The Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) causes Coronavirus Disease 2019 (COVID-19), which has been affecting worldwide health since December 2019 1. The epidemic has afflicted 223 countries worldwide 2 with a total of 11, 549,072 confirmed cases and 3,756,185 life losses documented in Africa till March 02, 2022 3. The first verified case of COVID-19 in Ethiopia was announced on March 13, 20204. As of March 2, 2022, a total of 468,786 confirmed COVID-19 cases and 7,486 deaths had been reported3. Ethiopia has undertaken a variety of preventive measures to reduce the frequency and mortality rate of COVID-19 infection 56. Despite the actions taken throughout the world, the impact of the pandemic is not meaningfully controlled 7. The health and financial burden of COVID-19 provoked the necessity for suitable and actual vaccine development 8. Hence, vaccination was considered as the paramount approach for halting the transmission of the infection 7. 

In May 2020, the 73rd World Health Assembly delivered a resolution identifying the role of wide-ranging immunization as a global public-health goal for stopping, containing, and halting transmission of SARS-CoV-2. The vaccine has been shown to reduce infections even among individuals who are not vaccinated, through the development of herd immunity, if most of the population become vaccinated 9.

Ethiopia has planned to vaccinate about 20% of the population until the end of 2021 being high priority was given to health care professionals, elderly and patients with chronic disease above the age of 55 years old 10.

Even if every segment of population is likely to be affected by COVID-19 infection, patients with co-morbidities like hypertension, obesity and diabetes are mainly at increased risk of complicating outcomes compared to those without 111213. The adverse effect of COVID-19 infection among people living with HIV was controversial 141516171819. HIV causes immunosuppression by depleting CD4 cells, thus reducing the capacity of the body to defend against bacterial, fungal, parasitic, and viral infections such as COVID-19 20. This vulnerability to infection is greater when the immunosuppression is severe and the patient is not on ART making the patient at risk of opportunistic infections 2122. The result of meta-analysis on mortality rate of people with HIV due to COVID-19 was 8.87 The existence of 1,034,640 HIV positive people in Ethiopia during this time period poses a challenge to health-care systems, necessitating vigorous preventive and treatment interventions 23. COVID-19 immunization, one of the preventative methods, produced the same level of immune response as well as no difference in adverse effects in people with HIV and people without HIV 24. As a result, it is required for programmatic objectives, optimal allocation of vaccine availability, and prioritizing of care for HIV-positive persons. The purpose of this study was to determine whether or not patients living with HIV were willing to receive the COVID-19 vaccine.

Vaccination is an important approach for mitigating the COVID-19 pandemic by instilling herd immunity in the community. The effectiveness of this technique is dependent on vaccine uptake in the population. According to the most recent COVID-19 estimates, up to 60–75 percent of the population needs to be vaccinated in order to stop the disease's spread and achieve herd immunity 26.

The established risk factors for COVID-19 acquisition and consequences, such as heart disease, kidney disease, diabetes, chronic pulmonary disease, and obesity, may be more prevalent in PLWHA 27. Existing clinical data suggest that the risk of acquiring deadly COVID-19 in PLWHA was 30% higher than in those without HIV infection. All currently available vaccinations can be used safely in patients living with HIV, independent of CD4 count or viral load suppression status 28. 

The prevalence and parameters associated with PLWHA's willingness to receive COVID-19 immunization were investigated in this study. As a result, 66% of PLWHA expressed desire to get the COVID-19 vaccine. This study's findings agree with those of an Ethiopian study (62.6%) 25. Reports of willingness to receive COVID-19 vaccine among PLWHA in current study was higher than findings from study in Turkey (29.2%) 29, Ethiopia (31.4%)30 and Palestine (37.8%)31, Wolayta-Ethiopia (45.5%)32, Southern Ethiopia (46.1%)33, China (57.2%)34 and south India (60%)35. And the finding of this study is lower than findings from, China (72.5)36, France (71.3%)37. This disparity could be explained by geographical heterogeneity, the methodology used, and the socio-demographic and socioeconomic features of the research populations.

The novelty of the COVID-19 disease may have contributed to the lower magnitude of vaccine adoption. As a result of the vaccine's rapid development, there may be ambiguity and misguided ideas about it, which leads to the false notion that the vaccine has not been sufficiently proven for safety and effectiveness, as well as restricted access to information, particularly in LMICs38. Furthermore, this increased vaccine hesitation could be linked to widespread misinformation about the COVID-19 vaccine on social media39. Despite the increased risk of developing COVID-19, the low rate of vaccination uptake in PLWHA provides fertile ground for exacerbating health-related side effects 40.

In our study, PLWHA with secondary and college education levels were less likely to be willing to be vaccinated with COVID 19 vaccine than non-educated participants. This is confirmed by studies from Gondar, Ethiopia, which found that participants with a university degree were less likely to receive the vaccine than those with a college diploma 10. In contrary, this study was not in-line with findings from41, (Palestine)31, USA42 which reported willingness of receiving vaccine increases as educational status of an individual increases. This might be due increased concerns about the mistrust in efficacy and efficiency of the vaccine 35. In addition, for HIV infected individuals, they may worry that the vaccine would further worsen their immune system 43.

Negative claims about vaccine effectiveness can profoundly influence vaccine uptake 44. Rumors regarding vaccination efforts being utilized for political goals, assertions that the COVID-19 vaccine was designed to reduce the global population, affect vaccination campaigns in various nations, particularly among the educated portion of the public who likely have better access to information. The odds of a participant being classified as hesitant increased by 26% for each additional source of information they mistrusted 3545. In this situation, stakeholders such as the federal ministry of health, the regional health bureau, and media organizations should broadcast reliable information to the population, thereby developing confidence, ensuring widespread vaccine coverage, and ultimately ending the pandemic.

In present study, participants who had good knowledge towards COVID-19 vaccine were 3.7 more likely to accept the COVID-19 vaccine when compared to respondents with poor knowledge. This was consistent with the findings from Ethiopia46, Ethiopia47, Pakistan31, Ethiopia 25, and the USA48.It might be due to having good knowledge about a COVID-19 vaccine being a prerequisite for using it.

Respondents who had a positive attitude towards the COVID-19 vaccines had a significantly higher acceptance rate of the COVID-19 vaccine (AOR=4.3) which was supported by the findings from Ethiopia47, Ethiopia46, Ethiopia49, South Africa50, Ethiopia33 worldwide51. This could be due to those who have positive attitude towards the vaccine are highly compliant towards preventive measures against the pandemic including vaccination. Therefore, information campaigns should focus on providing more information about COVID-19 vaccine safety, reassuring the population in order to maintain this positive attitude towards the intention to accept the vaccine.

Even though this study had strengths, there were some limitations. This study was cross sectional survey. Therefore the limitation of this study is temporal relationship can’t be determined. The other limitation is lack of control group (HIV negative persons)

Almost one-third of PLWHA on ART refused immunization. This study demonstrates the complexities of patients' imaginations regarding COVID-19 immunization and may aid physicians and other health care providers in understanding patients' perspectives on COVID-19 vaccination. Increased sensitization on the necessity of vaccines and the negative consequences of diseases, particularly among PLWHA, should be considered in the development of the COVID-19 vaccination campaign by prominent individuals such as health professionals and religious figures. Vaccination programs should be culturally appropriate and informed by people who have lived experiences in order to reach people who might otherwise be hesitant. Furthermore, the need of immunization and the negative implications of refusing the vaccine must be thoroughly explained.

Our heart full gratitude goes to the study participants and health care professionals working in Woldia comprehensive specialized hospital for their good face to conduct this work.