The emergence of the coronavirus disease (COVID-19) in late 2019 marked one of the most significant public health crises in modern history. The pandemic’s rapid global spread, high morbidity and mortality, and wide-ranging socio-economic impacts exposed gaps in health systems and governance across countries [1, 2]. In Nigeria, as in many low- and middle-income countries (LMICs), the pandemic tested the resilience of healthcare delivery structures, risk communication mechanisms, and public trust in health interventions [3, 4]. Vaccination has been widely recognized as a cornerstone of the global COVID-19 response. However, its success relies heavily on the population’s willingness to be vaccinated. The introduction of the COVID-19 vaccine in Nigeria was met with mixed reactions, ranging from cautious optimism to skepticism, fear, and outright rejection, especially among vulnerable or marginalized groups often referred to as “key populations.”

COVID-19 vaccine hesitancy, which is the delay in acceptance or refusal of vaccines despite availability has emerged as a significant challenge to global immunization efforts [5]. The World Health Organization (WHO) identified vaccine hesitancy as one of the top ten threats to global health even before the COVID-19 pandemic [5]. In Nigeria, the issue of vaccine hesitancy is multifaceted, influenced by sociocultural, religious, political, and historical contexts. Deep-seated mistrust of government and health authorities, misinformation about vaccine safety, and rumors about hidden agendas have all contributed to public reluctance [6]. The introduction of the COVID-19 vaccine reignited these concerns, with social media amplifying misinformation regarding side effects, infertility, and conspiracy theories about population control [7]. As a result, despite the availability of vaccines, Nigeria’s vaccination coverage has remained suboptimal compared to global targets.

The situation is further complicated among community key populations groups that are socially or medically marginalized, often facing multiple layers of vulnerability, stigma, and exclusion. These populations include people who inject drugs (PWID), female sex workers (FSW), men who have sex with men (MSM) living with HIV (PLHIV). Previous research in Nigeria has largely focused on general population attitudes toward COVID-19 vaccination, emphasizing factors such as age, education, religion, and exposure to information [8, 9]. While these studies have provided valuable insights, there remains a notable gap in understanding the perspectives of key populations, especially those with complex social vulnerabilities.

Despite the importance of vaccine acceptance, few qualitative studies have explored COVID-19 vaccine hesitancy among community key populations in Nigeria. Most existing data are quantitative and focus on general trends rather than contextual experiences. A qualitative exploration offers the depth and nuance needed to understand how individuals interpret, negotiate, and act upon health information within their specific social worlds. This study explored the perceptions, beliefs, and experiences that influence COVID-19 vaccine hesitancy among community key populations, PLHIV in Rivers State, Nigeria.

The study was conducted in Rivers State, located in southern Nigeria. Rivers State is a major oil-producing region with Port Harcourt as its capital, and serves as a commercial hub for the Niger Delta. The state has one of the highest urban populations in Nigeria, with a diverse mix of ethnicities and socio-economic backgrounds. During the COVID-19 pandemic, Rivers State reported one of the highest numbers of confirmed cases and deaths in the southern region, with 3,116 confirmed infections and 60 deaths as of December 2020 [11, 12]. The state also has a relatively high HIV prevalence rate (9.1%) [13] and houses several key population one-stop shops (OSS) providing integrated HIV prevention, testing, and treatment services. These OSS centers serve key populations. These service delivery points provided the ideal context for the study because they are established community-based spaces where key populations access health information, counseling, and treatment in an environment that fosters confidentiality and trust. The study was conducted across five OSS centers.

Purposive sampling was used to recruit participants who could provide rich, relevant, and diverse insights into the study topic. The sampling targeted adults (18 years and above) who identify as members of the community key population (MSM, FSW, and PWID) who were accessing HIV/AIDS services from the OSS centers. Recruitment was facilitated through peer-navigators, site coordinators, and community liaison officers affiliated with each OSS center. These individuals, trusted within their communities, introduced the study to potential participants, explained the objectives, and connected interested individuals with the research team. The inclusion criteria required participants to (i) be members of community key population groups; (ii) be receiving or have received HIV/AIDS care or support from an OSS in Rivers State; (iii) be willing to share personal experiences regarding COVID-19 vaccination; and (iv) provide informed consent. Study information sheets outlining the objectives, confidentiality assurances, and voluntary nature of participation were provided verbally and in writing. Those who agreed to participate signed written consent forms or provided verbal consent. Participants were assigned to focus group discussions based on community key population types (e.g., MSM, FSW, PWID) to encourage open conversation within familiar peer groups. Each FGD consisted of five to seven participants.

