COVID Vaccine Study Supplement to MWCCS Principal Investigators: C. Rinaldo and J. Martinson Innovation Fund Application to the Multicenter AIDS Cohort Study (MACS)/Women’s Interagency HIV Study (WIHS) Combined Cohort Study (MWCCS): COVID-19 Vaccine Acceptance and Hesitancy (CVHB) Study in People with HIV Scientific Justification A safe, highly immunogenic vaccine to prevent primary SARS-CoV-2 infection is needed to control the COVID-19 pandemic. As of January, 2021, the United States is racing to vaccinate a significant percentage of our 330 million population to control the COVID-19 pandemic. This extraordinary rapid development resulted from FDA emergency use authorization (EUA) of two COVID-19 vaccines in December, 2020, i.e., the Moderna mRNA-1273 vaccine that codes for the stabilized pre-fusion SARS- CoV-2 spike protein 1, and the Pfizer/BioNTech vaccine BNT162b1 that is a lipid-nanoparticle-formulated, nucleoside-modified mRNA vaccine that encodes the trimerized receptor-binding domain of the spike glycoprotein of SARS-CoV-2 2. Despite this enormous public health issue of stopping the COVID-19 pandemic, there are essentially no data on COVID-9 vaccine acceptance or efficacy in people with HIV (PWH). This is critically important for public health, in that an estimated 1.2 million people aged 13 and older have HIV in the United States, including an estimated 161,800 (14%) people whose infections had not been diagnosed 3. Although several COVID-19 vaccine clinical efficacy trials enrolled PWH without specific selectivity, there are insufficient data exist to determine the efficacy of COVID-19 vaccines in PWH. Indeed, prior to the COVID-19 pandemic, the CDC recommended that PWH with CD4 T cell counts of ≥200 or percentages ≥15% receive all licensed vaccines. Further, the CDC stated in a release December 12, 2020 (https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2020-12/slides-12-12/COVID-03- Mbaeyi.pdf): “The recently FDA-authorized Pfizer-BioNTech COVID-19 vaccine is not contraindicated for people living with HIV or others with immunocompromised conditions, though vaccine efficacy data does not currently exist for potentially immunocompromised individuals”. According to the CDC Advisory Committee on Immunization Practices (ACIP), “people living with HIV may still receive the vaccine, but should be counseled on unknown vaccine safety and efficacy profiles in immunocompromised persons.” The ACIP also recently recommended that health care personnel and residents of long-term care facilities (LTCFs) be offered vaccination in the initial phase of the COVID-19 vaccination program (Phase 1a) 4. In sum, PWH are looking to us for advice as their scientific and clinical HIV experts, with our response being that the COVID-19 vaccines “should be” safe and effective in them based on no specific data. Our proposed study aims to supply such data through a well-designed protocol nested in the most well-established and trusted MACS-WIHS Combined Cohort Study (MWCCS).

COVID Vaccine Study Supplement to MWCCS Principal Investigators: C. Rinaldo and J. Martinson Innovation Fund Application to the Multicenter AIDS Cohort Study (MACS)/Women’s Interagency HIV Study (WIHS) Combined Cohort Study (MWCCS): COVID-19 Vaccine Acceptance and Hesitancy (CVHB) Study in People with HIV Scientific Justification A safe, highly immunogenic vaccine to prevent primary SARS-CoV-2 infection is needed to control the COVID-19 pandemic. As of January, 2021, the United States is racing to vaccinate a significant percentage of our 330 million population to control the COVID-19 pandemic. This extraordinary rapid development resulted from FDA emergency use authorization (EUA) of two COVID-19 vaccines in December, 2020, i.e., the Moderna mRNA-1273 vaccine that codes for the stabilized pre-fusion SARS- CoV-2 spike protein 1, and the Pfizer/BioNTech vaccine BNT162b1 that is a lipid-nanoparticle-formulated, nucleoside-modified mRNA vaccine that encodes the trimerized receptor-binding domain of the spike glycoprotein of SARS-CoV-2 2. Despite this enormous public health issue of stopping the COVID-19 pandemic, there are essentially no data on COVID-9 vaccine acceptance or efficacy in people with HIV (PWH). This is critically important for public health, in that an estimated 1.2 million people aged 13 and older have HIV in the United States, including an estimated 161,800 (14%) people whose infections had not been diagnosed 3. Although several COVID-19 vaccine clinical efficacy trials enrolled PWH without specific selectivity, there are insufficient data exist to determine the efficacy of COVID-19 vaccines in PWH. Indeed, prior to the COVID-19 pandemic, the CDC recommended that PWH with CD4 T cell counts of ≥200 or percentages ≥15% receive all licensed vaccines. Further, the CDC stated in a release December 12, 2020 (https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2020-12/slides-12-12/COVID-03- Mbaeyi.pdf): “The recently FDA-authorized Pfizer-BioNTech COVID-19 vaccine is not contraindicated for people living with HIV or others with immunocompromised conditions, though vaccine efficacy data does not currently exist for potentially immunocompromised individuals”. According to the CDC Advisory Committee on Immunization Practices (ACIP), “people living with HIV may still receive the vaccine, but should be counseled on unknown vaccine safety and efficacy profiles in immunocompromised persons.” The ACIP also recently