Integration Models for Delivering COVID-19 Vaccines through HIV Services in Low-and Middle-Income Countries: A Scoping Review

1. Introduction

The Coronavirus Disease 2019 (COVID-19) is still a public health threat, even though the World Health Organization (WHO) no longer classifies it as a public health emergency of international concern [1]. The pandemic deeply affected nearly every part of society, including governments, healthcare systems, and global economies [2]. While various non-drug methods helped slow the spread of the virus, vaccination remains the main strategy for controlling COVID-19 [3]. Many studies have shown that traditional mRNA vaccines effectively prevent severe symptomatic infection, hospitalization, and death and are safe and effective across different populations [4,5].

At the start of the vaccine rollout, the WHO’s COVID-19 vaccine prioritization roadmap suggested focusing on reducing illness and death, especially with limited vaccine supply starting with healthcare workers and other frontline personnel due to their increased exposure and essential roles in responding to the pandemic [6]. Despite being an understandable approach, it unintentionally ignored the broader view of health as a basic human right, especially for other vulnerable groups. Evidence consistently shows that people aged 65 and older and those with existing medical conditions (comorbidities) are at much greater risk of getting COVID-19, experiencing long hospital stays, and facing worse health outcomes [7,8,9,10]. Several studies have also shown that people living with HIV are at higher risk of severe COVID-19 infections, qualifying them a priority group for preventive measures including vaccination [11,12]. While many PLHIV are willing to get the COVID-19 vaccine, the actual uptake has not been satisfactory [13]. Several reports show strong evidence that COVID-19 vaccines are safe for people living with HIV (PLHIV), with mostly mild, self-limited adverse events and good immunogenicity, particularly after booster doses [14,15,16,17] Despite this, there is still a significant gap in specialized vaccine delivery strategies for PLHIV. Most COVID-19 vaccination models, like mass vaccination sites, mobile clinics, fixed-post immunizations, and home services, were designed with the general population in mind [18,19] leaving the specific needs and access challenges faced by PLHIV unaddressed.

Recently, some countries have started incorporating COVID-19 vaccine delivery into regular healthcare services [20]. For instance, Heidari et al. describe models where vaccination clinics are located alongside services such as needle exchange programs, HIV and Sexually Transmitted Infections (STI) testing for people who inject drugs, and antenatal care visits for pregnant women at 20 weeks [21]. These integrated methods have improved vaccine access, especially by reducing the logistical and financial burdens related to transportation, childcare, and time off work. In addition, regular contact with healthcare providers and vaccine counseling in these settings have helped build trust and increase vaccine confidence [20,22]. Moreover, health systems facing critical staffing gaps often find it hard to offer separate COVID-19 vaccination services as vaccine supply improves and efforts to reach people unfamiliar with adult vaccination programs have generally faced setbacks due to vaccine hesitancy, misinformation, and ongoing structural obstacles [23].

To effectively tackle vaccine distribution for people living with HIV and enhance health outcomes, identifying and mapping the existing models used to deliver vaccines to this population is essential. Understanding these methods can help policymakers and healthcare providers design better research and implementation strategies. Furthermore, gaining a deeper insight into these models may offer helpful guidance on how future vaccine delivery and its integration into primary healthcare and vaccination programs can be improved, particularly in LMICs. This scoping review explored existing COVID-19 vaccine integration models in LMICs focusing on approaches relevant to PLHIV.

2. Materials and Methods

2.1. Study Design

We carried out a scoping review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. We performed a systematic search of the literature from 03 to 04 February 2025 across four electronic databases: PubMed, Web of Science, Cochrane Library, and EMBASE.

2.2. Eligibility Criteria

Inclusion and exclusion criteria were defined using a modified Population, Intervention, Comparison, Outcomes (PICO) framework focusing on studies involving PLHIV, men and women aged 18 and older residing in LMICs. Since our main interest was on how COVID-19 vaccination is integrated into HIV care services, we included studies that reported on strategies or models for delivering COVID-19 vaccines through HIV care platforms. Eligible study designs included all empirical research approaches: quantitative, qualitative, and mixed methods such as observational studies, randomized controlled trials, quasi-experimental studies, cohort and case-control studies, and single-case reports. We excluded studies if they were conducted outside of LMICs or did not focus on vaccine integration specifically for PLHIV.

2.3. Information Sources

We developed a thorough search strategy using Medical Subject Headings (MeSH) and Boolean operators. This strategy combined terms related to PLHIV, COVID-19 vaccines, and integration strategies. The search terms and strategies were based on an initial scoping search and consultations with experts. Full details of the search strategy and the databases used are provided in Table 1 below.