Data collection took place from June to August 2024 across the OSS facilities. Trained qualitative research assistants (RAs), supported by peer-navigators, facilitated all FGDs. Prior to data collection, the RAs underwent a two-day training on qualitative interviewing, research ethics, cultural sensitivity, and COVID-19 safety protocols. The focus group approach facilitated interactive discussions that revealed group norms, social dynamics, and shared beliefs about COVID-19 vaccination. Data were collected using FGD guides developed and adapted from similar studies on vaccine hesitancy. The guides were designed to elicit information about participants’ understanding of COVID-19, perceptions of the vaccine, sources of vaccine-related information, perceived risks and benefits, experiences with access to vaccination, and suggestions for improving uptake among key populations. The guides were validated through face and content validity assessments involving experts from the Rivers State Ministry of Health, the OSS management team, and independent qualitative researchers. Each FGD was conducted in a private, safe room within the OSS facility to ensure comfort and confidentiality. A moderator facilitated the discussion, while an assistant moderator took field notes and managed logistics. FGDs lasted between 60 and 90 minutes. The sessions were conducted in English. All discussions were audio-recorded with permission from participants, and nonverbal cues or contextual details were documented as field notes. At the end of each session, participants were given a summary of key points to confirm accuracy (member checking).

The qualitative analysis of FGDs among MSM, FSW, and PWID living with HIV/AIDS revealed a complex and layered pattern of COVID-19 vaccine hesitancy. Thematic analysis, as presented in Table 1, identified five major themes and fifteen sub-themes that together demonstrated the intersection of misinformation, disbelief, fear, structural constraints, and pathways toward acceptance.

The thematic map (Fig. 1) illustrates how the five key themes interact to shape vaccine hesitancy among key populations. Limited knowledge and misinformation, disbelief, and safety fears reinforce hesitancy, while trust, peer influence, and integrated services serve as enabling pathways toward acceptance.

In some cases, participants highlighted inequities in vaccine distribution, noting that supply shortages disproportionately affected community members while more privileged groups benefited from early access.

Participants frequently expressed deep mistrust toward government intentions during the COVID-19 pandemic, often interpreting vaccine distribution patterns and public health messaging through a lens of political manipulation and inequality. Several respondents believed that the government prioritized elites over ordinary citizens, reinforcing feelings of marginalization among community key populations. Participants described this perceived inequity in vaccine rollout, stating:

“when the vaccine came in most of us have no access to it, only top officials are having access to the vaccine…”(MSM/FSW, FGD)

Beyond inequitable access, many participants believed that government narratives about COVID-19 were politically motivated rather than grounded in public health evidence. Some viewed announcements of new cases or return of the virus as tactics linked to political agendas, financial gain, or changes in leadership. This was illustrated by a participants who explained:

“If it is based on my level of understanding and exposure, I can say COVID is been politicised. Because recently there's a meeting I've attended and someone there was saying COVID is back. And when Fubara assumed office, they were saying COVID is back because they allegedly wanted to cash it out” (MSM/PWID/FSW, FGD)

Others similarly felt that the government’s handling of COVID-19 lacked transparency, further reinforcing perceptions of political interference in public health matters. As participants stated:

“Negative impact of politics in the recent pandemic is: if you look at the nature of the way they treated the COVID you'll notice that there's politics” (MSM/PWID, FGD)

These expressions of distrust reflect broader perceptions that the pandemic response was shaped by political interests rather than genuine concern for community well-being. Such perceptions of injustice and exclusion weakened confidence in official vaccination campaigns and amplified existing hesitancy, as participants questioned both the motives behind the vaccine rollout and the fairness of access across social groups.

This qualitative exploration revealed that COVID-19 vaccine hesitancy among MSM, FSW, and PWID living with HIV/AIDS in Rivers State stemmed from the intersection of disbelief, misinformation, fear, structural barriers, stigma, and mistrust. Participants’ statements, particularly “I didn’t believe it was real”, capture a pervasive sense of skepticism and disconnection from formal public-health messaging. Although awareness of COVID-19 and its vaccines was high, acceptance was undermined by poor comprehension, contradictory information, and social and political contexts that shape health-seeking behaviour in key populations. Our findings highlight a continuum of vaccine attitudes, ranging from outright disbelief and fear to cautious acceptance once credible reassurance and peer influence were introduced. This aligns with the growing body of literature showing that vaccine hesitancy is not a fixed refusal but a dynamic process influenced by information, trust, and accessibility [15, 16].

Participants’ doubts about the reality or severity of COVID-19 mirror similar sentiments documented in other African settings where direct exposure to severe illness was limited. Studies from Nigeria and Tanzania have shown that many respondents expressed doubts about the existence of COVID-19. These studies also highlighted a broader mistrust of pharmaceutical companies and the vaccine development process [17, 18, 19]. In this study, many participants described never having seen anyone personally affected by COVID-19, reinforcing low risk perception and fatalistic attitudes. This disbelief must be understood within the socio-historical context of institutional distrust and misinformation that characterized Nigeria’s early pandemic response. Low trust in government communication, conflicting public statements, and the politicization of pandemic funds contributed to skepticism. Among stigmatized populations already alienated from mainstream health systems, such disbelief becomes amplified through peer communication networks and social media, where unverified claims easily circulate.

