Identifying Implementation Gaps in the HIV Prevention Cascade Among Peruvian Men Who Have Sex with Men

Abstract Background In Peru, HIV remains highly concentrated among men who have sex with men (MSM), yet PrEP uptake remains suboptimal despite expanded access through the public health system. This study examined implementation gaps in the HIV prevention cascade among MSM during the early onset of rollout of free PrEP. Methods Between June and August 2023, an online survey was conducted among Peruvian MSM. The survey included items on socio-demographics, recent sexual behavior, and PrEP-related knowledge, beliefs, and self-efficacy. Progression through the HIV prevention cascade was assessed, and co-variables were grouped according to the Behavioral Model for Vulnerable Populations. Descriptive statistics and multivariable logistic regression identified correlates of the two largest cascade gaps: seeking PrEP and initiating PrEP. Results Among 381 MSM eligible for PrEP, the largest drop-offs occurred between readiness and seeking PrEP (82.9% vs. 34.6%) and between seeking and initiating PrEP (34.6% vs. 19.2%). PrEP-seeking was positively associated with older age, access to actionable PrEP information, self-efficacy, prior HIV PEP use, inconsistent condom use, and recent STI history. PrEP initiation was associated with self-efficacy, higher income, and access to information. Positive beliefs about PrEP were negatively associated with initiation, and cost concerns were negatively associated with PrEP-seeking but not initiation. Conclusions Despite the national rollout of free PrEP, major gaps persist along the HIV prevention cascade. Awareness and interest alone have not translated into uptake. Addressing informational barriers, reinforcing self-efficacy, and strengthening enabling resources through digital strategies and mHealth interventions will be critical to improving PrEP engagement among MSM.