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

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Gallardo-Cartagena, David Oliveros, Robinson Cabello, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7843241/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version 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. Infectious Diseases Preventive Medicine HIV prevention Pre-exposure prophylaxis (PrEP) Men who have sex with men (MSM) Implementation science Health behavior Peru Figures Figure 1 Figure 2 Introduction Despite global progress in HIV prevention, HIV remains a critical public health issue in Peru, where new HIV diagnoses have increased by 81% between 2010 and 2023 [ 1 , 2 ]. Sexual and gender minorities bear a disproportionate burden of HIV, with prevalence estimated at 10% among men who have sex with men (MSM) and 30% among transgender women [ 3 ]. Furthermore, HIV incidence among MSM in Peru exceeds 5 per 100 person-years, making it one of the highest in the Americas [ 4 , 5 ]. These figures underscore the urgency of strengthening HIV prevention strategies tailored to key populations in Peru. HIV pre-exposure prophylaxis (PrEP), using either daily or event-driven emtricitabine/tenofovir disoproxil fumarate (F/TDF), is highly effective in preventing HIV transmission among MSM [ 6 , 7 ]. However, PrEP uptake and consistent use remains limited—particularly in Peru, where access through the public health system has only recently expanded [ 8 ]. Although F/TDF for HIV PrEP was approved by the Peruvian FDA in 2016, access was initially restricted to a few private providers or via demonstration projects. One such project, ImPrEP, was a large-scale demonstration project conducted between 2018 and 2021 across Brazil, Mexico, and Peru. In Peru, ImPrEP enrolled 2,293 MSM at 10 public primary health centers managed by the Peruvian Ministry of Health (MoH). Notably, only 63% of Peruvian MSM participants were actively seeking PrEP at enrollment, with lower adherence levels and higher discontinuation rates relative to their Brazilian and Mexican counterparts [ 9 ]. In June 2023, the Peruvian MoH integrated daily and event-driven F/TDF into its Combination HIV Prevention guidelines and began providing PrEP for free through select primary health centers nationwide [ 10 ]. Despite this policy advancement, concerns persist regarding slow uptake [ 3 , 8 ] and persistent implementation gaps across multiple stages of the HIV prevention cascade in Peru. These challenges highlight the need to further investigate the structural and behavioral factors limiting PrEP uptake and adherence in real-world settings. To bridge these gaps, it is essential to identify opportunities that can inform human-centered implementation strategies. The Behavioral Model for Vulnerable Populations provides a useful conceptual framework for understanding structural and individual-level factors that influence health-seeking behaviors and healthcare utilization among MSM [ 11 – 13 ]. This model outlines how predisposing factors (demographics, social structure, and health beliefs), enabling factors (personal, family, and community resources), and need factors (perceived and evaluated risk of HIV acquisition) shape engagement with the HIV prevention cascade. Understanding these determinants is critical for designing context-specific, person-centered interventions that support PrEP initiation, adherence, and retention in care [ 14 – 16 ]. Building on this framework, our study examined how these factors influence progression across key stages of the HIV prevention cascade among MSM in Peru. By analyzing data collected during the early phase of the national PrEP rollout, we aimed to generate evidence to guide the development of tailored, human-centered approaches that can improve PrEP uptake and implementation in real-world settings. Methods Study design We conducted a cross-sectional online survey between June and August, 2023 to assess the HIV prevention cascade among Peruvian MSM. The survey explored socio-demographics, sexual history (number of anal sex partners, frequency of condom use, partner’s HIV status, engagement in commercial sex, and STI diagnosis) in the past 6 months, as well as HIV and PrEP-related beliefs. We included questions designed to situate participants across key stages in the HIV prevention cascade (being eligible for PrEP, deciding to start PrEP, seeking PrEP, initiating PrEP and adhering to PrEP). The survey consisted of 29 multiple-choice and Likert-scale questions. Respondents were recruited through paid Meta ads (Instagram and Facebook) and geosocial networking apps (Grindr). Paid ads targeted individuals aged > 18 years residing in Peru. Respondents could access the survey via a secure URL link on an internet-connected electronic device. Electronic informed consent was obtained before respondents could start the survey. The consent form clearly stated that the survey was intended for adult MSM living in Peru, and by accepting the consent, respondents confirmed this self-identification. Responses were anonymous to protect participant confidentiality. Respondents were able to skip any questions they did not wish to answer. Participants were excluded from the analysis if they provided no responses, self-reported living with HIV, were assigned female at birth, identified as transgender or gender non-binary, or reported no history of anal sex. Incomplete responses were also excluded from this analysis. The final analytical sample was limited to individuals who completed the full survey and met eligibility criteria for PrEP, as defined below. PrEP eligibility PrEP eligibility was assessed based on criteria outlined in the Peruvian Combination HIV Prevention guidelines [ 10 ]. Participants were considered eligible if they reported any of the following in the past 6 months: having two or more sexual partners, engaging in any condomless sex, receiving a syndromic or etiologic diagnosis of a bacterial sexually transmitted infection (STI), requesting HIV post-exposure prophylaxis (HIV PEP), or having an HIV-positive partner who was not on treatment or had an unsuppressed viral load. The HIV Prevention Cascade in Peru All respondents were first provided with a brief explanation of key PrEP-related concepts through a short summary. This summary covered essential topics such as “What is PrEP?”, “How effective is PrEP?”, “Who should use PrEP?”, “What is required to take PrEP?”, “Where can PrEP be accessed in Peru?”. After reviewing the summary, respondents were presented with questions to assess their progression along the PrEP Cascade. These questions were adapted for the Peruvian context from those of the Motivational PrEP Cascade developed by Parsons et al [ 17 ], as follows: Decided to start PrEP : Respondents were asked “Have you decided to start PrEP?” , with responses on a 5-point Likert scale ranging from “Definitely no” to “Definitely yes” . Sought PrEP : Respondents were asked “Have you ever discussed starting PrEP with a physician in a primary health center currently offering PrEP?” , with response options of “Yes” or “No” . Ever initiated PrEP : Respondents were asked “Have you ever started PrEP?” , with possible answers of “Yes, I’m currently on PrEP” , “Yes, but I’m not currently on PrEP” , or “No” . Adherent to PrEP : Only respondents who reported having ever started PrEP were asked “In the past month (30 days). How many PrEP doses did you miss?” , with response on a numeric scale from 0–30. To be considered as having “reached” a particular stage in the cascade, respondents needed to select 'Yes' for yes/no questions or 'Probably yes'/'Definitely yes' on the Likert scale questions. For adherence, respondents were classified as “adherent” if they reported missing 13 or fewer doses in the past month, or the equivalent of taking at least four PrEP doses per week. Participants were not required to meet criteria for earlier stages to be counted in later ones, with the exception of adherence, which was only assessed among those who had initiated PrEP. Exploratory factor analysis To identify latent constructs related to participants’ knowledge, attitudes, and experiences with PrEP, we