recommended that health care personnel and residents of long-term care facilities (LTCFs) be offered vaccination in the initial phase of the COVID-19 vaccination program (Phase 1a) 4. In sum, PWH are looking to us for advice as their scientific and clinical HIV experts, with our response being that the COVID-19 vaccines “should be” safe and effective in them based on no specific data. Our proposed study aims to supply such data through a well-designed protocol nested in the most well-established and trusted MACS-WIHS Combined Cohort Study (MWCCS). In 2019, the WHO listed vaccine hesitancy, or the delay in acceptance or refusal of vaccination despite availability of vaccination services, as one of the top 10 threats to global health 5. As vaccine hesitancy rises, misinformation and anti-vaccine attacks on social media continue to circulate and dominate the vaccine conversation and present barriers to widespread vaccine uptake 6. Public acceptability of the MMR vaccine, HPV vaccine and pandemic vaccines (H1N1) has been contentious due to a combination of safety and efficacy concerns. Distrust in vaccines has led to low vaccination rates for measles and the flu. A 2018 survey from National Opinion Research Center (NORC) at the University of Chicago found that 43% of Americans forgo getting vaccinated against influenza. Vaccine hesitancy towards the COVID-19 vaccine is likely, while at the same time, research shows that enthusiasm for a vaccine is highest during a pandemic and immediately following vaccine release 7. In a recent study of determinants of COVID-19 vaccine acceptance in the US, 67% of participants said they would accept a COVID-19 vaccine if it is recommended for them 8. Other surveys found that 3 out of 4 people will get vaccinated at some time after a COVID-19 vaccine was available, with only 30% wanting to receive the vaccine as soon as it became available 7,9,10 COVID Vaccine Study Supplement to MWCCS Principal Investigators: C. Rinaldo and J. Martinson Hence, as of the current public roll-out of COVID-19 vaccines, there is only anecdotal evidence about COVID-19 vaccine hesitancy in PWH, and the immune responses and protective effects to SARS-CoV-2 vaccines. There also are no data on sex-based differences in PWH in the acquisition, progression, severity, and response to treatment of SARS-CoV-2 infection. PWH have low risk for AIDS due to extraordinary control of the infection by antiretroviral therapy (ART). Nevertheless, PWH are at increased risk of severe comorbidities 11. The MWCCS cohort (n=4016) currently has 1,169 active HIV- infected men and 1,569 active HIV infected women. The cohort is racially and ethnically diverse: 49% of participants identify as Black; 13% as Hispanic; 35% as White; and 3% as Asian, Middle Eastern, and other ethnoracial backgrounds. The current average age is 64/58yo HIVpos/HIVneg male and 52/54yo HIVpos/HIVneg female. Many have documented evidence of significant cardiovascular, pulmonary and other comorbidities. At last study visit (2018/2019), substantial proportions of active participants had prevalent underlying morbidities consistent with risk for severe COVID-19 disease sequelae: 42% had body-mass index≥30, consistent with obesity; 56% had prevalent hypertension; 22% had prevalent diabetes; 64% had dyslipidemia; 7% had history of cancer; and 12% had kidney disease 12. Thus, our MWCCS cohort represents a high-risk group for severe SARS-CoV-2 infection in terms of both elderly age and underlying comorbidities. Studies to date suggest that PWH are at similar risk of acquiring SARS-CoV-2 infection and undergoing severe symptoms and death as are HIV-uninfected persons of similar age, sex, and race/ethnicity 13-19. An analysis of SARS-CoV-2 infection in 122 PWH in England found that mortality was higher in PWH than HIV uninfected controls (HUC) after adjusting for age 20. HIV infection was associated with an increased risk of mortality among persons hospitalized for COVID-19. A recent surveillance study in the MWCCS indicates that PWH are twice likely to have a positive test for COVID-19 than HIV seronegative men and women 21 . Although age, race, current smoking, and BMI were not risk factors for positivity, the odds of SARS-CoV-2 positivity were higher among PWH than HIV seronegatives and among those living with another person versus living alone. In sum, we believe that it is critically important for the OAR to support this initiative and capitalize on the MWCCS platform and participants to address the acceptancy and demonstrate the benefits of the COVID-19 vaccines in PWH. This is similar to their capitalizing on existing NIH research platforms such as the HVTN and ACTG to study COVID-19 vaccines and treatments. Abstract and Specific Aims MWCCS participants are a high-risk group for severe COVID-19 disease in terms of being HIV-infected, predominately of elderly age, and having numerous underlying comorbidities. Therefore, it is imperative for their health that they be vaccinated with the new COVID-19 vaccines. To date, however, there are only anecdotal data on COVID-19 vaccine acceptance and efficacy in people with HIV (PWH). The MWCCS is ideal for analyzing (a) the acceptancy and effects of COVID-19 vaccine(s) in male and female PWH and matched HIV-uninfected controls (HUC), (b) the impact of age and co-morbidities on vaccine immune response and protection against COVID-19, and (c) the social, economic, and behavioral changes