OBJECTIVES

To understand the extent of racial disparities in SARS-CoV-2 vaccination among PWH and those vulnerable to HIV infection and to estimate the contributions of medical mistrust and vaccine-hesitant attitudes to these disparities.

DESIGN

Quantitative data analyses in a racially and gender-diverse, mixed-serostatus prospective cohort, the Multicenter AIDS Cohort Study (MACS)/Women's Interagency HIV Study (WIHS) Combined Cohort Study.

METHODS

Interviewer-assisted questionnaires assessed SARS-CoV-2 vaccination, medical mistrust, and vaccine-hesitant attitudes from March 2021 to September 2022 ( n  = 3948). Longitudinal analyses assessed effects of sociodemographics on medical mistrust and vaccine-hesitant attitudes. A hierarchical multivariable logistic regression assessed effects of these co-factors on SARS-CoV-2 vaccination. Causal mediation models assessed whether medical mistrust mediated the relationship between Black identity and vaccine-hesitant attitudes, and vaccine-hesitant attitudes mediated the relationship between Black identity and SARS-CoV-2 nonvaccination.

RESULTS

Participants' mean age was 56.7; 55.3% were Black, 52.6% cisgender female, 62.6% PWH. 10.1% reported never receiving SARS-CoV-2 vaccinations (13.4% of Black and 4.5% of White participants). Black-identified participants had higher odds of nonvaccination than White participants [aOR = 1.72; 95% confidence interval (CI) 1.08-2.72]. Medical mistrust mediated the relationship between Black identity and vaccine-hesitant attitudes, accounting for 46% of the effect ( P  < 0.0001). Vaccine-hesitant attitudes mediated the relationship between Black identity and SARS-CoV-2 nonvaccination to the extent that 57.7% (95% CI 25.3-90.1%) of the disparity would be eliminated if vaccine-hesitant attitudes among Black respondents were reduced to levels reported among other racial groups.

CONCLUSION

Findings indicate a profound need to build trustworthy healthcare environments to combat medical mistrust and vaccine-hesitant attitudes in Black communities in the United States, including those affected by HIV.