High COVID-19 vaccine uptake among HIV-positive smokers in Japan: effects of the health belief model - a single-center survey

High COVID-19 vaccine uptake among HIV-positive smokers in Japan: effects of the health belief model - a single-center survey | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article High COVID-19 vaccine uptake among HIV-positive smokers in Japan: effects of the health belief model - a single-center survey Reiko Sakama, Yuji Hirai, Keisuke Kamada, Ichiro Koga, Emi Hirayama, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7695970/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The effectiveness of vaccination against coronavirus disease 2019 (COVID-19) among people living with HIV (PLWH) has been increasingly documented in recent years. Large-scale cohort studies from Canada have demonstrated that COVID-19 vaccines confer significant protection in this population. However, low vaccination coverage among PLWH remains a concern. In parallel, previous studies have reported that smokers are more likely to exhibit vaccine hesitancy, resulting in reduced uptake of COVID-19 vaccination. This study aimed to investigate differences in the vaccination rates and clinical outcomes of COVID-19 infection between smokers and nonsmokers in a cohort of PLWH at a single center in Japan. Methods Among approximately 250 PLWH aged ≥ 18 years who were receiving outpatient care at a university hospital in Tokyo, Japan, 51 who had been diagnosed with COVID-19 between 2020 and 2023 were invited to participate in a questionnaire-based survey. Among these 51 patients, 38 provided informed consent and responded to the survey. A total of 43 infection episodes, including cases of multiple infections, were analyzed. Results A total of 38 participants (age range, 31–66 years) responded to the questionnaire (response rate: 74.5%). Five individuals experienced COVID-19 infection twice, resulting in a total of 43 infection episodes. As of April 20, 2025, the majority of participants were in their 40s (n = 15), and 97.4% (37/38) were male. Over 60% of the respondents reported a history of both smoking and alcohol consumption. All patients maintained virological suppression before and after COVID-19 infection. In total, 92.1% (35/38) of the patients had received at least one dose of a COVID-19 vaccine. Among smokers, the vaccination rate was 96%, which was higher than that among nonsmokers (86%); however, this difference was not statistically significant (p = 0.3743). Conclusions The present study found that smokers had a higher COVID-19 vaccination rate than nonsmokers. This finding contrasts with previous findings suggesting that smokers tend to have more negative attitudes toward vaccination. Factors such as access to health care, perceived infection risk, and treatment adherence may contribute to this discrepancy. HIV COVID-19 Vaccination Figures Figure 1 Figure 2 Introduction Since the emergence of coronavirus disease 2019 (COVID-19) in December 2019, more than 770 million infections have been reported worldwide (as of May 2025). Although the global outbreak has largely subsided and the World Health Organization declared an end to the Public Health Emergency of International Concern in May 2023, the impact of COVID-19 continues to persist among immunocompromised individuals and older populations [ 1 ]. In recent years, the effectiveness of vaccination against COVID-19 among people living with HIV (PLWH) has received increasing attention. Large-scale cohort studies conducted in Canada have demonstrated the preventive benefits of COVID-19 vaccination in PLWH [ 2 , 3 ]; however, low vaccination coverage remains a significant concern [ 4 ]. Additionally, smokers have been reported to exhibit more negative attitudes toward COVID-19 vaccination, leading to lower vaccination uptake [ 5 ]. Regarding clinical outcomes, some studies have reported increased mortality among PLWH following COVID-19 infection [ 6 – 10 ]. In contrast, other studies have suggested that those receiving antiretroviral therapy (ART) or those with sustained virologic suppression do not experience increased mortality and may have outcomes comparable to those of the general population [ 11 – 16 ]. Despite these global findings, data on COVID-19 vaccination coverage and clinical outcomes among PLWH in Japan remain limited. Therefore, this study aimed to investigate COVID-19 vaccination rates and clinical outcomes among PLWH at a single center in Japan, with a particular focus on comparing smokers and nonsmokers. Methods Inclusion criteria and sampling procedure Among more than 250 PLWH aged ≥ 18 years who were receiving outpatient care at a tertiary university hospital in Tokyo, those deemed unsuitable for study participation by the principal investigator were excluded. All 51 patients who reported having developed COVID-19 between October 2020 and February 2023 were invited to participate in a written questionnaire survey. A total of 38 patients consented to participate and completed the survey, including five individuals who experienced two separate episodes of COVID-19 infection. The questionnaire was either handed directly to patients during outpatient visits or sent by post with careful attention to privacy, following verbal or written consent. Responses were collected either in person or by mail and were accompanied by signed consent forms. In cases where patients did not return the questionnaire despite having provided verbal consent, reminders were given during subsequent clinic visits or via telephone. Study aim, design, and setting This study aimed to assess mortality and COVID-19 vaccination rates among PLWH who were receiving treatment for COVID-19 infection at a university hospital in Japan. Study measures A 14-item questionnaire was developed to collect information on the participants’ basic characteristics, date of HIV diagnosis, date of COVID-19 diagnosis, hospitalization status, symptoms before and after COVID-19 infection, history of close contact or cohabitation with infected individuals, number of COVID-19 vaccine doses received, and timing of vaccinations (Additional file 1). Among the 38 participants, five had experienced COVID-19 infection twice; thus, a total of 43 infection episodes were included in the analysis. Because the amount of missing data was minimal, no imputation was performed. The number of vaccine doses received was determined on the basis of the maximum possible number of vaccinations at the time of questionnaire completion [ 17 – 20 ]. In accordance with the recommendations of the Ministry of Health, Labour and Welfare of Japan, the interval between the second and third vaccine doses was initially set at a minimum of 6 months, and at least 5 months were required after the third dose. However, on October 19, 2022, this interval was shortened to 3 months or more [ 21 ]. On the basis of these guidelines, the maximum possible number of vaccine doses was calculated for each participant, and three individuals whose vaccination history was not definitive but likely were also included in the analysis. Statistical analysis Nonparametric analyses were performed using Fisher’s exact test with JMP Pro 16.0.0 (SAS Institute Inc., Cary, NC, USA). A two-tailed p value < 0.05 was considered to indicate statistical significance. Ethical considerations All data were fully anonymized, and no personally identifiable information was collected. The study protocol was approved by the Ethics Committee of Tokyo Women’s Medical University Hospital (approval No. 2021 − 0118). Results Study population and participant characteristics A total of 38 patients (age range, 31–66 years) responded to the questionnaire (response rate: 74.5%). Five patients experienced two episodes of COVID-19 infection. As of May 22, 2025, the majority of participants were in their 40s (n = 15), 97.4% were male (37/38), and 84.2% (32/38) resided in Tokyo. A history of smoking and alcohol consumption was reported by more than 60% of the participants (smoking: n = 27; alcohol consumption: n = 30). Lifestyle-related comorbidities considered potential risk factors for severe COVID-19 illness were present in 21.1% (8/38) of the participants, hepatitis in 34.2% (13/38), and a history of AIDS in 7.9% (3/38). All patients who were hospitalized for COVID-19 pneumonia were smokers (2/25). The overall COVID-19 vaccination rate was 92.1% (35/38), while the influenza vaccination rate was 41.9% (18/43) (Table 1 ). Table 1 Baseline characteristics of the study participants (n = 38) Characteristics N (%) Gender Male 37 (97.4) Female 1 (2.6) Age (years) 20s 0 (0) 30s 10 (26.3) 40s 15 (39.5) 50s 8 (21.1) 60s 5 (13.2) Residence Tokyo 32 (84.2) Other 6 (15.8) Current smoker Yes 27 (79.4) No 7 (20.6) Current drinker Yes 30 (78.9) No 4 (10.5) Medical history Chronic disease (DM, HL, HTN) 8 (21.1) Hepatitis (HBV, HCV) 13 (34.2) AIDS (PCP, cryptococcal meningitis) 3 (7.9) Duration of HIV infection (years) 0–9 10 (26.3) 10–19 24 (63.2) ≥ 20 4 (10.5) COVID-19 vaccination Yes 35 (92.1) No 3 (7.9) Influenza vaccination Yes 18 (41.9) No 25 (58.1) Admission Nonsmoker No 6 (85.7) Yes – due to pneumonia 0 (0) Yes – other reasons 1 (14.3) Smoker No 20 (80.0) Yes – due to pneumonia 2 (8.0) Yes – other reasons 3 (12.0) Abbreviations: DM, diabetes mellitus; HL, hyperlipidemia; HTN, hypertension; HBV, hepatitis B virus; HCV, hepatitis C virus; PCP, Pneumocystis pneumonia. Trends in HIV-RNA viral loads and CD4 counts before and after COVID-19 infection The majority of the participants (24/38; 63.2%) had been living with HIV for more than 10 years. All patients maintained long-term virologic suppression, with HIV-RNA levels remaining undetectable both before and after COVID-19 infection. CD4 counts prior to infection ranged from 131 to 1023/µL. A transient decline in CD4 counts was observed during the time of infection; however, post-infection levels recovered to equal or higher than pre-infection values, ranging from 203 to 1272/µL (Fig. 1 ). Hospitalization and variants A total of nine patients were hospitalized, including one individual who experienced two COVID-19 episodes and was hospitalized on both occasions. All hospitalizations occurred before May 8, 2023, when COVID-19 was classified under the Japanese Category II equivalent of infectious diseases. On the basis of the timing of infection [ 22 ], four patients (44.4%) were presumed to have been infected with the Delta variant, three of whom (75%) were admitted primarily for pneumonia. Five patients experienced two episodes of COVID-19 infection (four presumed Omicron variant and one presumed Delta variant); only one of these patients (11.1%) required hospitalization. Three patients had a history of AIDS, including one who was hospitalized. All three were classified as having mild COVID-19 according to Japanese clinical guidelines [ 23 ], defined as peripheral oxygen saturation ≥ 96%, absence of respiratory symptoms or presence of cough only without dyspnea, and no radiographic evidence of pneumonia. Vaccination rates and smoking status The COVID-19 vaccination rate was higher among smokers (26/27; 96%) than nonsmokers (6/7; 86%); however, this difference was not statistically significant (Fisher’s exact test, p = 0.3743). In contrast, the influenza vaccination rate was significantly lower among smokers (18/34; 42%) than among nonsmokers (28/34; 58%) (Fisher’s exact test, p = 0.0118). Vaccination and mortality rates By the time of the questionnaire survey, 60.5% of the participants (20 definite cases and three probable cases out of 38) had received the maximum number of COVID-19 vaccine doses recommended for their situation. Overall, 92.1% (35/38) of the participants had received at least one dose of a COVID-19 vaccine, whereas 7.9% (3/38) had never been vaccinated. Among the five patients who experienced two episodes of COVID-19 infection, four had received the maximum recommended number of vaccine doses at the time of infection, whereas one was considered to have possibly been under-vaccinated. No deaths occurred in any of the cases. Discussion Among the patients with HIV receiving care at our hospital, 38 of the 51 individuals who contracted COVID-19 responded to the questionnaire (response rate: 74.5%). Five patients experienced two episodes of COVID-19 infection. Lifestyle-related comorbidities such as diabetes mellitus, hypertension, and dyslipidemia, as well as older age and chronic kidney disease, have been reported to be prognostic factors for severe COVID-19 [ 24 – 26 ]. In the present study, only one patient was ≥ 65 years of age. Although some participants were current smokers or were undergoing treatment for lifestyle-related diseases, no cases of severe COVID-19 illness were observed. This may be attributable to the low number (one or two) of prognostic factors other than HIV infection—which itself represents an immunocompromised condition—in this study [ 26 ]. Trends in HIV-RNA viral loads and CD4 counts before and after COVID-19 infection All patients maintained long-term virologic suppression before and after COVID-19 infection. CD4 counts at the time of infection were available for only four patients; in all cases, a transient decrease was observed during infection, followed by recovery to pre-infection levels or higher counts after recovery (Fig. 1 ). Previous studies have also reported a decline in CD4 counts during COVID-19 infection, which has been attributed to impaired T-cell proliferation and functional exhaustion associated with elevated inflammatory cytokines such as interleukin (IL)-6, IL-10, and tumor necrosis factor-α, with the decrease being particularly pronounced in severe cases [ 27 ]. One study reported a significant reduction in CD4 counts at hospital admission, followed by a marked increase within 2 weeks and stabilization by 6 weeks [ 28 ]. Consistent with these findings, in the present study, patients with pneumonia presumed to be caused by the Delta variant exhibited a more pronounced CD4 decline compared with the other three patients. CD4 counts subsequently increased in all cases, aligning with trends reported in the literature. COVID-19 vaccination rates Previous studies have reported low COVID-19 vaccination rates, particularly among smokers [ 4 , 5 , 29 ]. In contrast, in our study, 92.1% (35/38) of the respondents had received at least one dose of a COVID-19 vaccine. This rate is substantially higher than the previously reported national average intention to vaccinate in Japan (65.7%) [ 30 ]. A previous survey on COVID-19 awareness among PLWH indicated that they generally possessed a high level of knowledge about COVID-19 and engaged in preventive behaviors [ 31 , 32 ]. Conversely, an online survey conducted in 10 countries across the Asia‒Pacific region reported a decrease in the frequency of HIV testing [ 33 ] and instances of delayed health-care-seeking behavior during the pandemic [ 34 ]. COVID-19 vaccination rates are reportedly lower among women, vary by race, and are higher among individuals with virologic suppression [ 35 , 36 ]. Vaccination uptake is also influenced by regional, economic, and psychological factors [ 37 – 39 ]. In the present study, the majority of the participants were male (37/38; 97.4%), and all had achieved virologic suppression, suggesting that our cohort represented a population with a relatively high likelihood of receiving COVID-19 vaccination. Vaccination rates and smoking status Overall, the COVID-19 vaccination rate among all respondents was 92.1% (35/38), with a higher rate observed among smokers (26/27; 96%). In contrast, the overall influenza vaccination rate was 41.9% (18/43), and the rate among smokers was lower, at 30% (8/27) (Fig. 2 ). Previous studies have reported