after COVID-19 immunization as compared to the individuals who opted to not take the vaccine. To address this issue, we will have 2 groups of MWCCS participants in this study: Group A: Male and female PWH and HUC who choose to receive a COVID-19 vaccine, Group B: Male and female PWH and HUC who choose NOT to receive a COVID-19 vaccine. The aims of our proposed longitudinal observational study for this OAR Innovation application are: Aim 1: To conduct an MWCCS-wide, mixed- methods investigation of the prevalence, correlates, and nuances of COVID-19 vaccine hesitancy among MWCCS participants. Results will help better understand the concerns of PWH and HUC populations regarding COVID-19 vaccines based on age, sex, race/ethnicity, and underlying comormidity burden. Aim 2: To determine the incidence of natural SARS-CoV-2 infections post-COVID-19 immunization in PWH as compared to HUC of the same age, sex, and ethnicity/race and also compare COVID Vaccine Study Supplement to MWCCS Principal Investigators: C. Rinaldo and J. Martinson with the incidence of infections in non-vaccinated individuals. Because of budgetary limitations in the OAR Innovation Fund supplement, we will restrict Aim 2 to obtaining one specimen at baseline, just prior vaccination in Group A, and within comparable time periods for Group B. Subsequent samples collected during the core MWCCS visits will be used in the serological analyzes. These samples will allow us to determine the serological COVID-19 status pre-immunization, and post-immunization seroconversions for S and N proteins. The titration of anti-S responses post immunization will indicate vaccine immune response, while anti-N antibody titers will indicate natural SARS-CoV-2 infection This information will allow the identification of asymptomatic and symptomatic individuals infected with SARS- CoV-2 post-vaccination and in non-vaccinated group. The if these infections in the MWCCS will allow a targeted use of core samples in depth investigation of the immune mechanisms of vaccine-mediated protection, the immunologic responses and virologic characteristics of breakthrough SARS-CoV-2 infections, and the impact of the vaccination on underlying HIV infection. Importantly, timely funding from this OAR Innovation opportunity is critical to our addressing these aims prior to the broad rollout of the COVID-19 vaccines to our PWH participants. We are in a race to obtain this critical information and specimens prior to the wide availability of current FDA EUA vaccines to our MWCCS participants. The MWCCS clinical research sites across the United States and the data center are ready to launch this new study as soon as funding is available and we receive sIRB approval. SPECIFIC AIM 1: Using a mixed-methods approach, assess the prevalence, correlates, and nuances of COVID-19 vaccine hesitancy among MWCCS participants. What are the COVID-19 vaccine hesitancy characteristics among PWH and HUC? Does HIV status or the presence of co- morbidities influence vaccine hesitancy? Do COVID-19 vaccine hesitancy characteristics change overtime among PWH and HUC? We deploy a baseline and follow-up survey, 3 months post-baseline, using validated instruments assessing medical mistrust, vaccine acceptance/hesitancy, and COVID-19 vaccine communication. We will also measure self-reported COVID-19 vaccine uptake, which will be complemented by adjudication via medical records; and develop a new measure to assess eligibility awareness. We will supplement these quantitative data with a micronarrative approach eliciting short narratives from MWCCS participants related to these domains. We hypothesize 1) that social position including male gender, Black race, region (U.S. South), low comorbidity burden, and younger age are associated with higher vaccine hesitancy; 2) that vaccine hesitancy will attenuate over time; 3) that vaccine eligibility awareness and vaccine uptake will increase over time; and 4) that relationships between social position and vaccine hesitancy will be mediated by medical mistrust and moderated by vaccine eligibility awareness. Our results will serve as a foundation for the development of future vaccine communication strategies for high-risk populations, including those aging with HIV and other chronic comorbidities, exemplified in the MWCCS. SPECIFIC AIM 2: Obtain pre-vaccination specimens to assess COVID-19 serological status against CoV-2 and monitor the incidence of SARS-COV-2 infections in vaccinated PWH as compared to HUC. These specimens collected just prior to immunization will allow further studies to address: What is the incidence of breakthrough infections in immunized individuals? Does HIV status or the presence of co-morbidities influence the incidence of breakthrough infections or the phenotype of the disease? Critical Supporting/Preliminary Data, including references The MWCCS has been gathering data since April, 2020, on the incidence of natural SARS-CoV-2 infection in its male and female, PWH and HUC, participants at the 13 MWCCS clinical sites across the United States. To date, PWH and HUC persons in the MWCCS show a prevalence of natural SARS- CoV-2 infection like their non-MWCCS counterparts. We have conducted a basic study of COVID-19 symptoms and SARS-CoV-2 PCR-based swab testing among participants of the MWCCS 21. A telephone COVID Vaccine Study Supplement to MWCCS Principal Investigators: C. Rinaldo and J. Martinson survey was collected April-June 