose of a COVID-19 vaccine of any type. Approximately 56.1% (22) had received at least a second dose of the COVID-19 vaccine, regardless of its type. This finding indicates that out of a hundred people who were on ART in the Bole Sub-city public health centers, only 79 were vaccinated, while the remaining 20 were not vaccinated despite their high vulnerability. Public health interventions should be tailored to address the specific needs and concerns of vulnerable groups, such as individuals living with HIV/AIDS, to increase vaccine acceptance and coverage. In December 2021, the uptake of COVID-19 vaccination was above 70% in all regions, with the notable exception to Sub-Saharan Africa (SAA) at 48%, and the highest uptake was in the Southeast Asia region (Thailand) at 93%, surpassing even the highest income region.19 The regional uptake of COVID-19 vaccination at 70% was close to the current uptake of 79.3%. The uptake of COVID-19 vaccination was higher in Thailand compared to the current findings, while the uptake in SSA was lower.

A study conducted in China to assess the safety of the COVID-19 vaccine in HIV-infected adults revealed that 100% of People Living with HIV/AIDS (PLWHA) had received at least one dose of the vaccine, with over 90% receiving both doses.11 Similarly, a study by the University of Rutgers indicated that most people living with HIV had received at least one dose of the COVID-19 vaccine [25]. However, a study among HIV-positive patients attending an ART Clinic in Southwest Ethiopia found that the overall intention to take the COVID-19 vaccine among HIV-positive patients was low at 33.7%,12 significantly lower compared to the current findings.

Regional and national variations in COVID-19 vaccination utilization were attributed to differences in the severity of the pandemic, vaccine supply-related issues (timeliness and quantity), socio-demographic characteristics, and variations in the study period. The Asian region had better vaccine uptake due to the pandemic reaching a critical stage, prompting individuals to seek vaccines independently, along with strong public health emergency declarations. Additionally, the region had better and earlier access to vaccines.

Understanding vaccine hesitancy, addressing access barriers, ensuring complete vaccination, leveraging emergency declarations, and analyzing factors are essential for enhancing vaccine acceptance, safety, and global equity.

The current findings indicated that 27.8% of the study participants had experienced adverse events related to COVID-19. Malaise, headache, numbness (34.4%), injection site pain (23.4%), muscle pain (14.1%), loss of appetite (8.6%), body temperature increment (2.3%), injection site swelling (2.3%), and nausea and vomiting (0.8%) were among the frequently mentioned events.

A study conducted in China revealed an adverse event rate of 22.8% after the first dose (D1), which was higher than that after the second dose (D2) (10.2%). Injection site reaction (17% after D1, 7.6% after D2), fatigue (3.5% after D1, 0.8% after D2), drowsiness (2.3% after D1, 1.7% after D2), and fever (1.9% after D1, 0% after D2) were reported. The most common severe symptoms after the first dose included fatigue, drowsiness, and dizziness, while after the second dose, drowsiness was the most common.15 The rate of adverse events in China was lower than the current finding. The evidence from this study lacks subgroup analysis on the rate of adverse events following each dose (D1, D2), and booster dose, but a study in China briefly presented subgroup findings. A study in Kabul, Afghanistan, showed mild to moderate and short-duration adverse effects, including muscle pain (68.3%), injection site pain (58.8%), fever (66.3%), and fatigue (66.3%). The rate of adverse events in Kabul was higher than the current findings of injection site pain (23.4%), muscle pain (14.1%), body temperature increment (2.3%), and fatigue (34.4%).10 Another pooled evidence revealed that the most common injection site reactions and delayed large local reactions from all vaccine types included redness/erythema (39%), itching (28%), urticarial rash (17%) on the neck, upper limbs, and trunk, morbilliform eruptions (6.5%), and Pityriasis rosea (3%).20 The prevalence of adverse events following immunization depends on the strength of surveillance, event category, and public awareness. So, such differences contribute to the variation in the occurrence of adverse events among Ethiopia, Afghanistan, and China.

Public health interventions should educate about adverse events, monitor side effects, and address concerns about vaccine acceptance and safety. Tailoring interventions based on differences can improve vaccine acceptance and trust. Prioritizing severe adverse event surveillance is crucial for public trust. Subgroup analysis and enhanced surveillance can guide targeted interventions effectively. Adapting interventions to local contexts and promoting awareness can enhance vaccine acceptance and safety, ensuring effectiveness in vaccination programs.

The findings of this study indicated that having moderate knowledge (AOR = 0.06, 95% CI = 0.01, 0.50) about COVID-19 and its vaccine had a statistically significant negative association with COVID-19 vaccine uptake, or conversely, low knowledge was positively associated with vaccine uptake. As mentioned earlier, the AOR is for HIV-positive individuals. Evidence from the study revealed that having good knowledge about COVID-19 and the benefits of the vaccine had a strong positive association with the intention to take the COVID-19 vaccine among HIV-positive patients attending the ART clinic.12 Similarly, knowledge about the COVID-19 disease was identified as one of the influencing factors associated with the level of adherence to COVID-19 preventive measures, in addition to socio-political conditions (such as unemployment, livelihood, and social events) within specific contexts.21 Reports also indicated that respondents who had no information about the vaccine believed that the vaccine itself caused COVID-19 disease, or thought the vaccine contained chips, which were reasons for their reluctance to vaccinate.22 Therefore, the findings of the current study and evidence from the literature present contradictions regarding the association between knowledge and COVID-19 vaccine uptake, for reasons that are not yet clear. The COVID-19 vaccine is listed among emergency use drugs, and educated individuals may have concerns about the rapid development of the vaccine. This finding highlights an important aspect of knowledge and attitude toward the COVID-19 vaccine. It emphasizes that the knowledge score, which is a subjective index, may not always align with practical knowledge. Some individuals may report a high level of knowledge but may exhibit lower levels of practical knowledge in real-life situations. This discrepancy underscores the complexity of assessing knowledge and its application in decision-making.