that smokers have lower vaccination rates for both COVID-19 and influenza compared with nonsmokers, and this is often attributed to concerns about vaccine safety and a fear of adverse effects [ 29 , 40 , 41 ]. In the present study, although the difference in COVID-19 vaccination rates between smokers and nonsmokers was not statistically significant (Fisher’s exact test, p = 0.3743), a higher vaccination rate was observed among smokers. This finding contrasts with prior research indicating that smokers tend to have more negative attitudes toward vaccination [ 5 ]. Vaccination behavior is likely influenced by factors beyond smoking status, including vaccine-related knowledge, trust in health-care providers, risk perception, and access to medical services. These factors are consistent with the health belief model (HBM), a theoretical framework in health behavior research that explains how individuals perceive health threats and decide to take preventive action [ 40 ]. The HBM comprises six main cognitive constructs: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to action. In the context of COVID-19 vaccination among PLWH, previous studies have shown that trust in vaccines and belief in their benefits are significant predictors of vaccination intention [ 42 ]. Other studies have reported that, compared with the general population, PLWH demonstrate a lower willingness to receive a second COVID-19 booster dose, a trend associated with perceived severity and perceived barriers [ 43 ]. In the present study, the widespread recognition of smoking and immunocompromised status as risk factors for severe COVID-19—facilitated by public awareness initiatives and the information-rich environment of a university hospital—may have contributed to promoting vaccination and encouraging preventive behaviors among smokers. It is also possible that some individuals experienced a sense of guilt for not routinely receiving vaccinations, such as the influenza vaccine, which may have led to behavioral change. Among the three patients who had not received a COVID-19 vaccine, only one reported unwillingness to be vaccinated, suggesting a generally high level of vaccination intention in this study. Previous studies have reported that smokers with higher risk perception are more likely to be vaccinated [ 29 ]. Moreover, knowledge of and concern about COVID-19 have been associated with preventive behaviors and adherence to ART, contributing to improved treatment outcomes [ 44 ]. Our findings are consistent with these reports. In contrast, the influenza vaccination rate was significantly lower among smokers than nonsmokers (Fisher’s exact probability test, p = 0.0118), suggesting that the motivational drivers for COVID-19 vaccination may differ from those for influenza vaccination. Moving forward, communicating the importance of vaccination to PLWH—including smokers—within the framework of the HBM may help facilitate positive behavior change. COVID-19 vaccination and mortality rates Previous studies have reported that the effectiveness of COVID-19 vaccination in preventing severe disease is approximately 54% with two doses and over 80% with three or more doses [ 45 ]. In immunocompromised patients—particularly organ transplant recipients—although the initial antibody acquisition rate after the first dose may be low, it improves with the second dose, and administration of a third booster dose is recommended [ 46 ]. Among PLWH, previous reports have indicated that COVID-19 vaccination does not result in reduced antibody acquisition rates or lower antibody titers; however, considering the antibody half-life, regular COVID-19 vaccination every 6–12 months is recommended [ 47 ]. In the present study, none of the five patients who experienced two episodes of COVID-19 developed severe disease or died. All had received three or more doses of a COVID-19 vaccine and were considered to have completed the maximum recommended number of doses at the time of infection, suggesting that vaccination may have contributed to the prevention of severe outcomes. Furthermore, previous studies have reported that the Omicron variant provides a sustained high level of protection against severe disease [ 48 ], and both vaccination and variant characteristics may have contributed to the favorable outcomes observed in our study. However, because some patients had multiple infections, it remains unclear whether vaccination contributed to reducing the frequency of infection. Virological suppression and mortality In this study, all patients maintained virological suppression before and after COVID-19 infection. Previous reports have shown that, among PLWH who achieve virological suppression, the effectiveness of COVID-19 vaccination is not reduced [ 2 ], and the incidence of severe COVID-19 is lower [ 49 ]. Therefore, it is likely that the sustained virological suppression in our study contributed to the absence of severe disease. Limitations This study has several limitations. First, this was a single-center study conducted at a university hospital in Tokyo, where most participants had good access to medical care. Therefore, the findings cannot be generalized to all PLWH in Japan. Future multicenter studies are needed to verify the external validity of these results. Second, this was a voluntary, questionnaire-based survey, which may have introduced self-selection bias. Patients with greater interest in COVID-19 and vaccination may have been more likely to respond. In addition, deaths that occurred among patients hospitalized at other institutions could not be captured, raising the possibility that the prevalence of severe disease or mortality in this study may have been over- or underestimated. Third, there was variability in the timing of questionnaire distribution and collection, which may have influenced the participants’ attitudes toward COVID-19 and, consequently, vaccination rates. Nonetheless, this study provides clinically meaningful insights by capturing the current status of COVID-19 infection and vaccination rates among PLWH in Japan. Conclusions In this study, smokers had higher COVID-19 vaccination rates but significantly lower influenza vaccination rates compared with nonsmokers. Although this partially contradicts previous studies reporting that smokers tend to have negative attitudes toward vaccination [ 5 ], vaccination behavior is likely influenced by factors beyond smoking status, such as vaccine-related knowledge, trust in health-care providers, risk perception, and access to medical services. Previous studies have also shown that smokers with higher risk perception are more likely to be vaccinated [ 29 ]. Our findings suggest that even among smokers, high COVID-19 vaccination rates may have been facilitated by social and clinical health promotion, influencing key constructs of the HBM—namely, perceived susceptibility, perceived severity, perceived benefits, and cues to action. These factors may have promoted behavior change through heightened recognition of the risk of severe disease and continuous engagement with health-care providers. This highlights the importance of risk communication and sustained patient–provider relationships in driving behavior change and improving the quality of care for patients with HIV. Abbreviations ART Antiretroviral therapy COVID-19 Coronavirus disease 2019 HBM Health belief model PLWH People living with HIV Declarations Consent for publication Not applicable. Human Ethics and Consent to Participate declarations Not applicable. Ethics approval and Consent to Participate This study was conducted in accordance with the Declaration of Helsinki. The study protocol was approved by the Ethics Committee of Tokyo Women’s Medical University Hospital (approval No. 2021-0118). Written informed consent was obtained from all participants prior to participation. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author Contribution R.S. conceived and designed the study. R.S., K.Ka., I.K., E.H., and K.Ki. collected the data. R.S. and K.H. performed the analysis and drafted the manuscript. All authors read and approved the final manuscript for submission. Acknowledgement The authors wish to thank all the participants and the clinical staff of Tokyo Women’s Medical University Hospital for their cooperation with this study. Data Availability The datasets generated and/or analyzed during the current study are not publicly available due to privacy restrictions but are available from the corresponding author on reasonable request. References COVID-19 cases | WHO COVID-19 dashboard. https://data.who.int/dashboards/covid19/cases . Accessed 22 May 2025. Chambers C, Samji H, Cooper CL, Costiniuk CT, Janjua NZ, Kroch AE, et al. Coronavirus disease 2019 vaccine effectiveness among a population-based cohort of people living with HIV. AIDS. 2022;36(15):F17–26. Fowokan A, Samji H, Puyat JH, Janjua NZ, Wilton J, Wong J, et al. 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Effect on SARS-CoV-2 Antibody Levels after the Vaccination in People Living with HIV Visiting Hiroshima University Hospital. J AIDS Res. 2023;25:92–8. Feikin DR, Abu-Raddad LJ, Andrews N, Davies MA, Higdon MM, Orenstein WA, et al. Assessing vaccine effectiveness against severe COVID-19 disease caused by Omicron variant: report from a meeting of the World Health Organization. Vaccine. 2022;40(26):3516–27. Pérez-Barragán E, Castillo-Flores JH, Mata-Marín JA, Franco López SG, Morales Martínez BA, Pérez Cavazos S. COVID-19 in people living with HIV: a single-center descriptive study. J Infect Dev Ctries. 2022;16(12):1796–9. Additional Declarations No competing interests reported. Supplementary Files Questionnaire.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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09:27:13","extension":"html","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":123196,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7695970/v1/333231dfd7a34c70d457a3ef.html"},{"id":95521875,"identity":"68943e4f-c471-4e81-b318-bd8691aab720","added_by":"auto","created_at":"2025-11-10 09:27:12","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":20717,"visible":true,"origin":"","legend":"\u003cp\u003eTrends in CD4 counts before and after COVID-19 infection\u003c/p\u003e","description":"","filename":"OnlineFigure1.TrendsinCD4countsbeforeandafterCOVID19infection.png","url":"https://assets-eu.researchsquare.com/files/rs-7695970/v1/752781607f2f993f54227884.png"},{"id":95521872,"identity":"72a3b84a-443c-4eb1-a1f0-30c91a14f2ff","added_by":"auto","created_at":"2025-11-10 09:27:12","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":13912,"visible":true,"origin":"","legend":"\u003cp\u003eVaccination rates by smoking status\u003c/p\u003e","description":"","filename":"OnlineFigure2.Vaccinationratesbysmokingstatus.png","url":"https://assets-eu.researchsquare.com/files/rs-7695970/v1/8f2fba88baf8424ded8b0d7f.png"},{"id":98775019,"identity":"adc4a669-2729-4f51-aef3-80a29113fc54","added_by":"auto","created_at":"2025-12-22 12:17:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":957063,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7695970/v1/eb3f933d-3398-47f1-860a-5a58c085c401.pdf"},{"id":95521874,"identity":"e31b9a5b-7193-419d-adcd-3a6b9edbd39b","added_by":"auto","created_at":"2025-11-10 09:27:12","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":44928,"visible":true,"origin":"","legend":"","description":"","filename":"Questionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-7695970/v1/30bee6113a6fac8ff2e2a685.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"High COVID-19 vaccine uptake among HIV-positive smokers in Japan: effects of the health belief model - a single-center survey","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSince the emergence of coronavirus disease 2019 (COVID-19) in December 2019, more than 770\u0026nbsp;million infections have been reported worldwide (as of May 2025). Although the global outbreak has largely subsided and the World Health Organization declared an end to the Public Health Emergency of International Concern in May 2023, the impact of COVID-19 continues to persist among immunocompromised individuals and older populations [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn recent years, the effectiveness of vaccination against COVID-19 among people living with HIV (PLWH) has received increasing attention. Large-scale cohort studies conducted in Canada have demonstrated the preventive benefits of COVID-19 vaccination in PLWH [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]; however, low vaccination coverage remains a significant concern [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Additionally, smokers have been reported to exhibit more negative attitudes toward COVID-19 vaccination, leading to lower vaccination uptake [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRegarding clinical outcomes, some studies have reported increased mortality among PLWH following COVID-19 infection [\u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In contrast, other studies have suggested that those receiving antiretroviral therapy (ART) or those with sustained virologic suppression do not experience increased mortality and may have outcomes comparable to those of the general population [\u003cspan additionalcitationids=\"CR12 CR13 CR14 CR15\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite these global findings, data on COVID-19 vaccination coverage and clinical outcomes among PLWH in Japan remain limited. Therefore, this study aimed to investigate COVID-19 vaccination rates and clinical outcomes among PLWH at a single center in Japan, with a particular focus on comparing smokers and nonsmokers.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eInclusion criteria and sampling procedure\u003c/h2\u003e\u003cp\u003eAmong more than 250 PLWH aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years who were receiving outpatient care at a tertiary university hospital in Tokyo, those deemed unsuitable for study participation by the principal investigator were excluded. All 51 patients who reported having developed COVID-19 between October 2020 and February 2023 were invited to participate in a written questionnaire survey.\u003c/p\u003e\u003cp\u003eA total of 38 patients consented to participate and completed the survey, including five individuals who experienced two separate episodes of COVID-19 infection. The questionnaire was either handed directly to patients during outpatient visits or sent by post with careful attention to privacy, following verbal or written consent. Responses were collected either in person or by mail and were accompanied by signed consent forms. In cases where patients did not return the questionnaire despite having provided verbal consent, reminders were given during subsequent clinic visits or via telephone.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy aim, design, and setting\u003c/h3\u003e\n\u003cp\u003eThis study aimed to assess mortality and COVID-19 vaccination rates among PLWH who were receiving treatment for COVID-19 infection at a university hospital in Japan.\u003c/p\u003e\n\u003ch3\u003eStudy measures\u003c/h3\u003e\n\u003cp\u003eA 14-item questionnaire was developed to collect information on the participants\u0026rsquo; basic characteristics, date of HIV diagnosis, date of COVID-19 diagnosis, hospitalization status, symptoms before and after COVID-19 infection, history of close contact or cohabitation with infected individuals, number of COVID-19 vaccine doses received, and timing of vaccinations (Additional file 1).\u003c/p\u003e\u003cp\u003eAmong the 38 participants, five had experienced COVID-19 infection twice; thus, a total of 43 infection episodes were included in the analysis. Because the amount of missing data was minimal, no imputation was performed.