30, 2020. Symptom and testing prevalence were explored. Multivariable logistic regression was used to examine the factors associated with SARS-CoV-2 positivity. The survey was completed by 3411 participants, including 2078 (61%) PWH and 1333 HUC participants from across the US. Thirteen percent (n = 441) were tested for SARS-CoV-2 infection (13.4% of PWH vs 12.2% of HUC). Among those tested, positivity was higher in PWH than HUC (11.2% vs 6.1%, p = 0.08). Reasons for not being tested included testing not being available (30% of participants) and not knowing where to get tested (16% of participants). Most symptoms reported since January 2020 were similar in PWH and HUC, including headache (23% vs. 24%), myalgias (19% vs 18%), shortness of breath (14% vs 13%), chills (12% vs 10%), fever (6% vs 6%) and loss of taste or smell (6% vs 7%). Among PWH who tested positive for SARS-CoV-2 DNA, the most common symptoms were headache (71%), myalgia (68%), cough (68%) and chills (65%). In multivariable analysis among those tested, the odds of SARS-CoV-2 positivity were higher among PWH than HUC (aOR = 2.22 95%CI = 01.01–4.85, p = 0.046) and among those living with others versus living alone (aOR = 2.95 95%CI = 1.18–7.40). Thus, the prevalence and type of COVID-19 symptoms are similar in PWH and HUC. SARS-CoV-2 infection may be elevated among PWH. In sum, this surveillance study in the MWCCS indicates that PWH are twice likely to have a positive test for COVID-19 than HIV seronegative men and women. Although age, race, current smoking, and BMI were not risk factors for positivity, the odds of SARS-CoV- 2 positivity were higher among PWH than HUC and among those living with another person versus living alone. Note that beyond this OAR study request, our goal is a longitudinal observation study to determine the impact of chronic HIV infection on the effect of COVID-19 vaccines. This will be a hypothesis-driven investigation of the immune mechanisms of vaccine-mediated protection and the impact of the vaccination on HIV infection. This vaccine research project will be the focus of a separate application for funding through the NIH. In the event that this latter proposal is not funded, the blood specimens obtained in this OAR Innovation study will still be of great value to numerous other studies being conducted by the MWCCS. In addition, this study complements the important ongoing MWCCS-wide COVID-19 study of vaccine hesitancy, compliance and uptake. Our mixed-methods approach (Aim 1) will leverage MWCCS core collection of vaccine uptake in order to establish temporal pathways and nuanced relationships between social position, medical mistrust, vaccine benefit mistrust, concerns about side effects, worries about corporate vaccine profiteering, and the preference for natural immunity. We will also build on existing core collection of general vaccine acceptance by 1) developing a new instrument assessing awareness of vaccine eligibility and access; 2) incorporating a vaccine communication instrument to better target messaging to high-risk populations; and 3) integrate a micronarrative component to explore in greater nuance individual-level factors that influence vaccine uptake decision-making, perceptions of vaccine communication strategies, vaccine distribution, and perceived vaccine hesitancy behaviors of the household and community. In addition, the data we propose to collect in the supplement could be leveraged after integration with COVID-19 core survey behavioral data to assess post-vaccine changes to COVID-19 prevention behaviors. This study will offer important insight into COVID-19 vaccine hesitancy and obstacles to vaccine acceptance, in addition to informing targeted communication strategies and intervention efforts that improve trust, increase uptake and break COVID-19 transmission dynamics among high-risk, aging populations with high comorbidity burden, exemplified in the MWCCS cohort. COVID Vaccine Study Supplement to MWCCS Principal Investigators: C. Rinaldo and J. Martinson Research Plan/Statement of Work Study cohort. Our proposed longitudinal observational study for this OAR Innovation application will directly address two significant, intertwined issues in our understanding of the effects of the new COVID- 19 vaccines on PWH, i.e., COVID-19 vaccine acceptance and COVID-19 vaccine benefit. The MWCCS is ideal for analyzing the acceptancy and effects of COVID-19 vaccine(s) in male and female PWH and matched HUC, and to investigate the impact of age and co-morbidities on vaccine immune response and protection against SARS-CoV-2 infection. To address this issue, we will have 2 groups of MWCCS participants in this study: Group A: Male and female PWH and HUC who choose to receive a COIVD-19 vaccine, Group B: Male and female PWH and HUC who choose NOT to receive a COIVD-19 vaccine. Specific Aim 1: Using a mixed-methods approach, we will assess the prevalence, correlates, and nuances of COVID-19 vaccine hesitancy among MWCCS participants. Our first aim is to understand the concerns of our MWCCS PWH and HUC populations regarding COVID-19 vaccines based on age, sex, region, ethnicity/race, and underlying comorbidity burden: Does HIV status or the presence of co- morbidities influence vaccine acceptancy? Thus, we will conduct an MWCCS-wide, intensive surveillance of COVID-19 attitudes to understand the concerns of PWH regarding vaccine acceptance while providing them with the best and most