conducted an exploratory factor analysis (EFA) as a data reduction strategy and to inform subsequent regression modeling [ 18 ]. We analyzed 19 survey items focused on these constructs. Prior to the EFA, we assessed the suitability of the dataset by calculating the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy for factor analysis and performing Bartlett’s test of sphericity [ 19 ]. We used principal axis factoring with Promax (oblique) rotation, as we expected the factors to be correlated. The number of factors retained was determined based on eigenvalues > 1.0, scree plot inspection, parallel analysis, and conceptual interpretability. The EFA was conducted as a two-stage process: first to identify key constructs embedded in the large pool of interrelated items, and second to generate composite scores representing distinct, modifiable themes related to PrEP implementation. These composite scores were subsequently used in regression models. Statistical analysis Descriptive statistics were used to summarize sample characteristics and construct the HIV Prevention Cascade. Co-variables were mapped onto domains of the Behavioral Model for Vulnerable Populations (Fig. 1 ). The outcomes of interest were the largest implementation gaps in the cascade, defined as the stages with the greatest percentage drop-off relative to the preceding stage and representing the most programmatically actionable stages for intervention. Univariate and multivariable logistic regression models were fitted to examine associations between co-variables and each outcome, comparing participants who reached the stage to those who did not, within the full sample of PrEP-eligible individuals. A forward selection approach was used to build the final multivariable models, based on the lowest Aikake Information Criterion (AIC) value. Results are reported as odds ratios (ORs) and adjusted odds ratios (aORs) with corresponding 95% confidence intervals (CIs). All analyses were conducted in R (version 4.3.1). Results Determination of analytical sample Among the 1,609 participants who consented to participate in the study, 837 (52%) individuals were initially excluded: 270 provided no responses, 253 self-reported having HIV, 22 were assigned female at birth, 29 identified as transgender or gender non-binary, and 236 reported no anal sex. Of the remaining 772 individuals, 240 submitted only partial responses limited to socio-demographic data. Individuals with incomplete responses were slightly younger (median age: 28.0 years [IQR: 22.0–33.0] vs. 29.0 years [IQR: 24.0–35.0], p = 0.001) and less likely to reside in Lima or Callao (58.3% vs. 71.4%, p < 0.001) than participants with complete responses. No significant differences were observed in income, education level, or other key variables. Among the 532 individuals with full responses, 214 (40%) did not meet PrEP eligibility criteria. The final analytical sample consisted of 381 MSM eligible for PrEP. Characteristics of MSM identified as eligible for PrEP The median age in the analytical sample was 29 years (IQR: 25–35), with 293 (76.9%) aged 25 years or older. Most participants had completed post-secondary education (78.7%, n = 300), resided in Lima or the nearby city of Callao (75.1%, n = 286). A majority (68.8%, n = 262) reported a monthly income below 2,000 PEN (~ US $ 550, approximately twice the minimum wage) [ 20 ]. In the past six months, 228 (59.8%) reported five or fewer anal sex partners, while condomless anal intercourse was highly prevalent (91.3%, n = 348). A total of 249 (65.4%) reported recent sexual activity with partners of unknown HIV status or with known unsuppressed HIV. A suspected or diagnosed bacterial STI was reported by 159 (41.7%). Most participants either perceived themselves to be at risk for HIV or were unsure (79.8%, n = 304). While PrEP awareness was high (91.6%, n = 349), fewer participants knew where to obtain PrEP and the steps required to access it (53.3%, n = 203), and 252 (66.1%) reported knowing someone in their social network who was using PrEP. Results of the exploratory factor analysis To distill key constructs from the 19 items assessing participants’ knowledge, attitudes, and experiences with PrEP, we conducted an EFA as described in the Methods. The data were well-suited for factor analysis (KMO = 0.93; Bartlett’s test p < 0.001), and principal axis factoring with Promax rotation was applied. A four-factor model was selected as the best representation of the data (Table 1 ). The final factor structure included the following themes: Positive attitudes & beliefs towards PrEP (8 items, Cronbach’s α = 0.90) – This factor captured participants' perceived benefits of PrEP, its acceptability, and the social support surrounding its use. Items included statements about feeling better while taking PrEP, believing it provides protection for both themselves and their partners, and perceiving social support for PrEP use. PrEP self-efficacy (4 items, Cronbach’s α = 0.92) – This factor reflected participants' confidence in their ability to take PrEP consistently, manage daily adherence, and attend required medical visits. Access to information about PrEP (5 items, Cronbach’s α = 0.74) – This factor encompassed participants' prior knowledge about PrEP, their awareness of access points in Peru, and their efforts to seek additional information. Cost concerns related to PrEP (2 items, Cronbach’s α = 0.82) – This factor captured concerns about financial barriers, including the cost of PrEP pills and required medical exams. Table 1 Exploratory factor analysis of PrEP-related survey items a (N = 381) Survey items Positive attitudes & beliefs towards PrEP PrEP self-efficacy Access to information about PrEP Cost concerns related to PrEP "I could use alarms or reminders to help me take PrEP." 0.8 "I could adapt my daily routine in a way that makes it easier for me to take PrEP." 0.8 "My sexual partner(s) would appreciate it if I used PrEP." 0.8 "I would feel better about myself if I took PrEP every day." 0.8 "I think that by using PrEP, I can also protect my partner(s) from HIV." 0.7 "I think that PrEP can help me stay protected against HIV." 0.6 "People close to me would support me in using PrEP." 0.6 "I think that using PrEP is something currently accepted by society." 0.5 "I believe I could take PrEP for a long time." 0.8 "I feel capable of taking a daily PrEP pill." 0.8 "I feel capable of attending appointments to receive the PrEP pills." 0.7 "I think taking PrEP is good for me, rather than being a burden." 0.7 "Before today, I already knew how and where to access PrEP in Peru." 0.7 "I know other people who are taking PrEP." 0.7 "I have searched for information online or asked other people about PrEP." 0.5 "I believe I have enough information to decide whether or not to start PrEP." 0.5 "Before today, I had already read or heard that PrEP can protect me from HIV." 0.3 "I am concerned about the cost of PrEP pills." 0.8 "I am concerned about the cost of the medical exams required to take PrEP." 0.8 a. Factor loadings < 0.30 are not displayed for clarity. Items were grouped based on the highest loading on a given factor. Composite scores were calculated by summing item responses within each factor, with all items scored on a 0–4 scale. Higher scores indicated stronger agreement or greater presence of the underlying construct. The possible score ranges were 0 to 32 for Positive attitudes & beliefs towards PrEP , 0 to 16 for PrEP self-efficacy , 0 to 20 for Access to information about PrEP , and 0 to 8 for Cost concerns related to PrEP . Across the full analytic sample, composite scores from the four EFA-derived factors reflected high motivation alongside persistent informational and structural barriers. Positive attitudes & beliefs towards PrEP were strong (median: 29.0, IQR: 25.0–32.0 out of 32), indicating broadly favorable perceptions. PrEP self-efficacy was also high (median: 16.0, IQR: 13.0–16.0 out of 16), suggesting participants felt confident in their ability to initiate and adhere to PrEP. In contrast, Access to information about PrEP showed greater variability (median: 16.0, IQR: 14.0–18.0 out of 20), pointing to uneven levels of practical