Despite being informed about the vaccine development phases, knowledgeable individuals may harbor reservations or negative attitudes toward the vaccine. This discrepancy between knowledge and attitude suggests that personal decisions are often influenced more by attitude than by mere knowledge alone. It implies that knowing does not guarantee a positive attitude toward a particular issue, such as vaccination.

Furthermore, the finding suggests that knowledgeable individuals may experience internal conflicts or contradictions when questioning the reasons behind their attitudes toward the vaccine. This internal questioning reflects the nuanced interplay between knowledge, attitude, and decision-making processes. It underscores that knowledge is just one aspect influencing attitudes, and other factors, such as personal beliefs and perceptions, play a significant role in shaping individual decisions.

Evidence from Bangladesh indicated that belief in conspiracy theories resulted in negative (attitudes and subjective norms) which led to poor COVID-19 vaccine acceptance. On the other hand, awareness, perceived benefit, positive attitudes, constructive subjective norms, and the perceived ease of obtaining the vaccine have a strong positive influence on COVID-19 vaccine acceptance.18 Similarly, having a medium attitude toward COVID-19 and its vaccine (AOR = 1.1, 95% CI: 0.70, 1.3) had a statistically significant positive association with COVID-19 vaccine uptake than having a lower attitude in the current study. The statistic implied that people who were on ART in health centers of Bole Sub-city with medium attitude (relatively positive) had 21.1 times higher uptake of the COVID-19 vaccine or people on ART in the same setting with low (negative attitude) had an uptake of vaccine by 91%. The findings underscore the importance of addressing attitudes toward vaccination, as they have a substantial impact on individuals’ decisions to receive the COVID-19 vaccine. It indicates that efforts to promote vaccine uptake should focus on improving attitudes, which may require more time and resources compared to simply providing knowledge about the vaccine. This highlights the complexity of behavior change and the need for targeted interventions to shift attitudes toward vaccination positively. Moreover, the mention of a potential mutual effect between awareness rates and attitude suggests a dynamic relationship between knowledge, awareness, and attitude. This implies that increasing awareness alone may not be sufficient to drive behavioral change; attitudes must also be addressed to achieve a meaningful impact on vaccine uptake.

Limitation

This study has the following limitations: First, this study adopted a cross-sectional design so that the causality between vaccination uptake and other variables could not be determined. Secondly, the sample was found to be over-represented by females, and highly educated, so caution is needed to be taken when generalizing the findings to the general population in Ethiopia. Third, recall bias may affect some variables like regular vaccine history, recent VL, and CD4 count. Fourth, reported ADR to the data collector might be misinterpreted by the data collector. Finally, did not use standardized tools. By addressing these limitations in future research studies, researchers can enhance the quality and reliability of their findings, improve the generalizability of results, and contribute to a better understanding of vaccination uptake and safety in the population.

Conclusion

More than three- a quarter of participants were vaccinated with at least one dose of COVID-19- vaccine of any type.

Nearly three-fifths of participants took at least two doses including a booster dose of J&J.

Nearly a quarter of participants had experienced adverse events related to COVID-19

Malaise, headache, numbness, injection site pain, muscle pain, and loss of appetite were common adverse events experienced by the study participants.

About three-fifths of participants reported their concern about ADR to the health bureau

Being knowledgeable (moderate and good) about COVID-19 had a statistically significant strong negative association with COVID-19 vaccine uptake.

Having a positive attitude (moderate and good) toward COVID-19 had a statistically significant positive association with COVID-19 vaccine uptake.

Hence, the call for them should continue to work and imply a significant barrier to achieving the vaccination of 100% of the most vulnerable group. Enhanced surveillance can guide targeted interventions effectively. Adapting interventions to local contexts and promoting awareness can enhance vaccine acceptance and safety, ensuring effectiveness in vaccination programs.

Acknowledgments

The authors are highly indebted to all study participants and administrative bodies at all levels who endorsed us to undertake this study.

Sendu Seid holds a Bachelor of Science (BSc) degree and a Master of Public Health (MPH) degree. She has experience working as both a clinician and in administrative roles. Her research interests center on maternal and child health care.

Teferi Gebru Gebremeskel possesses a BSc in Midwifery and an MPH in Public Health. He has worked as both an academician and a clinician. His research interests encompass the communicable disease (CDC) care continuum in developing countries, non-communicable diseases, and digital health.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Authors’ contributions

SS and TG designed the study and performed the statistical analysis, drafted the paper, data analysis and approved the final paper.

Ethics and consent

The study was conducted after receiving ethical clearance from Addis Ababa Medical and Business College. A letter of support was written to the Addis Ababa Public Health Research and Emergency Management Directorate Bureau and the Bole sub-city health office. The same procedure was followed to communicate with the health center’s authority to facilitate the study. Finally, written and verbal informed consent was obtained from every study participant included in the study during the data collection time after explaining the objectives of the study and the right to withdraw from the study at any time. The study participants included were aged > 15 years. All methods were performed following the relevant guidelines and regulations (Declaration of Helsinki).

Abbreviation

AIDs Acquired Immune Deficiency Syndrome

FD A Food and Drug Authority

ART Antiretroviral Therapy

HC Health Center

BCC Behavior change communication

HIV Human Immune Deficiency Virus

CD4 Cluster of differentiation

OH Ministry of Health;

SARS Severe Acute Respiratory Disease

D1 Dose One (first dose)

D2 Dose two (second dose)

ETB Ethiopian Birr
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