up-to-date information and advice on the efficacy and safety of these vaccines. We hypothesize 1) that social position including male gender, Black race, region (U.S. South), low comorbidity burden, and younger age are associated with higher vaccine hesitancy; 2) that vaccine hesitancy will attenuate over time; 3) that vaccine eligibility awareness and vaccine uptake will increase over time; and 4) that relationships between social position and vaccine hesitancy will be mediated by medical mistrust and moderated by vaccine eligibility awareness. The MWCCS cohort represents a high-risk group for severe SARS-CoV-2 infection in terms of HIV infection, older age and underlying comorbidities. Thus, it is ideal for analyzing the acceptancy of COVID- 19 vaccine(s) in men and women with and without HIV infection (Table 1). 5-10. We have seen an extremely publicized roll-out of the new COVID-19 vaccines in 2020 with contentious issues, e.g., anti- vaccination movement. The MWCCS participants will look to us for advice on this issue. Therefore, we are not predicating this concept on the types of vaccine that will be available - our approach will define overall benefit of various vaccine types. We propose to assess the benefit of new COVID 19 vaccines in PWH as compared to HUC in the MWCCS. In order to adequately prepare for this study at the MWCCS clinical sites and the DACC, as well as inform and consent our study participants, we need to establish this protocol well prior to the roll-out and availability of COVID 19 vaccines. Thus, we will have 2 groups of MWCCS participants in this study: Group A: Male and female PWH and HUC who choose to receive a COVID-19 vaccine; Group B: Male and female PWH and HUC who choose NOT to receive a COVID-19 vaccine. In Aim 1, we will conduct a MWCCS-wide, intensive surveillance of COVID-19 vaccine hesitancy. Because of budgetary limitations in the OAR Innovation Fund supplement, we will restrict Aim 2 to obtaining one serum specimen at baseline/pre- vaccination in both Groups A and B. We plan to economize in this study by using post-vaccination serologic specimens that have already been obtained or will be obtained at the MWCCS clinical sites within the next 6 mo to a year after the vaccination as part of the regular MWCCS clinic visit. This is assuming that these clinics are or will be open and fully functional by then. However, it is highly unlikely that the 13 MWCCS clinical sites and their satellite sites will all be fully functional before the COIVID-19 vaccines are available to our participants. Thus, this proposal will allow us to obtain the large number of pre-vaccine, baseline serum specimens from the Groups A and B participants. COVID Vaccine Study Supplement to MWCCS Principal Investigators: C. Rinaldo and J. Martinson In sum, this study will provide the participant base and initial biological specimens for a separate, in depth investigation of the immune mechanisms of vaccine-mediated protection, study of immunologic responses characteristics of breakthrough SARS-CoV-2 infections, and the impact of the vaccination on underlying HIV infection. In Aim 1 we will conduct mixed-methods research to assess the prevalence, correlates, and nuances of COVID-19 vaccine hesitancy among MWCCS participants. We will sequentially administer (2 times, 3 months apart) a validated vaccine acceptance survey with all consenting, active MWCCS participants in order to understand the prevalence and correlates of vaccine hesitancy. Further, we will develop a vaccine eligibility awareness survey, assessing current understanding of vaccine eligibility, availability, access, and uptake. In order to explore nuance related to vaccine acceptance and awareness, a micronarrative survey tool will be integrated to collect narrative responses about participant’s experiences with vaccine decision-making and COVID-19 vaccination 22. To examine vaccine hesitancy we will use the 12-item Vaccination Attitudes Examination (VAX) Scale, which contains 4 dimensions: vaccine benefit mistrust; concerns about side effects; worries about corporate vaccine profiteering; and the preference for natural immunity 23, modified to assess COVID-19 vaccines 24. In addition, we will develop and administer a new instrument that assesses participants’ COVID-19 vaccine awareness (by approved vaccine type), eligibility, access, and uptake. We will also utilize the Medical Mistrust Index, which has been used to evaluate racial differences in medical mistrust as a legacy of racist scientific experimentation, such as the Tuskegee Study, to evaluate associations between medical mistrust, vaccine hesitancy, and vaccine eligibility awareness 25. We construct generalized linear mixed models with repeated measures in order to observe temporal trends and test associations between sociodemographics (race, ethnicity, age, HIV status, gender, and region) and the following outcomes: 1) vaccine eligibility awareness; 2) medical mistrust; 3) vaccine hesitancy; and 4) vaccine uptake. Models will be additionally adjusted for income, prior SARS-CoV-2 infection and a syndemic index of existing key comorbidities associated with COVID-19 severity (chronic obstructive pulmonary disease; diabetes; hypertension; obesity; kidney disease; cardiovascular disease; cancer), leveraged from retrospective, adjudicated cohort data. We will use the generalized linear mixed methods approach, using repeated measures, in SAS (SAS PROC GLIMMIX) to