knowledge, information-seeking behavior, and perceived readiness to act. Cost Concerns were high overall (median: 8.0, IQR: 6.0–8.0 out of 8), suggesting ongoing misconceptions or lack of clarity around the costs associated with PrEP, despite its availability free of charge through the public health system. The HIV Prevention Cascade and Implementation Gaps: Interest in PrEP was high, with 341 (89.5%) expressing willingness to use it, 322 (84.5%) self-identifying as good candidates based on the PrEP summary provided, and 316 (82.9%) were ready to initiate PrEP. However, only 154 (40.4%) participants knew of a clinic likely to offer PrEP, and only 132 (34.6%) had ever sought it. Ultimately, 73 participants (19.2%) reported ever initiating PrEP, and only 30 (7.9%) were currently using at least four PrEP doses per week and were classified as adherent to daily oral PrEP. The two most relevant implementation gaps in the HIV prevention cascade involve the transition from deciding to start PrEP to actively seeking PrEP, and from seeking PrEP to actual PrEP uptake (Fig. 2 ). Notably, among those who had ever initiated daily oral PrEP, adherence over the past 30 days remained suboptimal, with only 30 of 73 (41.1%) reporting current use of at least four doses per week. Correlates of PrEP seeking and PrEP initiation Comparisons between different sub-groups are included in Table 2 . Compared to those who had never sought PrEP, individuals who had sought PrEP were more likely to be older (84.1% vs. 73.1% aged ≥ 25, p = 0.015), live in Lima or Callao (82.6% vs. 71.1%, p = 0.018), and report higher positive beliefs and attitudes towards PrEP (median: 31.0 vs. 28.0, p < 0.001), greater access to PrEP information (median: 18.0 vs. 15.0, p < 0.001), and higher self-efficacy (median: 16.0 vs. 15.0, p < 0.001). Individuals who had sought PrEP were also more likely to have requested HIV PEP (19.7% vs. 5.2%, p < 0.001). Similar patterns were observed among those who had ever initiated PrEP versus those who had not. PrEP initiators had higher rates of post-secondary education (87.7% vs. 72.4%, p = 0.039), lived more frequently in Lima or Callao (86.3% vs. 74.1%, p = 0.015), and had greater access to PrEP information (median: 19.0 vs. 15.0, p < 0.001). They also reported higher self-efficacy (median: 16.0 vs. 16.0, with tighter IQRs among initiators, p < 0.001), and were more likely to report incomes ≥ 2,000 soles (45.2% vs. 27.9%, p = 0.005). Prior HIV PEP use was more common among PrEP initiators (17.8% vs. 8.4%, p = 0.029). Table 2 Characteristics of respondents eligible for PrEP (N = 381), organized by domains of the Behavioral Model for Vulnerable Populations, and stratified by the two largest gaps in the HIV Prevention Cascade Sought PrEP Ever initiatied PrEP Yes, n = 132 No, n = 249 p-value a Yes, n = 73 No, n = 308 p-value a Predisposing Factors Age, years b 29.0 (26.0–34.0) 29.0 (24.0–36.0) 30.0 (26.0–35.0) 29.0 (25.0–35.0) Age category * < 25 years 21 (15.9%) 67 (26.9%) 13 (17.8%) 75 (24.4%) ≥ 25 years 111 (84.1%) 182 (73.1%) 60 (82.2%) 233 (75.6%) Education level * < Post-secondary 21 (15.9%) 60 (24.1%) 9 (12.3%) 72 (23.4%) Post-secondary 111 (84.1%) 189 (75.9%) 64 (87.7%) 223 (72.4%) City of residence * * Other provinces 23 (17.4%) 72 (28.9%) 10 (13.7%) 85 (27.6%) Lima & Callao 109 (82.6%) 177 (71.1%) 63 (86.3%) 258 (74.1%) Positive beliefs/attitudes towards PrEP b 31.0 (28.0–32.0) 28.0 (24.0–31.0) *** 31.0 (29.0–32.0) 29.0 (25.0–32.0) ** Enabling Resources Monthly income ** < 2000 soles 86 (65.2%) 176 (70.7%) 40 (54.8%) 222 (72.1%) ≥ 2000 soles 46 (34.8%) 73 (29.3%) 33 (45.2%) 86 (27.9%) Access to information about PrEP b 18.0 (16.0–19.2) 15.0 (13.0–17.0) *** 19.0 (17.0–20.0) 15.0 (13.0–17.0) *** Concerns for associated costs b 7.0 (6.0–8.0) 8.0 (6.0–8.0) * 7.0 (6.0–8.0) 8.0 (6.0–8.0) Need factors in past 6 months Number of anal sex partners ** * ≤ 5 partners 64 (48.5%) 164 (65.9%) 35 (47.9%) 193 (62.7%) > 5 partners 68 (51.5%) 85 (34.1%) 38 (52.1%) 115 (37.3%) Condom use during anal sex Always 8 (6.1%) 25 (10.0%) 6 (8.2%) 27 (8.8%) Inconsistent 124 (93.9%) 224 (90.0%) 67 (91.8%) 281 (91.2%) HIV status of sex partner(s) HIV- or with undetectable HIV 48 (36.4%) 84 (33.7%) 28 (38.4%) 104 (33.8%) Unknown or detectable HIV 84 (63.6%) 165 (66.3%) 45 (61.6%) 204 (66.2%) Self-perception of HIV risk Not at risk 27 (20.5%) 50 (20.1%) 15 (20.5%) 62 (20.1%) At risk or unsure 105 (79.5%) 199 (79.9%) 58 (79.5%) 246 (79.9%) Transactional sex No 103 (78.0%) 214 (85.9%) 60 (82.2%) 257 (83.4%) Yes 29 (22.0%) 35 (14.1%) 13 (17.8%) 51 (16.6%) Any bacterial STI diagnosed No 69 (52.3%) 153 (61.4%) 40 (54.8%) 182 (59.1%) Yes 63 (47.7%) 96 (38.6%) 33 (45.2%) 126 (40.9%) Requested HIV PEP c *** * No 106 (80.3%) 236 (94.8%) 60 (82.2%) 282 (91.6%) Yes 26 (19.7%) 13 (5.2%) 13 (17.8%) 26 (8.4%) PrEP Self-efficacy b 16.0 (15.0–16.0) 15.0 (12.0–16.0) *** 16.0 (16.0–16.0) 16.0 (12.0–16.0) *** a Wilcoxon rank sum test; Pearson's Chi-squared test; Fisher's exact test. b median (IQR). c Post-exposure prophylaxis *p < 0.05. **p < 0.01. ***p < 0.001 Factors associated with seeking PrEP: In multivariable analyses, several factors across the domains of the Behavioral Model for Vulnerable Populations were associated with seeking PrEP (Table 3 ). Among predisposing factors, older age was significantly associated with a greater likelihood of seeking PrEP, while no other variables in this domain remained in the final model. Within the need factors domain, individuals who reported inconsistent condom use, had a recent history of a suspected or diagnosed bacterial STI, or had previously requested HIV PEP were more likely to seek PrEP. Higher self-efficacy was also positively associated with PrEP-seeking behavior. Enabling resources emerged as the most consistent and actionable drivers of PrEP engagement: participants with greater access to actionable PrEP information were significantly more likely to seek PrEP, whereas those reporting higher cost concerns were less likely to do so. Table 3 Factors associated with seeking PrEP among Peruvian MSM eligible for PrEP (N = 381) Unadjusted Adjusted OR 95% CI p-value aOR 95% CI p-value Predisposing Factors Age ≥ 25 years 1.95 1.15–3.42 * 2.10 1.13–4.09 ** Post-secondary education 1.68 0.98–2.96 Lives in Lima or Callao 1.93 1.15–3.32 * Has positive beliefs & attitudes towards PrEP 1.12 1.05–1.19 *** Enabling Resources Monthly income ≥ 2000 soles 1.29 0.82–2.02 Have access to information about PrEP 1.41 1.29–1.55 *** 1.44 1.31–1.60 *** Has concerns for associated costs 0.83 0.70–0.99 * 0.74 0.60–0.91 ** Need factors in past 6 months > 5 partners anal sex partners 2.05 1.33–3.16 ** Inconsistent condom use during anal sex 1.73 0.79–4.20 3.84 1.50–10.93 ** Partner(s) of unknown HIV status / detectable HIV 0.89 0.57–1.39 Self-perceived at risk for HIV 0.98 0.58–1.67 Transactional sex 1.72 0.99–2.97 1.73 0.90–3.33 Any bacterial STI diagnosed 1.46 0.95–2.23 1.93 1.15–3.24 * Requested HIV post-exposure prophylaxis 4.45 2.24–9.26 *** 4.25 1.92–9.90 *** PrEP Self-efficacy 1.19 1.07–1.33 ** *p < 0.05. **p < 0.01. ***p < 0.001 Factors associated with initiating PrEP: In multivariable analyses, fewer variables were significantly associated with PrEP initiation compared to the earlier stage of seeking PrEP (Table 4 ). Within predisposing factors, positive beliefs and attitudes toward PrEP exhibited a negative association in the adjusted model, suggesting that while favorable perceptions are common, they may not sufficiently drive initiation in the absence of other enabling conditions. Within the need factors domain, higher PrEP self-efficacy was positively associated with initiation, underscoring its role in facilitating the transition from intention to action. Enabling resources once again emerged as key drivers of progression in the HIV prevention cascade. Individuals with higher income and greater access to PrEP-related information were significantly more likely to have initiated PrEP. Table 4 Factors associated with initiating PrEP among Peruvian MSM eligible for PrEP (N = 381) Unadjusted Adjusted OR 95% CI p-value aOR 95% CI p-value Predisposing Factors Age ≥ 25 years 1.49 0.79–2.96 Post-secondary education 