Consistent with global research on vaccine misinformation, participants’ narratives revealed extensive exposure to rumours and conspiracy theories ranging from concerns about depopulation to fears of death or infertility. Similar findings have been documented in Ghana and among Nigerian youth [20, 21, 22]. These narratives exploit existing mistrust of government and Western medicine, particularly among marginalized communities. Our data also show that while health-care providers were trusted information sources, outreach was inconsistent and rarely tailored to the realities of key populations. In line with findings from [23] research, the lack of targeted, community-friendly communication creates information gaps easily filled by misinformation, shaping perceptions, fueling rumor-sharing, and undermining trust in health interventions among vulnerable groups.

Fear of side effects, especially perceived interference with ART, emerged as a central theme. For many participants, the uncertainty about how vaccines might interact with HIV medication outweighed potential benefits. Comparable concerns have been observed among people living with HIV in China [24].

Beyond cognitive and emotional factors, vaccine hesitancy in this study was entrenched in structural realities: vaccine stock-outs, long queues, distance to facilities, transport costs, and informal user fees. Such barriers convert willingness into inaction. Similar operational challenges have been reported across Nigeria’s vaccination campaigns [25, 26]. Socio-economic vulnerability also influenced risk prioritization. Participants frequently emphasized immediate survival needs food, shelter, daily income over preventive health behaviours, reflecting a well-recognized trade-off among impoverished populations [27]. These constraints illustrate that hesitancy is often a symptom of inequitable access rather than pure attitudinal resistance.

Experiences of stigma and discrimination, especially for MSM, were strong deterrents to vaccine acceptance. Participants described ridicule and moral judgment from healthcare staff, consistent with previous evidence that stigma within health systems discourages engagement with HIV and other services [28]. Vaccine hesitancy among key populations cannot be disentangled from broader social exclusion. Participants’ narratives revealed that hesitancy was compounded by perceptions of corruption, elite privilege, and politicization of vaccine distribution. The belief that “top officials got vaccinated first” echoes public outrage observed during Nigeria’s initial vaccine roll-out [29 & 30]. Public trust is critical for vaccination success.

Despite pervasive hesitancy, this study identified clear facilitators of vaccine acceptance. Foremost among them was trust in healthcare workers, peers, and the ART system. When information was delivered by familiar nurses or peer educators, participants felt reassured and more willing to vaccinate. This finding resonates with the 3 Cs model of vaccine hesitancy (confidence, complacency, convenience) and with literature emphasizing interpersonal trust as a key determinant of confidence [31]. Integration of vaccination into HIV care settings emerged as both a practical and psychological facilitator. By reducing logistical barriers and providing a non-stigmatizing environment, integrated services transformed vaccine acceptance from an external obligation to part of routine care. Peer influence also functioned as a social catalyst. Observing friends successfully vaccinated without harm provided counter-narratives to circulating rumours, gradually shifting group norms toward acceptance. Social proof theory suggests that such vicarious experience can be a powerful behavioural driver, particularly in tightly connected communities [32].

The strength of this study is its qualitative design, which provided rich, context-specific insights into the perceptions and lived experiences of marginalized communities often excluded from quantitative surveys. The inclusion of diverse key populations enhanced data depth and transferability. However, the findings should be interpreted with caution. Social-desirability bias may have influenced some responses, particularly regarding vaccine acceptance. The study was conducted in one Nigerian state and may not capture regional heterogeneity. Additionally, data were collected during a specific period of the vaccine rollout; perceptions may evolve as new variants or booster campaigns emerge.

The study presents several important implications for programming and policy aimed at improving COVID-19 vaccine acceptance among community key populations living with HIV/AIDS. First, communication strategies must be tailored to the unique concerns of MSM, FSW, and PWID, offering clear guidance on vaccine–ART interactions, side-effect management, and stigma reduction, delivered through trusted channels such as peer educators, social media, and local languages. Integrating vaccination into existing HIV/OSS service points can further enhance access by leveraging established trust and aligning vaccination with ART refill schedules to reduce missed opportunities. Peer-led, community-driven approaches in which trained community key-population members act as vaccine champions can also help dispel rumours, normalise vaccination, and reach hidden networks. At the structural level, governments and partners should ensure uninterrupted vaccine supply, transparent allocation, and the removal of informal fees, while mobile outreach and transportation support address geographic and financial barriers. Additionally, reducing stigma by providing ongoing healthcare worker training on confidentiality, diversity, and non-discrimination is essential for inclusive service delivery. Finally, building public trust through consistent government communication, open sharing of vaccine safety information, and visible accountability is critical to countering disbelief and fostering confidence in vaccination initiatives.

This study provided a nuanced understanding of COVID-19 vaccine hesitancy among community key populations. Five themes and 15 sub-themes were identified. “I didn’t believe it was real” reflects a spectrum of disbelief, fear, and mistrust shaped by misinformation, stigma, and systemic inequities. Importantly, vaccine hesitancy was not rooted in ignorance or apathy but emerged from historical and ongoing exclusion from formal health systems. Integrating vaccination services into existing HIV/OSS care platforms is essential for improving accessibility and uptake among key populations. In addition, tailored and culturally sensitive education campaigns should be developed to address the specific concerns of key populations.