assess our key hypotheses: 1) that social position including male gender, Black race, region (U.S. South) and younger age are associated with higher vaccine hesitancy; 2) that vaccine hesitancy will attenuate over time; and 3) that vaccine eligibility awareness and vaccine uptake will increase over time. We will then build a series of causal mediation models (see Figure 1) to examine relationships between cross-stratified sociodemographics (predictors); medical mistrust (mediator); and vaccine hesitancy (outcome), controlling for income, prior SARS-CoV-2 infection, and COVID-19 severity potential (confounders), and moderated by vaccine eligibility awareness. These models will use the three-way decomposition approach for causal mediation 26,27. This approach requires a more targeted set of predictors and a set of confounding variables. Following recent literature in quantitative analysis of causal inference mediation 27, we will cross- stratify social position predictors, focusing on all possible permutations of sociodemographic categories, using white, non- Hispanic, non-Southern, HIV- women as the referent category (reflecting the lowest anticipated degree of vaccine hesitancy). These analyses will allow us to assess, for each Figure 1. Causal mediation models. COVID Vaccine Study Supplement to MWCCS Principal Investigators: C. Rinaldo and J. Martinson sociodemographic permutation on vaccine hesitancy, a pure direct effect, constituting the expected increase in vaccine hesitancy due to social position; a pure indirect effect, constituting the mediating effect of medical mistrust on vaccine hesitancy; and the additional interaction effect of medical mistrust on each respective vaccine hesitancy due to social position. The 3-way decomposition approach will thus provide context to generalized linear mixed model results, allowing us to identify particular intersections of marginalized social positions most strongly associated with vaccine hesitancy, and most affected by medical mistrust. Causal mediation analyses will be conducted using SAS PROC CAUSALMED. To better understand the landscape of vaccine communication and to lay the groundwork for more effective vaccine communication strategies, we will during the baseline quantitative survey deploy an unpublished instrument assessing effective COVID-19 vaccine communication strategies developed by the DeBeaumont Foundation (https://debeaumont.org/covid-vaccine-poll). These questions are intended to assess, in an exploratory fashion, suggestions for COVID-19 vaccination communication. We will concurrently pursue a micronarrative elicitation approach, for which respondents will be asked in a narrative survey prompt (via text or voice, based on participant preference) to elicit a specific story related to COVID-19 vaccine decision-making or uptake, followed by a series of closed questions that explore factors influencing vaccine decision-making, perceptions of vaccine access and distribution, and perceived vaccine acceptance and hesitancy behaviors of the household and community. Open-text narrative responses will be analyzed thematically and key factors in COVID-19 vaccine decision-making will be explored among four response types: vaccine-accepting and aware of eligibility; vaccine-accepting and unaware of eligibility; vaccine-hesitant and aware; and vaccine-hesitant and unaware. Estimated sample and power for Aim 1: All MWCCS participants will be invited to take part in this Administrative Supplement study. Based on participation rates (84%) in the MWCCS COVID-19 Psychosocial Modules disseminated in 2020, we estimate a total n=3411 (6822 person-observations) at each of 2 waves for survey completion (788 HIV+ men; 798 HIV- men; 1290 HIV+ women; 535 HIV- women). Approaches for estimating sample sizes for causal mediation models are not yet standardized; however, research suggests that sample sizes of n=30-460 are typically sufficient for identifying small effect sizes (power=0.8; α=0.05), with this range dependent on missing data, number of latent factors, and strength of factor loading 28. Integration of methods and data: In this explanatory sequential mixed-methods design, qualitative and quantitative methods and data will be integrated to facilitate richer understanding of the effect paths of intersectional stigma on comorbidity control, and to identify promising strategies for intervening along these paths 29. To interpret our data, we will compare qualitative and quantitative results to pinpoint areas where data from each method converges, diverges, or elucidates 30. Study investigators (Drs. Krier and Friedman) will present jointly displayed qualitative and quantitative findings at two venues: 1) a MWCCS National Community Advisory Board (NCAB) meeting; and 2) a virtual community forum, conducted via Zoom, open to all MWCCS participants and local practitioners. These forums will serve as platforms to disseminate study findings to stakeholders; triangulate results by eliciting community feedback; and generate substantial community input to help consolidate promising intervention frameworks to increase vaccine acceptance that emerge from comparing and contrasting qualitative and quantitative results 31. By offering a method to triangulate qualitative and quantitative findings that might be difficult to interpret separately, this approach will maximize interpretative salience 32. Results from Aim 1 will help develop a framework