2.17 1.08–4.87 * Lives in Lima or Callao 2.40 1.23–5.17 * Has positive beliefs & attitudes towards PrEP 1.15 1.06–1.25 ** 0.84 0.73–0.96 * Enabling Resources Monthly income ≥ 2000 soles 2.13 1.26–3.60 ** 2.15 1.19–3.90 * Have access to information about PrEP 1.53 1.36–1.74 *** 1.55 1.35–1.81 *** Has concerns for associated costs 0.96 0.78–1.18 Need factors in past 6 months > 5 partners anal sex partners 1.82 1.09–3.06 * Inconsistent condom use during anal sex 1.07 0.45–2.97 Partner(s) of unknown HIV status / detectable HIV 0.82 0.49–1.40 Self-perceived at risk for HIV 0.97 0.53–1.89 Transactional sex 1.09 0.54–2.08 Any bacterial STI diagnosed 1.19 0.71–1.99 Requested HIV post-exposure prophylaxis 2.35 1.11–4.77 * PrEP Self-efficacy 1.48 1.24–1.82 *** 1.50 1.17–1.99 ** *p < 0.05. **p < 0.01. ***p < 0.001 Discussion This study is the first to examine factors associated with key stages of the PrEP prevention cascade among MSM in Peru, offering insights into implementation gaps during the initial phase of the national rollout of free PrEP. Consistent with findings from other settings [ 21 – 23 ], we observed high levels of awareness and interest in PrEP. Nonetheless, substantial drop-offs in seeking and initiating PrEP were identified, pointing to missed opportunities for better implementation. By organizing findings according to the Behavioral Model for Vulnerable Populations, we identified actionable predisposing, enabling, and need-related factors that inform targeted implementation strategies. Our findings highlight that a lack of practical, actionable information, such as where and how to obtain PrEP, is a major barrier to uptake. While PrEP awareness was high, only one-third of participants had ever sought it, and less than one in five had initiated it. These findings point to the urgent need for patient-centered strategies that directly address this information gap. While access to information was a key enabler of both seeking and initiating PrEP, our findings show that not all positive perceptions translate into action. For example, although favorable beliefs about PrEP were widely endorsed, they were not significantly associated with uptake after seeking PrEP, and in adjusted models, were inversely associated with PrEP initiation. This highlights a gap between motivation and follow-through, reinforcing the need for strategies that not only educate but also facilitate decision-making, reduce friction in service navigation, and support the behavioral shift from intention to action. Lingering cost concerns were negatively associated with seeking PrEP, suggesting that perceived financial barriers may still deter individuals from engaging with PrEP services in the first place. In addition, higher income was positively associated with PrEP initiation. Although this may reflect earlier access to PrEP through private providers prior to the public rollout, it nonetheless points to structural inequities in who is most likely to navigate the PrEP cascade. These findings underscore the need for equity-focused implementation efforts and improved communication strategies to correct cost-related misconceptions, especially given that PrEP is now available free of charge through the public health system. A human-centered implementation research approach is essential to understanding and addressing the complex and context-specific barriers that hinder PrEP uptake among MSM in Peru. Unlike top-down interventions, human-centered strategies begin with the perspectives, needs, and lived experiences of end-users [ 24 ], including potential PrEP users, current clients, and healthcare providers. This approach recognizes that MSM in Peru often face overlapping barriers such as stigma, discrimination, fear of being outed, and logistical constraints like long wait times or lack of privacy in clinics [ 25 – 28 ]. By involving users in the design and iteration of solutions, human-centered approaches foster trust, improve usability, and ensure that interventions are aligned with real-world needs. Human-centered approaches, particularly low-intensity social media campaigns (SMCs), are well-suited to reach younger MSM who are less engaged in traditional health systems. In this study, we were able to reach over 1,600 MSM in just a few weeks through online outreach alone, underscoring the potential of digital platforms to rapidly connect with key populations. Prior studies show that targeted SMCs can effectively increase awareness and uptake of clinical services, especially when messages are culturally tailored, platform-specific, and delivered by peer influencers [ 29 – 32 ]. In Peru, access to the internet and smartphones have increased substantially over the past decade [ 33 ]. As of 2023, nearly all young MSM report access to both [ 34 , 35 ], with their primary digital environments including Whatsapp, Instagram, Facebook, sex-partnering apps, YouTube, and TikTok—offering key opportunities for strategic messaging. A national SMC that clearly communicates that PrEP is available free of charge through the public health system, along with information on eligibility, where to access services (e.g., a PrEP clinic locator with hours of operation), and any associated requirements, such as lab tests or follow-up visits, could directly address the core informational barriers and cost-related misconceptions identified in this study. These strategies align with the Expert Recommendations for Implementing Change (ERIC), such as “distribute educational materials” and “use mass media,” and could be enhanced by including peer-driven testimonials and real-time Q&A through WhatsApp or chatbot platforms [ 36 – 38 ]. Beyond awareness, individual-level enablers such as PrEP self-efficacy and prior experience with HIV prevention (e.g., PEP use) were positively associated with PrEP uptake, indicating that digital decision-support tools (DSTs) that describe PrEP options and how to access care could reinforce motivation and help translate intention into action [ 39 – 42 ]. Such DSTs might include PrEP decision aids, which have been found to be successful elsewhere [ 43 , 44 ]. Integration of such tools into mHealth platforms, like the JomPrEP app in Malaysia, has shown promise to increase the uptake of PrEP [ 45 , 46 ]. These tools also offer potential for supporting adherence once PrEP is initiated, but may be especially valuable in helping users translate high motivation into actual uptake, particularly among those who have already engaged with health services but face uncertainty or concerns about navigating the logistics of receiving PrEP. At the clinical and system level, our findings also suggest a mismatch between demands on patients and providers and the healthcare system’s capacity to deliver. This mismatch is particularly evident in the second major drop-off of the cascade—between seeking and initiating PrEP—where readiness alone was insufficient. Even when individuals had discussed PrEP with a provider, the lack of progression may reflect system-level barriers, such as limited provider time, inadequate follow-up processes, or unclear pathways to initiation. This underscores the need not only to create demand through patient-centered interventions, but also to promote enabling conditions within the health system to absorb and sustain that demand. Strengthening provider capacity, clinic workflows, and service delivery infrastructure will be essential to closing the gaps observed in the PrEP cascade. As PrEP awareness and motivation grow, especially among MSM with higher self-efficacy and access to information, health systems must be prepared to respond effectively and equitably. To this end, ERIC implementation strategies, such as audit and feedback and educational meetings, can help address barriers related to provider knowledge, competing priorities, and workflow inefficiencies [ 47 , 48 ]. Incorporating these strategies into Peru’s national PrEP rollout could reinforce provider engagement and alignment with updated PrEP protocols. For instance, audit and feedback can be used to highlight missed opportunities for PrEP counseling and initiation, while educational meetings can provide structured, evidence-based training