\u003c/p\u003e\u003cp\u003eThe number of vaccine doses received was determined on the basis of the maximum possible number of vaccinations at the time of questionnaire completion [\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In accordance with the recommendations of the Ministry of Health, Labour and Welfare of Japan, the interval between the second and third vaccine doses was initially set at a minimum of 6 months, and at least 5 months were required after the third dose. However, on October 19, 2022, this interval was shortened to 3 months or more [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. On the basis of these guidelines, the maximum possible number of vaccine doses was calculated for each participant, and three individuals whose vaccination history was not definitive but likely were also included in the analysis.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eNonparametric analyses were performed using Fisher\u0026rsquo;s exact test with JMP Pro 16.0.0 (SAS Institute Inc., Cary, NC, USA). A two-tailed p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to indicate statistical significance.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003eAll data were fully anonymized, and no personally identifiable information was collected. The study protocol was approved by the Ethics Committee of Tokyo Women\u0026rsquo;s Medical University Hospital (approval No. 2021\u0026thinsp;\u0026minus;\u0026thinsp;0118).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eStudy population and participant characteristics\u003c/h2\u003e\u003cp\u003eA total of 38 patients (age range, 31\u0026ndash;66 years) responded to the questionnaire (response rate: 74.5%). Five patients experienced two episodes of COVID-19 infection. As of May 22, 2025, the majority of participants were in their 40s (n\u0026thinsp;=\u0026thinsp;15), 97.4% were male (37/38), and 84.2% (32/38) resided in Tokyo.\u003c/p\u003e\u003cp\u003eA history of smoking and alcohol consumption was reported by more than 60% of the participants (smoking: n\u0026thinsp;=\u0026thinsp;27; alcohol consumption: n\u0026thinsp;=\u0026thinsp;30). Lifestyle-related comorbidities considered potential risk factors for severe COVID-19 illness were present in 21.1% (8/38) of the participants, hepatitis in 34.2% (13/38), and a history of AIDS in 7.9% (3/38).\u003c/p\u003e\u003cp\u003eAll patients who were hospitalized for COVID-19 pneumonia were smokers (2/25). The overall COVID-19 vaccination rate was 92.1% (35/38), while the influenza vaccination rate was 41.9% (18/43) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline characteristics of the study participants (n\u0026thinsp;=\u0026thinsp;38)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37 (97.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20s\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e30s\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (26.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e40s\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (39.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e50s\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (21.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e60s\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (13.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTokyo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32 (84.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (15.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCurrent smoker\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27 (79.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (20.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCurrent drinker\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30 (78.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (10.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMedical history\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChronic disease (DM, HL, HTN)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (21.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHepatitis (HBV, HCV)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (34.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAIDS (PCP, cryptococcal meningitis)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (7.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDuration of HIV infection (years)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u0026ndash;9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (26.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u0026ndash;19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (63.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (10.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCOVID-19 vaccination\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35 (92.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (7.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInfluenza vaccination\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (41.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25 (58.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAdmission\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNonsmoker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (85.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes \u0026ndash; due to pneumonia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes \u0026ndash; other reasons\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (14.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (80.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes \u0026ndash; due to pneumonia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (8.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes \u0026ndash; other reasons\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (12.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003eAbbreviations: DM, diabetes mellitus; HL, hyperlipidemia; HTN, hypertension; HBV, hepatitis B virus; HCV, hepatitis C virus; PCP, \u003cem\u003ePneumocystis\u003c/em\u003e pneumonia.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eTrends in HIV-RNA viral loads and CD4 counts before and after COVID-19 infection\u003c/h3\u003e\n\u003cp\u003eThe majority of the participants (24/38; 63.2%) had been living with HIV for more than 10 years. All patients maintained long-term virologic suppression, with HIV-RNA levels remaining undetectable both before and after COVID-19 infection. CD4 counts prior to infection ranged from 131 to 1023/\u0026micro;L. A transient decline in CD4 counts was observed during the time of infection; however, post-infection levels recovered to equal or higher than pre-infection values, ranging from 203 to 1272/\u0026micro;L (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eHospitalization and variants\u003c/h2\u003e\u003cp\u003eA total of nine patients were hospitalized, including one individual who experienced two COVID-19 episodes and was hospitalized on both occasions. All hospitalizations occurred before May 8, 2023, when COVID-19 was classified under the Japanese Category II equivalent of infectious diseases. On the basis of the timing of infection [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], four patients (44.4%) were presumed to have been infected with the Delta variant, three of whom (75%) were admitted primarily for pneumonia.\u003c/p\u003e\u003cp\u003eFive patients experienced two episodes of COVID-19 infection (four presumed Omicron variant and one presumed Delta variant); only one of these patients (11.1%) required hospitalization.