for future COVID-19 vaccine communication approaches that use trusted sources from target populations and are highly targeted – in this case, tailored to diverse populations with high underlying comorbidity prevalence. These strategies have been recently recommended as best-practices by the NIH Office of Behavioral and Social Sciences Research 33. COVID Vaccine Study Supplement to MWCCS Principal Investigators: C. Rinaldo and J. Martinson a. Pre-enrollment: Establish MWCCS-wide COVID vaccine study protocol at all 13 clinical sites with IRB approval; includes plans for coordinating/consenting/providing participant incentives at each site. b. Enrollment: Each MWCCS clinical site staff will be responsible for enrolling their participants into this COVID vaccine study. This includes: Email, standard mail and website announcements and outreach to MWCCS participants explaining our new COVID vaccine study TABLE 1: COVID-19 Vaccine Acceptance and Benefit (CVAE) Study: SCOPE OF WORK COMPONENT ELIGIBILITY DESCRIPTION Study consent and enrollment All participants (anticipate ~60% of participants at each site) Staff at each of the MWCCS primary and ancillary CRS will consent participants to the study. We anticipate that the consent will be an addendum to the CCS main consent. This consent will include: the mention of participant completion of the CCS questionnaire on vaccine acceptance (VACACC), the administration of a mixed- methods survey at baseline and at 3 months on vaccine hesitancy, and the provision of pre- and post-vaccine blood specimens (total of 2 samples per participant). When available as part of the participant's MWCCS core 101 and supplemental clinic visits, and within six months before and 6 months after the COVID-19 vaccination, we will use blood specimens taken in our MWCCS clinics for this study. When these specimens are not available, blood samples self-collected by the participants will be obtained and shipped directly to the study blood processing site at Pitt. A study enrollment form would be completed in Gemini. Anticipated budget period 4/1/21-3/31/22. Consent reimbursement: $5-10 (site specific). Vaccine hesitancy questionnaire All participants (anticipate ~60% of participants at each site) Mixed-method survey addressing thoughts and feelings on the COVID-19 vaccines will be administered to the participants. This survey will be conducted at baseline and at three months. The components of this survey will include: • Vaccine hesitancy (VAX 12-item measure) • Vaccine eligibility awareness • Medical Mistrust • Risk communication • Micronarrative responses of vaccine decision-making and vaccination Completion estimate of 30-35 minutes. Participants will be reimbursed $10 each time they complete the survey. Pitt plans to develop a Qualtrics survey for this component. Participants could complete the survey on their phones or computers. Blood collection - antibody testing All participants (anticipate ~60% of participants at each site) Blood collection for antibody testing that is not available from regular MWCCS clinic visits will be done pre-vaccination at the core visit and post-vaccination via home collection, as stated above. For the core visit/repository, 2 ml of serum is needed. Serum samples from participants who completed v101 prior to this project's start date also qualify (upon signed consent). This would be for participants who completed the in-person visit Nov 2020 – Mar 2022. For self- collection kits, Pitt will provide sites with the return labels. Sites will need to link the MWCCS participant ID to the bar code on the kit, document the distribution and mail the kit to the participants. The participant name should not appear on the kit. Participants will then ship the kit back to the Pitt blood processing laboratory. Pitt staff will notify the primary MWCCS site once a self-collected kit has arrived at the Pitt lab so the site can reimburse the participants. Sites would then send incentive to participant. Sites may want to call the participant COVID Vaccine Study Supplement to MWCCS Principal Investigators: C. Rinaldo and J. Martinson beforehand to advise of reimbursement, i.e., one $10 incentive per participant for each blood donation. Vaccination All participants (anticipate ~60% of participants at each site) Vaccination to be administered through participant PCP, participating pharmacies, health centers, etc. Sites would need to call participants to monitor when they anticipate on being immunized. This question could be asked when calling participant to advise them of the monetary reimbursement, or at another scheduled CCS call. Upon consenting, participants will be informed to call their local CRS to report vaccination (including boosters) along with proper ascertainment record to receive $5 incentive. Verification of vaccination All participants (anticipate ~60% of participants at each site) ATC form in Gemini to collect type of vaccine, date of vaccine, location and if second booster is required. May require release to obtain record. $5 incentive is given to each participant for ascertainment record of vaccination. TABLE 2: CVAE Protocol - Timeline C= consent time point Q1 2021) 3 mos V = vaccination V+6mo Consent (phone) X Self-collected blood X Vaccine hesitancy questionnaire X X Vaccination Ascertainment X V101 core visit X X Specific Aim 2: We will obtain a self-collected blood sample just prior immunization that will be used to determine the