for providers to build confidence and competence in PrEP delivery. More intensive strategies, such as guided facilitation and practice transformation approaches, should also be considered in high-volume clinics [ 49 ]. These strategies, which include collaborative learning, workflow redesign, and coaching, are especially effective when layered with lower-intensity interventions. Differentiated PrEP delivery models, such as community-based initiation, telehealth, pharmacy pick-up, or multi-month dispensing, can further enhance accessibility and retention by reducing logistical barriers. As interest in PrEP grows among MSM, these adaptations will be key to ensuring that health services are not only available, but also responsive, person-centered, and scalable. Limitations Despite its many important findings, this analysis has limitations. First, reliance on self-reported data may have introduced recall and social desirability biases, particularly in responses related to sexual behaviors, PrEP use, and healthcare engagement. Second, the cross-sectional nature of the analysis precludes causal inference between individual-level factors and PrEP-seeking or initiation behaviors. Third, although the sample includes a diverse group of MSM, it was largely urban and recruited online, potentially limiting generalizability to rural or more marginalized populations who may face different structural barriers or have lower levels of internet access. It is important to note, however, that Peru’s HIV epidemic among MSM is primarily concentrated in urban areas, where internet penetration is high. In addition, while data were collected during the very initial rollout phase of the national PrEP program (July–August 2023), public awareness and service delivery were still in early development and may not reflect the intended scale of PrEP access. As of February 2025, PrEP is available at 120 public primary health centers nationwide; however, uptake remains critically low, with only an estimated 4,000 MSM receiving PrEP, representing less than 3% of the approximately 140,000 who could benefit from its use. Notably, use is still heavily concentrated in Lima and Callao, which account for approximately 80–85% of these MSM users. This persistently low uptake highlights that the barriers identified in our study remain highly relevant and continue to limit the reach and impact of the national PrEP program. Finally, transgender women were not included in the analysis due to small numbers in the sample. While this limitation was necessary to maintain analytic clarity, it is important to acknowledge that transgender women represent a distinct population with unique health needs and structural barriers that warrant focused study and tailored interventions [ 50 ]. As of February 2025, fewer than 200 transgender women in Peru had initiated PrEP, further underscoring the need for dedicated research and programmatic attention. Future Directions Future research should prioritize longitudinal studies to better understand transitions across the PrEP cascade and the sustainability of PrEP use over time. Additionally, implementation science research is needed to evaluate the real-world impact of tailored, human-centered interventions, including digital tools, social media campaigns, and differentiated service delivery models. By addressing both structural and behavioral barriers identified in this study, Peru can enhance the effectiveness of its national PrEP program and extend its reach to MSM who remain underserved. Conclusions Despite high levels of interest and willingness to use PrEP among MSM in Peru, our analysis of the HIV Prevention Cascade reveals substantial implementation gaps. While 82.9% of participants expressed readiness to initiate PrEP, only 34.6% had ever sought it, and just 19.2% had initiated use, underscoring critical barriers to PrEP engagement. Informational barriers remain a key obstacle to PrEP engagement, particularly in the early stages of the cascade. However, our findings also underscore that motivation and awareness do not guarantee uptake: actionable knowledge, psychological readiness, and system navigation support are equally essential for helping individuals move from intention to initiation. These findings indicate that national availability of PrEP through the public health system is not sufficient on its own to drive meaningful uptake, as evidenced by the fact that, more than a year into the rollout, fewer than 3% of MSM who could benefit are currently receiving it. To close the gaps identified along the PrEP cascade, implementation strategies must be both targeted and multi-level. Beyond addressing awareness, strategies must support users in translating intention into behavior through digital outreach, social media campaigns, decision-support tools, and person-centered service navigation. At the same time, system-level adaptations, including audit and feedback, educational outreach to providers, and differentiated service delivery, will be essential to strengthen clinical readiness and ensure that individuals who express interest are supported through to PrEP initiation. By aligning these strategies with the ERIC framework and prioritizing human-centered design, Peru can optimize its PrEP program and make meaningful progress toward its HIV prevention goals. Declarations Funding: The authors did not receive support from any organization for the submitted work. Competing interests: The authors have no competing interests to declare that are relevant to the content of this article. Ethics approval: The study protocol, survey, and informed consent were approved by the Via Libre Bioethics Committee (Approval No. 9008, 2023a). Consent to participate: Informed consent was obtained from all individual participants included in the study. Ackowledgments: We thank David Velásquez, Hugo Sánchez, María del Rosario (MaR) León, Felipe Vilcachagua, Yamir Salazar, and José Luis Castro of the Community Engagement Team at the Peru Clinical Trials Unit (CTU) for their invaluable support. We are also grateful to Patricia Alarcón and Dora Germán for their coordination efforts. Finally, we extend our sincere thanks to all study participants for their time and contributions. Data Sharing: Research data can be made available upon reasonable request References Ministerio de Salud del Perú, Centro Nacional de Epidemiología, Prevención y Control de Enfermedades (CDC MINSA). Situación epidemiológica del VIH-SIDA en el Perú n.d. https://www.dge.gob.pe/vih/uploads/nacional_vih.html (accessed November 13, 2024). Nachega JB, Musoke P, Kilmarx PH, Gandhi M, Grinsztejn B, Pozniak A, et al. Global HIV control: is the glass half empty or half full? Lancet HIV 2023;10:e617–22. https://doi.org/10.1016/S2352-3018(23)00150-9. UNAIDS. Perú - Country Factsheets (2023) n.d. https://www.unaids.org/es/regionscountries/countries/peru (accessed November 13, 2024). Torres TS, Teixeira SLM, Hoagland B, Konda KA, Derrico M, Moreira RI, et al. Recent HIV infection and annualized HIV incidence rates among sexual and gender minorities in Brazil and Peru (ImPrEP seroincidence study): a cross-sectional, multicenter study. Lancet Reg Health Am 2023;28:100642. https://doi.org/10.1016/j.lana.2023.100642. Corey L, Gilbert PB, Juraska M, Montefiori DC, Morris L, Karuna ST, et al. Two Randomized Trials of Neutralizing Antibodies to Prevent HIV-1 Acquisition. N Engl J Med 2021;384:1003–14. https://doi.org/10.1056/NEJMoa2031738. Fonner VA, Dalglish SL, Kennedy CE, Baggaley R, O’Reilly KR, Koechlin FM, et al. Effectiveness and safety of oral HIV preexposure prophylaxis for all populations. AIDS Lond Engl 2016;30:1973–83. https://doi.org/10.1097/QAD.0000000000001145. Chou R, Evans C, Hoverman A, Sun C, Dana T, Bougatsos C, et al. Preexposure Prophylaxis for the Prevention of HIV Infection: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2019;321:2214–30. https://doi.org/10.1001/jama.2019.2591. Menacho L, Konda KA, Lecca L, Cabello R, Lankowski A, Benites C, et al. Optimising PrEP uptake and use in Peru: no time to lose! Lancet HIV 2024;11:e204–6. https://doi.org/10.1016/S2352-3018(24)00038-9. Veloso VG, Cáceres CF, Hoagland B, Moreira RI, Vega-Ramírez