\u003c/p\u003e\u003cp\u003eThree patients had a history of AIDS, including one who was hospitalized. All three were classified as having mild COVID-19 according to Japanese clinical guidelines [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], defined as peripheral oxygen saturation\u0026thinsp;\u0026ge;\u0026thinsp;96%, absence of respiratory symptoms or presence of cough only without dyspnea, and no radiographic evidence of pneumonia.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eVaccination rates and smoking status\u003c/h2\u003e\u003cp\u003eThe COVID-19 vaccination rate was higher among smokers (26/27; 96%) than nonsmokers (6/7; 86%); however, this difference was not statistically significant (Fisher\u0026rsquo;s exact test, p\u0026thinsp;=\u0026thinsp;0.3743). In contrast, the influenza vaccination rate was significantly lower among smokers (18/34; 42%) than among nonsmokers (28/34; 58%) (Fisher\u0026rsquo;s exact test, p\u0026thinsp;=\u0026thinsp;0.0118).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eVaccination and mortality rates\u003c/h2\u003e\u003cp\u003eBy the time of the questionnaire survey, 60.5% of the participants (20 definite cases and three probable cases out of 38) had received the maximum number of COVID-19 vaccine doses recommended for their situation. Overall, 92.1% (35/38) of the participants had received at least one dose of a COVID-19 vaccine, whereas 7.9% (3/38) had never been vaccinated.\u003c/p\u003e\u003cp\u003eAmong the five patients who experienced two episodes of COVID-19 infection, four had received the maximum recommended number of vaccine doses at the time of infection, whereas one was considered to have possibly been under-vaccinated. No deaths occurred in any of the cases.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAmong the patients with HIV receiving care at our hospital, 38 of the 51 individuals who contracted COVID-19 responded to the questionnaire (response rate: 74.5%). Five patients experienced two episodes of COVID-19 infection.\u003c/p\u003e\u003cp\u003eLifestyle-related comorbidities such as diabetes mellitus, hypertension, and dyslipidemia, as well as older age and chronic kidney disease, have been reported to be prognostic factors for severe COVID-19 [\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In the present study, only one patient was \u0026ge;\u0026thinsp;65 years of age. Although some participants were current smokers or were undergoing treatment for lifestyle-related diseases, no cases of severe COVID-19 illness were observed. This may be attributable to the low number (one or two) of prognostic factors other than HIV infection\u0026mdash;which itself represents an immunocompromised condition\u0026mdash;in this study [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eTrends in HIV-RNA viral loads and CD4 counts before and after COVID-19 infection\u003c/h2\u003e\u003cp\u003eAll patients maintained long-term virologic suppression before and after COVID-19 infection. CD4 counts at the time of infection were available for only four patients; in all cases, a transient decrease was observed during infection, followed by recovery to pre-infection levels or higher counts after recovery (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePrevious studies have also reported a decline in CD4 counts during COVID-19 infection, which has been attributed to impaired T-cell proliferation and functional exhaustion associated with elevated inflammatory cytokines such as interleukin (IL)-6, IL-10, and tumor necrosis factor-α, with the decrease being particularly pronounced in severe cases [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. One study reported a significant reduction in CD4 counts at hospital admission, followed by a marked increase within 2 weeks and stabilization by 6 weeks [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eConsistent with these findings, in the present study, patients with pneumonia presumed to be caused by the Delta variant exhibited a more pronounced CD4 decline compared with the other three patients. CD4 counts subsequently increased in all cases, aligning with trends reported in the literature.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eCOVID-19 vaccination rates\u003c/h2\u003e\u003cp\u003ePrevious studies have reported low COVID-19 vaccination rates, particularly among smokers [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In contrast, in our study, 92.1% (35/38) of the respondents had received at least one dose of a COVID-19 vaccine. This rate is substantially higher than the previously reported national average intention to vaccinate in Japan (65.7%) [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA previous survey on COVID-19 awareness among PLWH indicated that they generally possessed a high level of knowledge about COVID-19 and engaged in preventive behaviors [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Conversely, an online survey conducted in 10 countries across the Asia‒Pacific region reported a decrease in the frequency of HIV testing [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] and instances of delayed health-care-seeking behavior during the pandemic [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCOVID-19 vaccination rates are reportedly lower among women, vary by race, and are higher among individuals with virologic suppression [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Vaccination uptake is also influenced by regional, economic, and psychological factors [\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. In the present study, the majority of the participants were male (37/38; 97.4%), and all had achieved virologic suppression, suggesting that our cohort represented a population with a relatively high likelihood of receiving COVID-19 vaccination.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eVaccination rates and smoking status\u003c/h2\u003e\u003cp\u003eOverall, the COVID-19 vaccination rate among all respondents was 92.1% (35/38), with a higher rate observed among smokers (26/27; 96%). In contrast, the overall influenza vaccination rate was 41.9% (18/43), and the rate among smokers was lower, at 30% (8/27) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003ePrevious studies have reported that smokers have lower vaccination rates for both COVID-19 and influenza compared with nonsmokers, and this is often attributed to concerns about vaccine safety and a fear of adverse effects [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. In the present study, although the difference in COVID-19 vaccination rates between smokers and nonsmokers was not statistically significant (Fisher\u0026rsquo;s exact test, p\u0026thinsp;=\u0026thinsp;0.3743), a higher vaccination rate was observed among smokers. This finding contrasts with prior research indicating that smokers tend to have more negative attitudes toward vaccination [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Vaccination behavior is likely influenced by factors beyond smoking status, including vaccine-related knowledge, trust in health-care providers, risk perception, and access to medical services. These factors are consistent with the health belief model (HBM), a theoretical framework in health behavior research that explains how individuals perceive health threats and decide to take preventive action [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. The HBM comprises six main cognitive constructs: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to action. In the context of COVID-19 vaccination among PLWH, previous studies have shown that trust in vaccines and belief in their benefits are significant predictors of vaccination intention [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Other studies have reported that, compared with the general population, PLWH demonstrate a lower willingness to receive a second COVID-19 booster dose, a trend associated with perceived severity and perceived barriers [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the present study, the widespread recognition of smoking and immunocompromised status as risk factors for severe COVID-19\u0026mdash;facilitated by public awareness initiatives and the information-rich environment of a university hospital\u0026mdash;may have contributed to promoting vaccination and encouraging preventive behaviors among smokers. It is also possible that some individuals experienced a sense of guilt for not routinely receiving vaccinations, such as the influenza vaccine, which may have led to behavioral change. Among the three patients who had not received a COVID-19 vaccine, only one reported unwillingness to be vaccinated, suggesting a generally high level of vaccination intention in this study.