SARS-CoV-2 serological status prior immunization. This sample will be the baseline reference to detect seroconversions induced by the vaccine antigens, and by natural infections when comparing to MWCCS core samples collected afterwards. Based on the seroconversions of S and N proteins, we will be able to detect vaccine responses and breakthrough infections in immunized individuals and compare the incidence of infection in immunized versus non-immunized groups and determine if the HIV status or the presence of co-morbidities influence the incidence of breakthrough infections or the phenotype of the disease. Because of budgetary limitations in the OAR Innovation Fund supplement, we will restrict Aim 2 to obtaining one specimen at baseline/pre-vaccination in Group A, and within comparable time periods for Group B. This study will provide the unique participant base and initial biological specimens for a separately funded investigation of the immune mechanisms of vaccine-mediated protection and the impact of the vaccination on underlying HIV infection. We will target recruitment of 1,126 PWH and 1,126 HUC MWCCS men and women (Table 3). Considering the demographic characteristics and number of MWCCS active participants and a conservative vaccine acceptance rate of 70%, we estimate that 1,576 participants will want to be vaccinated (Group A) and the other 676 will not, or could prefer to be vaccinated at later time (Group B). Assuming that there will be no bias on vaccine acceptance between PWH and HUC, we estimate that COVID Vaccine Study Supplement to MWCCS Principal Investigators: C. Rinaldo and J. Martinson in Group A, 788 will be PWH and the 788 HUC, and in the non-vaccinated Group B, 338 will be PWH and 338 HUC. We will enroll MWCCS participants who meet CDC immunization priority guidelines and have consented to participate in this study to self-administer blood collections prior receiving the immunization. The devices for blood collection (see Figure 2) and instructions for self-collection and shipping will be send to the participants after the consent. The participant will collect the blood and mail to the to the Pitt MWCCS laboratory site for processing and storage. The study will accept the participation of individuals taking any of the vaccines available. COVID Vaccine Study Supplement to MWCCS Principal Investigators: C. Rinaldo and J. Martinson TABLE 3 Aim 1 Interview all MWCCS participants and administer a vaccine hesitancy questionnaire. (Group A) Male and female PWH who choose to receive a COVID-19 vaccine; Male and female HUC who choose to receive a COVID-19 vaccine. (Group B) Male and female PWH and HUC who choose NOT to receive a COVID-19 vaccine; Male and female HUC who choose NOT to receive a COVID-19 vaccine. Aim 2 MWCCS participants Groups A (vaccinated) and B (non- vaccinated) PWH = 1,126 (788 vaccinated and 338 non-vaccinated) • Male = 563 (394 vaccinated and 169 non-vaccinated) • Female = 563 (394 vaccinated and 169 non-vaccinated) HUC = 1,126 (788 vaccinated and 338 non-vaccinated) • Male = 563 (394 vaccinated and 169 non-vaccinated) • Female = 563 (394 vaccinated and 169 non-vaccinated) We have benefitted from information provided by Drs. Dorry Segev, Brian Boyarsky and Jacqueline Wang of Johns Hopkins University Medical School who are conducting a study on SARS-CoV-2 infection in organ transplant recipients that has been using the 7sbio self-obtained blood specimen device (Figure 2) with great success. A video tutorial will be provided to explain how to self-collect blood samples and mailing to the samples to the Pitt MWCCS laboratory. The self-collected blood samples will be mailed at ambient temperature to the research center in appropriate packaging provided with the collection kit. The vaccine(s) will be administered locally by their PCP or medical provider. In cases where more than one vaccine becomes available, we will document the vaccine type and doses received but we will not restrict the type of vaccine used by our participants. At the time of this OAR application (January, 2021), most COVID-19 vaccines in Phase III trials in the USA require two separate immunizations applied about 3 to 4 weeks apart. Therefore, a second, self-administered blood collection will be done by the participants six months after their first immunization. COVID Vaccine Study Supplement to MWCCS Principal Investigators: C. Rinaldo and J. Martinson FIGURE 2. Seventh Sense Biosystems – At home blood collection kit • Push-button blood collection device • At-home kit currently approved for research purposes only, not FDA-approved. • Currently used successfully in the organ transplantation COVID-19 study, Johns Hopkins University School of Medicine. • $15/Test borne by the MWCCS supplemental budget. Website: http://www.7sbio.com/ Videos: https://www.youtube.com/watch?v=HEcJvl3-rDg https://www.cnbc.com/video/2017/07/22/seventh-sense-painless-blood-draw-review.html COVID Vaccine Study Supplement to MWCCS Principal Investigators: C. Rinaldo and J. Martinson References 1. Jackson LA, Anderson EJ, Rouphael NG, et al. An mRNA Vaccine against SARS-CoV-2 - Preliminary Report. N Engl J Med 2020; 383(20): 1920-31. 2. Mulligan MJ, Lyke KE, Kitchin N, et al. Phase I/II study of COVID-19 RNA vaccine BNT162b1 in adults. Nature 2020; 586(7830): 589-93. 3. Prevention CfDCa. Estimated HIV incidence and prevalence in the United States, 2014–2018. 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