H, Konda KA, et al. Same-day initiation of oral pre-exposure prophylaxis among gay, bisexual, and other cisgender men who have sex with men and transgender women in Brazil, Mexico, and Peru (ImPrEP): a prospective, single-arm, open-label, multicentre implementation study. Lancet HIV 2023;10:e84–96. https://doi.org/10.1016/S2352-3018(22)00331-9. Ministerio de Salud del Perú. Norma Técnica de Salud “ Prevención Combinada del Virus de la Inmunodeficiencia Humana para Poblaciones en Alto Riesgo” 2023. Gelberg L, Andersen RM, Leake BD. The Behavioral Model for Vulnerable Populations: application to medical care use and outcomes for homeless people. Health Serv Res 2000;34:1273–302. Small LFF. Use of Mental Health Services among People with Co-Occurring Disorders and other Mental Health co-morbidities: Employing the Behavioral Model of Vulnerable Populations. Ment Health Subst Use Dual Diagn 2010;3:81–93. https://doi.org/10.1080/17523281003717871. Babitsch B, Gohl D, von Lengerke T. Re-revisiting Andersen’s Behavioral Model of Health Services Use: a systematic review of studies from 1998-2011. Psycho-Soc Med 2012;9:Doc11. https://doi.org/10.3205/psm000089. Chen NE, Meyer JP, Avery AK, Draine J, Flanigan TP, Lincoln T, et al. Adherence to HIV treatment and care among previously homeless jail detainees. AIDS Behav 2013;17:2654–66. https://doi.org/10.1007/s10461-011-0080-2. Maru DS-R, Bruce RD, Walton M, Mezger JA, Springer SA, Shield D, et al. Initiation, adherence, and retention in a randomized controlled trial of directly administered antiretroviral therapy. AIDS Behav 2008;12:284–93. https://doi.org/10.1007/s10461-007-9336-2. Krishnan A, Wickersham JA, Chitsaz E, Springer SA, Jordan AO, Zaller N, et al. Post-release substance abuse outcomes among HIV-infected jail detainees: results from a multisite study. AIDS Behav 2013;17 Suppl 2:S171-180. https://doi.org/10.1007/s10461-012-0362-3. Parsons JT, Rendina HJ, Lassiter JM, Whitfield THF, Starks TJ, Grov C. Uptake of HIV Pre-Exposure Prophylaxis (PrEP) in a National Cohort of Gay and Bisexual Men in the United States. J Acquir Immune Defic Syndr 1999 2017;74:285–92. https://doi.org/10.1097/QAI.0000000000001251. Fabrigar LR, Wegener DT, MacCallum RC, Strahan EJ. Evaluating the use of exploratory factor analysis in psychological research. Psychol Methods 1999;4:272–99. https://doi.org/10.1037/1082-989X.4.3.272. Shrestha N. Factor Analysis as a Tool for Survey Analysis. Am J Appl Math Stat 2021;9:4–11. https://doi.org/10.12691/ajams-9-1-2. Ministerio de Trabajo y Promoción del Empleo del Perú. Decreto Supremo N.° 003-2022-TR n.d. https://www.gob.pe/institucion/mtpe/normas-legales/2890811-003-2022-tr (accessed May 26, 2025). Assaf RD, Konda KA, Torres TS, Vega-Ramirez EH, Elorreaga OA, Diaz-Sosa D, et al. Are men who have sex with men at higher risk for HIV in Latin America more aware of PrEP? PloS One 2021;16:e0255557. https://doi.org/10.1371/journal.pone.0255557. Sun Z, Gu Q, Dai Y, Zou H, Agins B, Chen Q, et al. Increasing awareness of HIV pre-exposure prophylaxis (PrEP) and willingness to use HIV PrEP among men who have sex with men: a systematic review and meta-analysis of global data. J Int AIDS Soc 2022;25:e25883. https://doi.org/10.1002/jia2.25883. Yi S, Tuot S, Mwai GW, Ngin C, Chhim K, Pal K, et al. Awareness and willingness to use HIV pre-exposure prophylaxis among men who have sex with men in low- and middle-income countries: a systematic review and meta-analysis. J Int AIDS Soc 2017;20:21580. https://doi.org/10.7448/IAS.20.1.21580. Göttgens I, Oertelt-Prigione S. The Application of Human-Centered Design Approaches in Health Research and Innovation: A Narrative Review of Current Practices. JMIR MHealth UHealth 2021;9:e28102. https://doi.org/10.2196/28102. Calabrese SK. Understanding, Contextualizing, and Addressing PrEP Stigma to Enhance PrEP Implementation. Curr HIV/AIDS Rep 2020;17:579–88. https://doi.org/10.1007/s11904-020-00533-y. Dubov A, Galbo P, Altice FL, Fraenkel L. Stigma and Shame Experiences by MSM Who Take PrEP for HIV Prevention: A Qualitative Study. Am J Mens Health 2018;12:1843–54. https://doi.org/10.1177/1557988318797437. Feyissa GT, Lockwood C, Woldie M, Munn Z. Reducing HIV-related stigma and discrimination in healthcare settings: A systematic review of quantitative evidence. PloS One 2019;14:e0211298. https://doi.org/10.1371/journal.pone.0211298. Oliveros Gómez D, Machavariani E, Altice FL, Gálvez de León S, Earnshaw V, Montenegro-Idrogo JJ, et al. Influence of Stigma on Engagement in HIV Care and Adherence to Antiretroviral Therapy in Specialized HIV Clinics Targeting Men Who Have Sex with Men and Transgender Women in Lima, Peru. AIDS Behav 2024;28:2755–68. https://doi.org/10.1007/s10461-024-04401-3. Patel VV, Ginsburg Z, Golub SA, Horvath KJ, Rios N, Mayer KH, et al. Empowering With PrEP (E-PrEP), a Peer-Led Social Media-Based Intervention to Facilitate HIV Preexposure Prophylaxis Adoption Among Young Black and Latinx Gay and Bisexual Men: Protocol for a Cluster Randomized Controlled Trial. JMIR Res Protoc 2018;7:e11375. https://doi.org/10.2196/11375. Kudrati SZ, Hayashi K, Taggart T. Social Media & PrEP: A Systematic Review of Social Media Campaigns to Increase PrEP Awareness & Uptake Among Young Black and Latinx MSM and Women. AIDS Behav 2021;25:4225–34. https://doi.org/10.1007/s10461-021-03287-9. Li C, Xiong Y, Muessig KE, Tang W, Huang H, Mu T, et al. Community-engaged mHealth intervention to increase uptake of HIV pre-exposure prophylaxis (PrEP) among gay, bisexual and other men who have sex with men in China: study protocol for a pilot randomised controlled trial. BMJ Open 2022;12:e055899. https://doi.org/10.1136/bmjopen-2021-055899. Mulawa MI, Rosengren AL, Amico KR, Hightow-Weidman LB, Muessig KE. mHealth to reduce HIV-related stigma among youth in the United States: a scoping review. mHealth 2021;7:35. https://doi.org/10.21037/mhealth-20-68. Krishnan A, Ferro EG, Weikum D, Vagenas P, Lama JR, Sanchez J, et al. Communication technology use and mHealth acceptance among HIV-infected men who have sex with men in Peru: implications for HIV prevention and treatment. AIDS Care 2015;27:273–82. https://doi.org/10.1080/09540121.2014.963014. Mobile internet use in Peru by age 2023. Statista n.d. https://www.statista.com/statistics/982795/mobile-internet-user-penetration-rate-peru-age-group/ (accessed May 6, 2025). Encuesta Nacional de Hogares (ENAHO) 2022 - [Instituto Nacional de Estadística e Informática – INEI] | Plataforma Nacional de Datos Abiertos n.d. https://datosabiertos.gob.pe/dataset/encuesta-nacional-de-hogares-enaho-2022-instituto-nacional-de-estad%C3%ADstica-e-inform%C3%A1tica-%E2%80%93 (accessed May 6, 2025). Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci 2015;10:21. https://doi.org/10.1186/s13012-015-0209-1. Yakovchenko V, Chinman MJ, Lamorte C, Powell BJ, Waltz TJ, Merante M, et al. Refining Expert Recommendations for Implementing Change (ERIC) strategy surveys using cognitive interviews with frontline providers. Implement Sci Commun 2023;4:42. https://doi.org/10.1186/s43058-023-00409-3. Lovero KL, Kemp CG, Wagenaar BH, Giusto A, Greene MC, Powell BJ, et al. Application of the Expert Recommendations for Implementing Change (ERIC) compilation of strategies to health intervention implementation in low- and middle-income countries: a systematic review. Implement Sci IS 2023;18:56. https://doi.org/10.1186/s13012-023-01310-2. Liu AY, Vittinghoff E, von Felten P, Rivet Amico K, Anderson PL, Lester R, et al. Randomized Controlled Trial of a Mobile Health Intervention to Promote Retention and Adherence to Preexposure Prophylaxis Among Young People at Risk for Human Immunodeficiency Virus: The EPIC Study. Clin Infect Dis Off Publ Infect Dis Soc Am 2019;68:2010–7. https://doi.org/10.1093/cid/ciy810. Li C, Xiong Y, Maman S, Matthews DD, Fisher EB, Tang W, et al. An instant messaging mobile phone application for promoting HIV pre-exposure prophylaxis uptake among Chinese gay, bisexual and other men who have sex with men: A mixed methods feasibility and piloting randomized controlled trial study. PloS One 2023;18:e0285036. https://doi.org/10.1371/journal.pone.0285036. Lin B, Liu J, He W, Pan H, Ma Y, Zhong