\u003c/p\u003e\u003cp\u003ePrevious studies have reported that smokers with higher risk perception are more likely to be vaccinated [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Moreover, knowledge of and concern about COVID-19 have been associated with preventive behaviors and adherence to ART, contributing to improved treatment outcomes [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Our findings are consistent with these reports.\u003c/p\u003e\u003cp\u003eIn contrast, the influenza vaccination rate was significantly lower among smokers than nonsmokers (Fisher\u0026rsquo;s exact probability test, p\u0026thinsp;=\u0026thinsp;0.0118), suggesting that the motivational drivers for COVID-19 vaccination may differ from those for influenza vaccination. Moving forward, communicating the importance of vaccination to PLWH\u0026mdash;including smokers\u0026mdash;within the framework of the HBM may help facilitate positive behavior change.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eCOVID-19 vaccination and mortality rates\u003c/h2\u003e\u003cp\u003ePrevious studies have reported that the effectiveness of COVID-19 vaccination in preventing severe disease is approximately 54% with two doses and over 80% with three or more doses [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. In immunocompromised patients\u0026mdash;particularly organ transplant recipients\u0026mdash;although the initial antibody acquisition rate after the first dose may be low, it improves with the second dose, and administration of a third booster dose is recommended [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Among PLWH, previous reports have indicated that COVID-19 vaccination does not result in reduced antibody acquisition rates or lower antibody titers; however, considering the antibody half-life, regular COVID-19 vaccination every 6\u0026ndash;12 months is recommended [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the present study, none of the five patients who experienced two episodes of COVID-19 developed severe disease or died. All had received three or more doses of a COVID-19 vaccine and were considered to have completed the maximum recommended number of doses at the time of infection, suggesting that vaccination may have contributed to the prevention of severe outcomes. Furthermore, previous studies have reported that the Omicron variant provides a sustained high level of protection against severe disease [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], and both vaccination and variant characteristics may have contributed to the favorable outcomes observed in our study. However, because some patients had multiple infections, it remains unclear whether vaccination contributed to reducing the frequency of infection.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eVirological suppression and mortality\u003c/h2\u003e\u003cp\u003eIn this study, all patients maintained virological suppression before and after COVID-19 infection. Previous reports have shown that, among PLWH who achieve virological suppression, the effectiveness of COVID-19 vaccination is not reduced [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], and the incidence of severe COVID-19 is lower [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Therefore, it is likely that the sustained virological suppression in our study contributed to the absence of severe disease.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThis study has several limitations. First, this was a single-center study conducted at a university hospital in Tokyo, where most participants had good access to medical care. Therefore, the findings cannot be generalized to all PLWH in Japan. Future multicenter studies are needed to verify the external validity of these results.\u003c/p\u003e\u003cp\u003eSecond, this was a voluntary, questionnaire-based survey, which may have introduced self-selection bias. Patients with greater interest in COVID-19 and vaccination may have been more likely to respond. In addition, deaths that occurred among patients hospitalized at other institutions could not be captured, raising the possibility that the prevalence of severe disease or mortality in this study may have been over- or underestimated.\u003c/p\u003e\u003cp\u003eThird, there was variability in the timing of questionnaire distribution and collection, which may have influenced the participants\u0026rsquo; attitudes toward COVID-19 and, consequently, vaccination rates.\u003c/p\u003e\u003cp\u003eNonetheless, this study provides clinically meaningful insights by capturing the current status of COVID-19 infection and vaccination rates among PLWH in Japan.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this study, smokers had higher COVID-19 vaccination rates but significantly lower influenza vaccination rates compared with nonsmokers. Although this partially contradicts previous studies reporting that smokers tend to have negative attitudes toward vaccination [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], vaccination behavior is likely influenced by factors beyond smoking status, such as vaccine-related knowledge, trust in health-care providers, risk perception, and access to medical services. Previous studies have also shown that smokers with higher risk perception are more likely to be vaccinated [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur findings suggest that even among smokers, high COVID-19 vaccination rates may have been facilitated by social and clinical health promotion, influencing key constructs of the HBM\u0026mdash;namely, perceived susceptibility, perceived severity, perceived benefits, and cues to action. These factors may have promoted behavior change through heightened recognition of the risk of severe disease and continuous engagement with health-care providers. This highlights the importance of risk communication and sustained patient\u0026ndash;provider relationships in driving behavior change and improving the quality of care for patients with HIV.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eART\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Antiretroviral therapy\u003cbr\u003eCOVID-19\u0026nbsp; \u0026nbsp; \u0026nbsp;Coronavirus disease 2019\u003cbr\u003eHBM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Health belief model\u003cbr\u003ePLWH \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; People living with HIV\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki. The study protocol was approved by the Ethics Committee of Tokyo Women\u0026rsquo;s Medical University Hospital (approval No. 2021-0118). Written informed consent was obtained from all participants prior to participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eR.S. conceived and designed the study. R.S., K.Ka., I.K., E.H., and K.Ki. collected the data. R.S. and K.H. performed the analysis and drafted the manuscript. All authors read and approved the final manuscript for submission.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors wish to thank all the participants and the clinical staff of Tokyo Women\u0026rsquo;s Medical University Hospital for their cooperation with this study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to privacy restrictions but are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCOVID-19 cases | WHO COVID-19 dashboard. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://data.who.int/dashboards/covid19/cases\u003c/span\u003e\u003cspan address=\"https://data.who.int/dashboards/covid19/cases\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 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Front Immunol. 2022;13:931039.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKrebs NM, D\u0026rsquo;Souza G, Bordner C, Allen SI, Hobkirk AL, Foulds J, et al. COVID-19 vaccination uptake and hesitancy among current tobacco users. Tob Use Insights. 2021;14:1179173X211068027.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYoda T, Katsuyama H. Willingness to receive COVID-19 vaccination in Japan. Vaccines (Basel). 2021;9(1):48.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIradukynda PG, Pierre G, Muhozi V, Denhere K, Dzinamarira T. Knowledge, attitude, and practice towards COVID-19 among people living with HIV/AIDS in Kigali, Rwanda. J Community Health. 2021;46(2):245\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eErly S, Menza TW, Granillo L, Navejas M, Udeagu CCN, Brady KA, et al. Impact of COVID-19 on people living with HIV: data from five Medical Monitoring Project sites, 2020\u0026ndash;2022. J Acquir Immune Defic Syndr. 2024;96(2):106\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePulse survey in HIV care COVID-19 pandemic. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.gilead.co.jp/-/media/gilead-japan/pdfs/news-and-press/press-releases/2020/pulse-survey--in-hiv-care-covid-19-pandemic_201210.pdf\u003c/span\u003e\u003cspan address=\"https://www.gilead.co.jp/-/media/gilead-japan/pdfs/news-and-press/press-releases/2020/pulse-survey--in-hiv-care-covid-19-pandemic_201210.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 22 May 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKitajima T. Impact of COVID-19 pandemic on prevention and treatment of HIV/AIDS. J Soc Sci. Kyorin Univ. 2020;36(1\u0026ndash;2):85\u0026ndash;92. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.kyorin-u.ac.jp/univ/faculty/social_science/research/social-science/pdf/2020Vol.36no1%2C2_kitajima.pdf\u003c/span\u003e\u003cspan address=\"https://www.kyorin-u.ac.jp/univ/faculty/social_science/research/social-science/pdf/2020Vol.36no1%2C2_kitajima.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 22 May 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSulaiman SK, Musa MS, Tsiga-Ahmed FI, Sulaiman AK, Bako AT. A systematic review and meta-analysis of the global prevalence and determinants of COVID-19 vaccine acceptance and uptake in people living with HIV. Nat Hum Behav. 2024;8(1):100\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBoschung K, Gill MJ, Krentz HB, Dalere J, Beckthold B, Fonseca K, et al. COVID-19 vaccine uptake among people with HIV: identifying characteristics associated with vaccine hesitancy. Sci Rep. 2023;13(1):20610.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSiewe Fodjo JN, Faria de Moura Villela E, Van Hees S, Vanholder P, Reyntiens P, Colebunders R. Follow-up survey of the impact of COVID-19 on people living with HIV during the second semester of the pandemic. Int J Environ Res Public Health. 2021;18(9):4635.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMatsumoto S, Nagai M, Tran LK, Yamaoka K, Nguyen HDT, Dinh Van T, et al. Multicenter observational survey on psychosocial and behavioral impacts of COVID-19 in people living with HIV in Northern Vietnam. Sci Rep. 2023;13(1):20321.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCummings PE, Lakoh S, Yendewa SA, Massaquoi SPE, James PB, Sahr F, et al. 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J AIDS Res. 2023;25:92\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFeikin DR, Abu-Raddad LJ, Andrews N, Davies MA, Higdon MM, Orenstein WA, et al. Assessing vaccine effectiveness against severe COVID-19 disease caused by Omicron variant: report from a meeting of the World Health Organization. Vaccine. 2022;40(26):3516\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eP\u0026eacute;rez-Barrag\u0026aacute;n E, Castillo-Flores JH, Mata-Mar\u0026iacute;n JA, Franco L\u0026oacute;pez SG, Morales Mart\u0026iacute;nez BA, P\u0026eacute;rez Cavazos S. COVID-19 in people living with HIV: a single-center descriptive study. J Infect Dev Ctries. 2022;16(12):1796\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"HIV, COVID-19, Vaccination","lastPublishedDoi":"10.21203/rs.3.rs-7695970/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7695970/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe effectiveness of vaccination against coronavirus disease 2019 (COVID-19) among people living with HIV (PLWH) has been increasingly documented in recent years. Large-scale cohort studies from Canada have demonstrated that COVID-19 vaccines confer significant protection in this population. However, low vaccination coverage among PLWH remains a concern. In parallel, previous studies have reported that smokers are more likely to exhibit vaccine hesitancy, resulting in reduced uptake of COVID-19 vaccination. This study aimed to investigate differences in the vaccination rates and clinical outcomes of COVID-19 infection between smokers and nonsmokers in a cohort of PLWH at a single center in Japan.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e Among approximately 250 PLWH aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years who were receiving outpatient care at a university hospital in Tokyo, Japan, 51 who had been diagnosed with COVID-19 between 2020 and 2023 were invited to participate in a questionnaire-based survey. Among these 51 patients, 38 provided informed consent and responded to the survey. A total of 43 infection episodes, including cases of multiple infections, were analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 38 participants (age range, 31\u0026ndash;66 years) responded to the questionnaire (response rate: 74.5%). Five individuals experienced COVID-19 infection twice, resulting in a total of 43 infection episodes. As of April 20, 2025, the majority of participants were in their 40s (n\u0026thinsp;=\u0026thinsp;15), and 97.4% (37/38) were male. Over 60% of the respondents reported a history of both smoking and alcohol consumption. All patients maintained virological suppression before and after COVID-19 infection. In total, 92.1% (35/38) of the patients had received at least one dose of a COVID-19 vaccine. Among smokers, the vaccination rate was 96%, which was higher than that among nonsmokers (86%); however, this difference was not statistically significant (p\u0026thinsp;=\u0026thinsp;0.3743).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe present study found that smokers had a higher COVID-19 vaccination rate than nonsmokers. This finding contrasts with previous findings suggesting that smokers tend to have more negative attitudes toward vaccination. Factors such as access to health care, perceived infection risk, and treatment adherence may contribute to this discrepancy.\u003c/p\u003e","manuscriptTitle":"High COVID-19 vaccine uptake among HIV-positive smokers in Japan: effects of the health belief model - a single-center survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-10 09:27:08","doi":"10.21203/rs.3.rs-7695970/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dc5cf5d4-d6b9-443c-b05e-a638ee29b25c","owner":[],"postedDate":"November 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T11:54:12+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-10 09:27:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7695970","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7695970","identity":"rs-7695970","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}