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

Despite expansion of publicly funded HIV pre-exposure prophylaxis (PrEP) in Peru, uptake remains limited. We conducted a cross-sectional online survey (June-August 2023) among 463 men who have sex with men eligible for PrEP to examine progression across the PrEP cascade and identify implementation-relevant determinants of PrEP seeking and initiation. Although 78.6% reported readiness to start PrEP, only 30.5% had sought PrEP and 17.3% had ever initiated. Exploratory factor analysis identified five implementation-related constructs, including actionable PrEP knowledge, self-efficacy, action planning, social support, and cost concerns. In stage-specific multivariable models, higher actionable PrEP knowledge was strongly associated with seeking PrEP (aOR 4.01, 95% CI 2.61-6.33) and initiation (aOR 3.17, 95% CI 1.52-7.01). Higher income was also associated with initiation. Substantial implementation gaps exist between readiness and uptake. Multi-level strategies that strengthen meaningful knowledge delivery and reduce structural barriers may improve PrEP cascade progression in Peru.