X. Effect of a Reminder System on Pre-exposure Prophylaxis Adherence in Men Who Have Sex With Men: Prospective Cohort Study Based on WeChat Intervention. J Med Internet Res 2022;24:e37936. https://doi.org/10.2196/37936. Palmer L, Wickersham JA, Gautam K, Maviglia F, Bruno B-D, Azwa I, et al. User preferences for an mHealth app to support HIV testing and pre-exposure prophylaxis uptake among men who have sex with men in Malaysia. PLOS Digit Health 2024;3:e0000643. https://doi.org/10.1371/journal.pdig.0000643. Meyer J, Price C, Tracey D, Sharpless L, Song Y, Madden L, et al. Preference for and Efficacy of a PrEP Decision Aid for Women with Substance Use Disorders. Patient Prefer Adherence 2021;15:1913–27. https://doi.org/10.2147/PPA.S315543. Celum C, Seidman D, Travill D, Dehlendorf C, Gumede S, Zewdie K, et al. A decision support tool has similar high PrEP uptake and increases early PrEP persistence in adolescent girls and young women in South Africa: results from a randomized controlled trial. J Int AIDS Soc 2023;26:e26154. https://doi.org/10.1002/jia2.26154. Shrestha R, Wickersham JA, Khati A, Azwa I, Ni Z, Kamarulzaman A, et al. Clinic-Integrated Mobile Health Intervention (“JomPrEP” App) to Improve Uptake of HIV Testing and Pre-exposure Prophylaxis Among Men Who Have Sex With Men in Malaysia: Protocol for an Intervention Development and Multiphase Trial. JMIR Res Protoc 2022;11:e43318. https://doi.org/10.2196/43318. Shrestha R, Altice FL, Khati A, Azwa I, Gautam K, Gupta S, et al. Clinic-Integrated Smartphone App (JomPrEP) to Improve Uptake of HIV Testing and Pre-exposure Prophylaxis Among Men Who Have Sex With Men in Malaysia: Mixed Methods Evaluation of Usability and Acceptability. JMIR MHealth UHealth 2023;11:e44468. https://doi.org/10.2196/44468. Goorts K, Dizon J, Milanese S. The effectiveness of implementation strategies for promoting evidence informed interventions in allied healthcare: a systematic review. BMC Health Serv Res 2021;21:241. https://doi.org/10.1186/s12913-021-06190-0. Kovacs E, Strobl R, Phillips A, Stephan A-J, Müller M, Gensichen J, et al. Systematic Review and Meta-analysis of the Effectiveness of Implementation Strategies for Non-communicable Disease Guidelines in Primary Health Care. J Gen Intern Med 2018;33:1142–54. https://doi.org/10.1007/s11606-018-4435-5. Pantoja T, Opiyo N, Lewin S, Paulsen E, Ciapponi A, Wiysonge CS, et al. Implementation strategies for health systems in low-income countries: an overview of systematic reviews. Cochrane Database Syst Rev 2017;9:CD011086. https://doi.org/10.1002/14651858.CD011086.pub2. Reisner SL, Apedaile D, Silva-Santisteban A, Huerta L, Aguayo-Romero R, Perez-Brumer A. The PrEP cascade in a sample of HIV-negative or unknown status adolescent and young adult transgender women in Peru. Int J STD AIDS 2025;36:141–50. https://doi.org/10.1177/09564624241272940. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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06:27:05","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":190613,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7843241/v1/015a3cddc3dc11a438b419f9.html"},{"id":93462165,"identity":"00c2be3f-8842-40ef-8796-f5c6492445c9","added_by":"auto","created_at":"2025-10-14 06:27:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":191869,"visible":true,"origin":"","legend":"\u003cp\u003eAdaptation of the Behavioral Model for Vulnerable Populations to illustrate factors influencing progression along the HIV prevention cascade among Peruvian men who have sex with men\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7843241/v1/6deb37e8c00a19de4e5bcd5d.png"},{"id":93462168,"identity":"2ef44965-d3fa-419c-a6ea-3cd54250cbe5","added_by":"auto","created_at":"2025-10-14 06:27:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":164447,"visible":true,"origin":"","legend":"\u003cp\u003eHIV Prevention Cascade among Peruvian men who have sex with men (MSM) and implementation gaps (N = 381)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7843241/v1/0a29ec2da2a011e3594a3f03.png"},{"id":93463469,"identity":"4d665434-e2f6-4fca-97c4-39062a4c2369","added_by":"auto","created_at":"2025-10-14 06:51:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1634843,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7843241/v1/c3137061-25f6-402f-b724-06bd31f67acb.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eIdentifying Implementation Gaps in the HIV Prevention Cascade Among Peruvian Men Who Have Sex with Men\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDespite global progress in HIV prevention, HIV remains a critical public health issue in Peru, where new HIV diagnoses have increased by 81% between 2010 and 2023 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Sexual and gender minorities bear a disproportionate burden of HIV, with prevalence estimated at 10% among men who have sex with men (MSM) and 30% among transgender women [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Furthermore, HIV incidence among MSM in Peru exceeds 5 per 100 person-years, making it one of the highest in the Americas [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These figures underscore the urgency of strengthening HIV prevention strategies tailored to key populations in Peru.\u003c/p\u003e\u003cp\u003eHIV pre-exposure prophylaxis (PrEP), using either daily or event-driven emtricitabine/tenofovir disoproxil fumarate (F/TDF), is highly effective in preventing HIV transmission among MSM [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, PrEP uptake and consistent use remains limited\u0026mdash;particularly in Peru, where access through the public health system has only recently expanded [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Although F/TDF for HIV PrEP was approved by the Peruvian FDA in 2016, access was initially restricted to a few private providers or via demonstration projects. One such project, ImPrEP, was a large-scale demonstration project conducted between 2018 and 2021 across Brazil, Mexico, and Peru. In Peru, ImPrEP enrolled 2,293 MSM at 10 public primary health centers managed by the Peruvian Ministry of Health (MoH). Notably, only 63% of Peruvian MSM participants were actively seeking PrEP at enrollment, with lower adherence levels and higher discontinuation rates relative to their Brazilian and Mexican counterparts [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn June 2023, the Peruvian MoH integrated daily and event-driven F/TDF into its Combination HIV Prevention guidelines and began providing PrEP for free through select primary health centers nationwide [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Despite this policy advancement, concerns persist regarding slow uptake [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and persistent implementation gaps across multiple stages of the HIV prevention cascade in Peru. These challenges highlight the need to further investigate the structural and behavioral factors limiting PrEP uptake and adherence in real-world settings.\u003c/p\u003e\u003cp\u003eTo bridge these gaps, it is essential to identify opportunities that can inform human-centered implementation strategies. The Behavioral Model for Vulnerable Populations provides a useful conceptual framework for understanding structural and individual-level factors that influence health-seeking behaviors and healthcare utilization among MSM [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This model outlines how predisposing factors (demographics, social structure, and health beliefs), enabling factors (personal, family, and community resources), and need factors (perceived and evaluated risk of HIV acquisition) shape engagement with the HIV prevention cascade. Understanding these determinants is critical for designing context-specific, person-centered interventions that support PrEP initiation, adherence, and retention in care [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBuilding on this framework, our study examined how these factors influence progression across key stages of the HIV prevention cascade among MSM in Peru. By analyzing data collected during the early phase of the national PrEP rollout, we aimed to generate evidence to guide the development of tailored, human-centered approaches that can improve PrEP uptake and implementation in real-world settings.