2.4. Selection Process

Two reviewers, PK and SB independently carried out the screening and review process using Rayyan, an online tool for managing systematic reviews. Any differences in opinion were resolved through discussion or with input from third reviewers, NMM or RC. In the first screening phase, we assessed titles and abstracts for eligibility. We then performed full-text screening on all records that met the inclusion criteria. We documented the reasons for excluding studies during the full-text review stage.

2.5. Data Extraction and Synthesis

We extracted data from the included studies using a standardized form created by the authors and summarized it in a table. The structured extraction included study characteristics, model type, model features, strategies, outcomes, and lessons learned. We performed a narrative synthesis with tabulation to analyze the data.

3. Results

3.1. Study Selection

The search resulted in 558 records. After removing 154 duplicates, 404 records were left for title and abstract screening. From these, 59 records were found to be potentially relevant and were reviewed in full text. Ultimately, three studies met the inclusion criteria and were part of the final analysis as shown in Figure 1 below.

3.2. Characteristics of the Included Studies

All included studies were from sub-Saharan Africa, specifically Tanzania (n = 2) and Zambia (n = 1). They both focused on people living with HIV, their families, and healthcare workers. The Tanzanian studies [24,25] included a case study and an abstract presented at the National Health Summit. The Zambian study was a report from the national COVID-19 vaccination campaign [23].

Table 2. Charactristics of the included Studies.

Title	Author	Year	Country	Study type	Setting	Target population	Age	Integration model	Strategies used	Outcomes	Lessons learnt
Accelerating COVID-19 Vaccination Among People Living With HIV and Health Care Workers (HCWs) in Tanzania: Case Study	Jalloh et al.	2024	Tanzania	Case study	562 high-volume HIV clinics	PLHIV and (HCWs)	≥20 years	Diverse partnership model	Expanding the number of certified vaccinators by training HCWs Creating vaccination points in high-volume HIV clinics starting with administrative regions where there was strong buy-in from regional health authorities Engaging HCWs to address their concerns and build their vaccination confidence Strengthening capacity of HCWs and community health workers to facilitate vaccination in facility- and community-based settings, Monitoring uptake of COVID-19 vaccination in high-volume facilities	Increased vaccination uptake: the proportion of fully vaccinated adult PLHIV increased from <1% to 97% and the proportion of fully vaccinated HCWs increased from 23% to 80% in the monitored facilities between September 2021 and September 2022.	Needing close partnerships and engagement of political, government, and religious leaders for planning, capacity-building, demand creation, and service delivery to enhance vaccination reach, uptake, and acceptance at community, national and regional levels Incorporating innovative strategies to address gaps in knowledge, supply chain, or service delivery, such as providing vaccination incentives, engaging peer champions, integrating with other health services, combining outreach and vaccination with mass community gatherings, and using live media coverage of vaccination and promotion Ensuring adequate preparation and planning to forecast vaccination demand, ensure timely data entry and management, and reduce vaccination wastage
Leveraging HIV Program and Civil Society to Accelerate COVID-19 Vaccine Uptake, Zambia	Bobo et al.	2022	Zambia	National Vaccination campaign	HIV treatment centres	PLHIV and their family members	Not reported	A mixed service delivery model	Engaged HIV treatment centres by using existing human resources by adequately preparing HIV healthcare workers to offer vaccination and encouraging them to get vaccinated themselves, Developing targeted promotional materials for persons living with HIV who are at increased risk for severe illness and rapidly adapting and implementing similar models across the country. Engaged civil society leaders to endorse vaccination and using a mixed service delivery model that