“I didn’t believe it was real”: a qualitative exploration of COVID-19 vaccine hesitancy among key populations living with HIV/AIDS in Rivers State, Nigeria

BACKGROUND: COVID-19 vaccination remains one of the most effective interventions against the pandemic; however, hesitancy continues to impede equitable coverage, particularly among key populations. In Nigeria, MSM, FSW, and PWID face heightened vulnerability to both HIV/AIDS and COVID-19, but remain underrepresented in vaccination research. Rivers State reported one of the highest numbers of confirmed cases and deaths in the southern region. The state also has a relatively high HIV prevalence rate and houses several key population OSSs. This study explored COVID-19 vaccine hesitancy among these key populations living with HIV/AIDS in Rivers State, Nigeria. METHODS: A qualitative descriptive design was employed using FGDs with MSM, FSW, and PWID receiving ART at selected HIV treatment OSSs. A total of 8 FGDs were conducted, each involving 5-7 participants (48 participants in total). Data collection continued until thematic saturation was achieved. Discussions were audio-recorded, transcribed verbatim, and analysed inductively using systematic text condensation in NVivo 12. We developed themes iteratively to capture participants' experiences and interpretations of COVID-19 vaccination. RESULTS: Five interrelated themes emerged: (1) limited and contradictory knowledge about COVID-19 and its vaccines; (2) disbelief and low perceived susceptibility summed up by the recurring phrase "I didn't believe it was real"; (3) fear of side effects and uncertainty regarding vaccine-ART interactions; (4) structural, socio-economic, and stigma-related barriers reinforcing mistrust; and (5) trust, peer influence, and integration of services as facilitators of acceptance. Participants described misinformation, political distrust, and discrimination at health facilities as major deterrents. CONCLUSIONS: COVID-19 vaccine hesitancy among key populations in Rivers State was shaped by disbelief, fear, and structural exclusion rather than outright refusal. Interventions that integrate vaccination within key population HIV/AIDS services, leverage peer networks, provide clear ART-compatible health information, and promote stigma-free healthcare environments can effectively build confidence and increase vaccine uptake among marginalized groups.