Global Disparities in Vaccine Reimbursement for Adults Living with HIV: A Cross-Sectional Survey of 120 Countries

Objective: Adults living with HIV are at increased risk of vaccine-preventable infections, yet access to recommended vaccines varies globally. We evaluated national vaccination guidelines, public reimbursement, and on-site vaccination availability across countries with different income levels. Methods: We conducted a cross-sectional survey of HIV clinicians and experts representing 120 countries. The 26-item questionnaire assessed vaccination guidelines, recommendations, public reimbursement, and on-site vaccination availability. Countries were classified according to World Bank income group. Generalized linear mixed-effects models assessed routine recommendations, full reimbursement, and recommendation-reimbursement gaps by vaccine type and income group. Results: A total of 124 responses representing 120 countries were analyzed, including 38 low-/lower-middle-income (LIC/LMIC), 36 upper-middle-income (UMIC), and 50 high-income countries (HIC). HIV-specific national vaccination guidelines were reported by 37% of respondents, increasing from 18% in LIC/LMIC to 52% in HIC (p=0.026). Only 30% reported full public reimbursement for all recommended vaccines (13% LIC/LMIC, 28% UMIC, 44% HIC;p=0.007). Mixed-effects analyses showed significant differences in routine recommendations and full reimbursement by vaccine type and income group. The adjusted probability of routine recommendation was lower in LIC/LMIC than HIC countries (52.6% vs 77.6%; adjusted p=0.0013). Among recommended vaccines, more than 94% of influenza, pneumococcal, and hepatitis B vaccinations lacked full reimbursement in LIC/LMIC, based on adjusted estimates. Reimbursement gaps for HPV and herpes zoster vaccines remained substantial even in HIC. On-site vaccination was also less available in LIC/LMIC than in HIC (55% vs 78%; p=0.020). Conclusions: Significant income-related disparities persist in vaccination policy and implementation for adults living with HIV. Gaps between recommendations and financial access are particularly pronounced in lower-income settings, while HPV and herpes zoster reimbursement remains limited across all income groups. Expanding HIV-specific vaccination policies, improving public reimbursement, and integrating vaccination into routine HIV services are essential to improve access to recommended vaccines for this population.