added community-delivered vaccination based on successful community HIV programs to existing static service delivery. Some strategies were adapted from Zambia’s robust childhood vaccination program	Increased COVID 19 vaccination coverage in Zambia (Reported outcomes for all COVID 19 vaccinations in Zambia not PLHIV)	Planning and coordination: Leverage existing in-country systems/programs/resources for COVID-19 vaccination. Engage national, provincial, and district health bodies from the outset. Develop district-level micro plans based on standard tools that are approved at provincial and achieved by lower levels (i.e., district health offices, service delivery teams). national levels. Use joint planning by Ministry of Health, funding organizations, and provincial representatives. Establish centralized Monitoring and evaluation (M&E) tools for national tracking of progress. Begin with a small pilot in a few sites and rapidly iterate to improve quality, using a continuous quality-improvement approach. Scale-up successful practices rapidly to quickly enhance effect. Develop targets that can be implemented and achieved by lower levels (i.e., district health offices, service delivery teams). Service delivery: 9. Adequately capacitate HCWs in HIV, Maternal and Child Health (MCH), and other clinics to deliver COVID-19 vaccines. 10. Invest in community mobilization and service delivery to overcome limits of a static service delivery approach and reach the greatest number of eligible persons, which means offering vaccines at public places (e.g., markets, malls, churches), chiefdoms, workplaces, congregate settings, and others. 11. Use existing community health services for HIV as vaccination points. 12. Anticipate additional human resource needs and ensure adequate financial resources to support them. Demand generation: 13. Ensure adequate HCW training in HIV and other clinics to answer patients’ and eligible family members’ questions about COVID-19 vaccines. 14. Encourage HCWs themselves to get vaccinated against COVID-19 by creating a safe space for unvaccinated HCWs to have their questions answered. 15. Engage public and private media nationally to address myths and misconceptions about COVID-19 vaccines. 16. Develop promotional materials that emphasize the value of COVID-19 vaccination for persons living with HIV because of the elevated risk for severe illness among members of this group. 17. Engage civil society (community, traditional, religious, and business leaders) to champion COVID-19 vaccination. Listen to and address their concerns about COVID-19 vaccines. 18. Use routine patient reminder call for upcoming visits to share information about vaccine availability in HIV clinics. Monitoring and Evaluation (M&E) 19. Harmonize COVID-19 vaccine data collection in HIV and other clinics with the national COVID-19 vaccine M&E system. 20. Conduct frequent data analysis to inform site-level performance assessments and guide targeted quality improvement. 21. Generate feedback loops, particularly for poorly performing districts. Logistics: 22. Push adequate vaccine supplies to each district based on their estimated target populations with the micro plan. 23. Take inventory of health facility capacity to adequately store COVID-19 vaccines and use existing infrastructure where possible. 24. Ensure that HIV clinic vaccine supply is incorporated into the wider health facility request Safety: 25. Provide Adverse Event Following Immunisation (AEFI) training to HCWs. 26. Strengthen AEFI reporting system within HIV clinics.
Call-back strategy an approach for scaling up Covid-19 vaccination among PLHIV in Geita region, afya jumuishi project	Magadula et al.	2023	Tanzania	Not clear	44 facilities in Tanzania	PLHIVs	Not reported	Call-back strategy	Orienting HCWs and Community Based Health workers (CBHs), Calling PLHIV and inviting them for facility vaccinations, Physical follow up	Increased number of PLHIV vaccinated, a total of 22,686 PLHIVs (83% from the shared list) were called and fully vaccinated. This contributed to 42% of total vaccinations of PLHIV	Innovations within implementation are key in accelerating timely achievements in program indicators along with monitoring of consumables and preventing wastage of resources.

Table 2. Charactristics of the included Studies.

Title	Author	Year	Country	Study type	Setting	Target population	Age	Integration model	Strategies used	Outcomes	Lessons learnt
Accelerating COVID-19 Vaccination Among People Living With HIV and Health Care Workers (HCWs) in Tanzania: Case Study	Jalloh et al.	2024	Tanzania	Case study	562 high-volume HIV clinics	PLHIV and (HCWs)	≥20 years	Diverse partnership model	Expanding the number of certified vaccinators by training HCWs Creating vaccination points in high-volume HIV clinics starting with administrative regions where there was strong buy-in from regional health authorities Engaging HCWs to address their concerns and build their vaccination confidence Strengthening capacity of HCWs and community health workers to facilitate vaccination in facility- and community-based settings, Monitoring uptake of COVID-19 vaccination in high-volume facilities	Increased vaccination uptake: the proportion of fully vaccinated adult PLHIV increased from <1% to 97% and the proportion of fully vaccinated HCWs increased from 23% to 80% in the monitored facilities between September 2021 and September 2022.	Needing close partnerships and engagement of political, government, and religious leaders for planning, capacity-building, demand creation, and service delivery to enhance vaccination reach, uptake, and acceptance at community, national and regional levels Incorporating innovative strategies to address gaps in knowledge, supply chain, or service delivery, such as providing vaccination incentives, engaging peer champions, integrating with other health services, combining outreach and vaccination with mass community gatherings, and using live media coverage of vaccination and promotion Ensuring adequate preparation and planning to forecast vaccination demand, ensure timely data entry and management, and reduce vaccination wastage
Leveraging HIV Program and Civil Society to Accelerate COVID-19 Vaccine Uptake, Zambia	Bobo et al.	2022	Zambia	National Vaccination campaign	HIV treatment centres	PLHIV and their family members	Not reported	A mixed service delivery model	Engaged HIV treatment centres by using existing human resources by adequately preparing HIV healthcare workers to offer vaccination and encouraging them to get vaccinated themselves, Developing targeted promotional materials for persons living with HIV who are at increased risk for severe illness and rapidly adapting and implementing similar models across the country. Engaged civil society leaders to endorse vaccination and using a mixed service delivery model that added community-delivered vaccination based on successful community HIV programs to existing static service delivery. Some strategies were adapted from Zambia’s robust childhood vaccination program	Increased COVID 19 vaccination coverage in Zambia (Reported outcomes for all COVID 19 vaccinations in Zambia not PLHIV)	Planning and coordination: Leverage existing in-country systems/programs/resources for COVID-19 vaccination. Engage national, provincial, and district health bodies from the outset. Develop district-level micro plans based on standard tools that are approved at provincial and achieved by lower levels (i.e., district health offices, service delivery teams). national levels. Use joint planning by Ministry of Health, funding organizations, and provincial representatives. Establish centralized Monitoring and evaluation (M&E) tools for national tracking of progress. Begin with a small pilot in a few sites and rapidly iterate to improve quality, using a continuous quality-improvement approach. Scale-up successful practices rapidly to quickly enhance effect. Develop targets that can be implemented and achieved by lower levels (i.e., district health offices, service delivery teams). Service delivery: 9. Adequately capacitate HCWs in HIV, Maternal and Child Health (MCH), and other clinics to deliver COVID-19 vaccines. 10. Invest in community mobilization and service delivery to overcome limits of a static service delivery approach and reach the greatest number of eligible persons, which means offering vaccines at public places (e.g., markets, malls, churches), chiefdoms, workplaces, congregate settings, and others. 11. Use existing community health services for HIV as vaccination points. 12. Anticipate additional human resource needs and ensure adequate financial resources to support them. Demand generation: 13. Ensure adequate HCW training in HIV and other clinics to answer patients’ and eligible family members’ questions about COVID-19 vaccines. 14. Encourage HCWs themselves to get vaccinated against COVID-19 by creating a safe space for unvaccinated HCWs to have their questions answered. 15. Engage public and private media nationally to address myths and misconceptions about COVID-19 vaccines. 16. Develop promotional materials that emphasize the value of COVID-19 vaccination for persons living with HIV because of the elevated risk for severe illness among members of this group. 17. Engage civil society (community, traditional, religious, and business leaders) to champion COVID-19 vaccination. Listen to and address their concerns about COVID-19 vaccines. 18. Use routine patient reminder call for upcoming visits to share information about vaccine availability in HIV clinics. Monitoring and Evaluation (M&E) 19. Harmonize COVID-19 vaccine data collection in HIV and other clinics with the national COVID-19 vaccine M&E system. 20. Conduct frequent data analysis to inform site-level performance assessments and guide targeted quality improvement. 21. Generate feedback loops, particularly for poorly performing districts. Logistics: 22. Push adequate vaccine supplies to each district based on their estimated target populations with the micro plan. 23. Take inventory of health facility capacity to adequately store COVID-19 vaccines and use existing infrastructure where possible. 24. Ensure that HIV clinic vaccine supply is incorporated into the wider health facility request Safety: 25. Provide Adverse Event Following Immunisation (AEFI) training to HCWs. 26. Strengthen AEFI reporting system within HIV clinics.
Call-back strategy an approach for scaling up Covid-19 vaccination among PLHIV in Geita region, afya jumuishi project	Magadula et al.	2023	Tanzania	Not clear	44 facilities in Tanzania	PLHIVs	Not reported	Call-back strategy	Orienting HCWs and Community Based Health workers (CBHs), Calling PLHIV and inviting them for facility vaccinations, Physical follow up	Increased number of PLHIV vaccinated, a total of 22,686 PLHIVs (83% from the shared list) were called and fully vaccinated. This contributed to 42% of total vaccinations of PLHIV	Innovations within implementation are key in accelerating timely achievements in program indicators along with monitoring of consumables and preventing wastage of resources.

3.3. Integration Models Used for COVID-19 Vaccination and HIV Services in Low- and Middle-Income Countries

The reviewed studies identified three distinct models for integrating COVID-19 vaccine delivery with HIV care services. These include the call-back strategy, the diverse partnership model, and a mixed service delivery model as explained in Table 3 below.

4. Discussion

To our knowledge, this is the first review to focus on models and/or strategies for integrating COVID-19 vaccination with HIV care and services in low- and middle-income countries. Two of the studies included effectively used common themes that helped them succeed [23,24].

The mixed service delivery model used in Zambia focused on planning and coordination. It aimed to use existing in-country systems, programs, and resources for COVID-19 vaccination through joint planning with the Ministry of Health, funding organizations, and provincial representatives. Similarly, the diverse partnership model highlighted cooperation and coordination as key factors for improving vaccine uptake. Strong collaboration between healthcare providers and public health agencies is recognized as crucial for successful health programs and interventions [26,27].

Building capacity was a major theme in all the studies. This included promoting vaccine awareness and education to combat misconceptions, as well as offering incentives to meet vaccination goals. Community health workers (CHWs) served as important links between healthcare workers and communities, while training healthcare workers in community mobilization and service delivery helped address the challenges of static service models. This method increased access by providing vaccines in public locations like markets, malls, and churches. Past studies have also emphasized the important role of community mobilization in improving intervention acceptance, enabling communities to take charge, and encouraging social and behavior change through peer support and local solutions [28,29,30].

Effective integration required solid logistics and supply chain systems, along with clear monitoring and evaluation methods. Both models focused on making sure there was a steady vaccine supply for district-level populations, using existing infrastructure for vaccine storage when possible. Research suggests that single-dose vaccines could increase coverage, and strong involvement from stakeholders is necessary to fund vaccine purchase, transportation, and distribution [31] as well as reliable supply chains for health commodities are essential to strong health systems and are important for reaching national and regional health security goals [32].

The call-back strategy was consistently used across all models to increase vaccine acceptance and uptake among people living with HIV. This strategy involved creating targeted promotional materials that highlighted the increased risk of severe COVID-19 illness for this group. Regular patient reminder calls informed individuals about vaccine availability at HIV clinics, while engaging patient champions helped reach PLHIV within their communities. Evidence supports the effectiveness of the call-back approach in enhancing patient understanding, maintaining treatment plans, and reducing unnecessary healthcare visits [33].

Limitations

This scoping review focuses on a topic that is very important for public health. However, the studies included are the lowest level in the hierarchy of evidence and are only relevant to the African context. The lack of higher-level evidence, like systematic reviews or randomized controlled trials, limits how far we can apply our findings beyond the specific areas we looked at. Even with a thorough search strategy, we found no eligible studies from outside Africa, which restricts the geographic range of the review.

5. Conclusions

This scoping review shows that incorporating COVID-19 vaccination into trusted health platforms, especially HIV services, can significantly increase uptake among high-risk groups like people living with HIV and healthcare workers in low- and middle-income countries. The reviewed models were successful by including vaccination in familiar care pathways, empowering healthcare workers to adjust delivery at the facility level and encouraging equitable access through community involvement and focused outreach. These methods strengthened the connection between vaccine demand and supply while reducing waste and leveraging the trust patients have in their providers.

The experiences from Tanzania and Zambia highlight that innovation tailored to specific contexts, along with strong partnerships across political, government, religious, and community areas, can achieve rapid and lasting improvements, even in resource-limited environments. Expanding these models will need ongoing investment, political support, and a willingness to adjust to future public health challenges.

Recommendations for Future Vaccine Implementation

Based on the lessons learnt in this review, we suggest the following priority actions for policymakers, implementers, and partners:

• Use Existing Health Platforms: Building on established systems like HIV clinics and community health programs would allow effective and sustainable vaccination integration
• Train Healthcare Workers: Providing ongoing training in vaccine delivery, community engagement would help address vaccine hesitancy.
• Improve Community Engagement and Education: Using culturally relevant communication strategies with community leaders, patient advocates, and civil society would boost vaccine awareness and uptake.
• Implement Reminder and Follow-Up Systems: Using call-back and reminder methods would reduce missed opportunities and increase completion rates, particularly among PLHIV.
• Ensure Equitable Access and Remove Barriers: Considering providing transport reimbursements, mobile services, and flexible hours would address logistical and economic challenges.
• Strengthen Data Systems and Monitoring: Creating strong monitoring and evaluation systems to track coverage and identify gaps would help adjust strategies as needed.
• Foster Multisectoral Partnerships: Involving government agencies, NGOs, religious and political leaders, and donors would facilitate coordinated resources, advocacy, and policy support.
• Plan for strong Supply Chain: Keeping a steady vaccine supply with suitable cold-chain capacity would likely avoid stockouts and waste, especially in remote areas.
• Support Research on Innovative Delivery Models: Encouraging use of implementation science would assess and expand new methods like mixed service delivery and community-based vaccination.
• Prepare for Future Health Emergencies: Building rapid integration and adaptation processes within health systems would lead to quick response to emerging infectious disease threats.