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eWe conducted a cross-sectional online survey between June and August, 2023 to assess the HIV prevention cascade among Peruvian MSM. The survey explored socio-demographics, sexual history (number of anal sex partners, frequency of condom use, partner\u0026rsquo;s HIV status, engagement in commercial sex, and STI diagnosis) in the past 6 months, as well as HIV and PrEP-related beliefs. We included questions designed to situate participants across key stages in the HIV prevention cascade (being eligible for PrEP, deciding to start PrEP, seeking PrEP, initiating PrEP and adhering to PrEP). The survey consisted of 29 multiple-choice and Likert-scale questions.\u003c/p\u003e\u003cp\u003eRespondents were recruited through paid Meta ads (Instagram and Facebook) and geosocial networking apps (Grindr). Paid ads targeted individuals aged\u0026thinsp;\u0026gt;\u0026thinsp;18 years residing in Peru. Respondents could access the survey via a secure URL link on an internet-connected electronic device. Electronic informed consent was obtained before respondents could start the survey. The consent form clearly stated that the survey was intended for adult MSM living in Peru, and by accepting the consent, respondents confirmed this self-identification. Responses were anonymous to protect participant confidentiality. Respondents were able to skip any questions they did not wish to answer.\u003c/p\u003e\u003cp\u003eParticipants were excluded from the analysis if they provided no responses, self-reported living with HIV, were assigned female at birth, identified as transgender or gender non-binary, or reported no history of anal sex. Incomplete responses were also excluded from this analysis. The final analytical sample was limited to individuals who completed the full survey and met eligibility criteria for PrEP, as defined below.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePrEP eligibility\u003c/h3\u003e\n\u003cp\u003ePrEP eligibility was assessed based on criteria outlined in the Peruvian Combination HIV Prevention guidelines [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Participants were considered eligible if they reported any of the following in the past 6 months: having two or more sexual partners, engaging in any condomless sex, receiving a syndromic or etiologic diagnosis of a bacterial sexually transmitted infection (STI), requesting HIV post-exposure prophylaxis (HIV PEP), or having an HIV-positive partner who was not on treatment or had an unsuppressed viral load.\u003c/p\u003e\n\u003ch3\u003eThe HIV Prevention Cascade in Peru\u003c/h3\u003e\n\u003cp\u003eAll respondents were first provided with a brief explanation of key PrEP-related concepts through a short summary. This summary covered essential topics such as \u0026ldquo;What is PrEP?\u0026rdquo;, \u0026ldquo;How effective is PrEP?\u0026rdquo;, \u0026ldquo;Who should use PrEP?\u0026rdquo;, \u0026ldquo;What is required to take PrEP?\u0026rdquo;, \u0026ldquo;Where can PrEP be accessed in Peru?\u0026rdquo;. After reviewing the summary, respondents were presented with questions to assess their progression along the PrEP Cascade. These questions were adapted for the Peruvian context from those of the Motivational PrEP Cascade developed by Parsons et al [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], as follows:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eDecided to start PrEP\u003c/em\u003e: Respondents were asked \u003cem\u003e\u0026ldquo;Have you decided to start PrEP?\u0026rdquo;\u003c/em\u003e, with responses on a 5-point Likert scale ranging from \u003cem\u003e\u0026ldquo;Definitely no\u0026rdquo;\u003c/em\u003e to \u003cem\u003e\u0026ldquo;Definitely yes\u0026rdquo;\u003c/em\u003e.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eSought PrEP\u003c/em\u003e: Respondents were asked \u003cem\u003e\u0026ldquo;Have you ever discussed starting PrEP with a physician in a primary health center currently offering PrEP?\u0026rdquo;\u003c/em\u003e, with response options of \u003cem\u003e\u0026ldquo;Yes\u0026rdquo;\u003c/em\u003e or \u003cem\u003e\u0026ldquo;No\u0026rdquo;\u003c/em\u003e.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eEver initiated PrEP\u003c/em\u003e: Respondents were asked \u003cem\u003e\u0026ldquo;Have you ever started PrEP?\u0026rdquo;\u003c/em\u003e, with possible answers of \u003cem\u003e\u0026ldquo;Yes, I\u0026rsquo;m currently on PrEP\u0026rdquo;\u003c/em\u003e, \u003cem\u003e\u0026ldquo;Yes, but I\u0026rsquo;m not currently on PrEP\u0026rdquo;\u003c/em\u003e, or \u003cem\u003e\u0026ldquo;No\u0026rdquo;\u003c/em\u003e.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eAdherent to PrEP\u003c/em\u003e: Only respondents who reported having ever started PrEP were asked \u003cem\u003e\u0026ldquo;In the past month (30 days). How many PrEP doses did you miss?\u0026rdquo;\u003c/em\u003e, with response on a numeric scale from 0\u0026ndash;30.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eTo be considered as having \u0026ldquo;reached\u0026rdquo; a particular stage in the cascade, respondents needed to select 'Yes' for yes/no questions or 'Probably yes'/'Definitely yes' on the Likert scale questions. For adherence, respondents were classified as \u0026ldquo;adherent\u0026rdquo; if they reported missing 13 or fewer doses in the past month, or the equivalent of taking at least four PrEP doses per week. Participants were not required to meet criteria for earlier stages to be counted in later ones, with the exception of adherence, which was only assessed among those who had initiated PrEP.\u003c/p\u003e\n\u003ch3\u003eExploratory factor analysis\u003c/h3\u003e\n\u003cp\u003eTo identify latent constructs related to participants\u0026rsquo; knowledge, attitudes, and experiences with PrEP, we conducted an exploratory factor analysis (EFA) as a data reduction strategy and to inform subsequent regression modeling [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. We analyzed 19 survey items focused on these constructs. Prior to the EFA, we assessed the suitability of the dataset by calculating the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy for factor analysis and performing Bartlett\u0026rsquo;s test of sphericity [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWe used principal axis factoring with \u003cem\u003ePromax\u003c/em\u003e (oblique) rotation, as we expected the factors to be correlated. The number of factors retained was determined based on eigenvalues\u0026thinsp;\u0026gt;\u0026thinsp;1.0, scree plot inspection, parallel analysis, and conceptual interpretability. The EFA was conducted as a two-stage process: first to identify key constructs embedded in the large pool of interrelated items, and second to generate composite scores representing distinct, modifiable themes related to PrEP implementation. These composite scores were subsequently used in regression models.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics were used to summarize sample characteristics and construct the HIV Prevention Cascade. Co-variables were mapped onto domains of the Behavioral Model for Vulnerable Populations (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The outcomes of interest were the largest implementation gaps in the cascade, defined as the stages with the greatest percentage drop-off relative to the preceding stage and representing the most programmatically actionable stages for intervention. Univariate and multivariable logistic regression models were fitted to examine associations between co-variables and each outcome, comparing participants who reached the stage to those who did not, within the full sample of PrEP-eligible individuals. A forward selection approach was used to build the final multivariable models, based on the lowest Aikake Information Criterion (AIC) value. Results are reported as odds ratios (ORs) and adjusted odds ratios (aORs) with corresponding 95% confidence intervals (CIs). All analyses were conducted in R (version 4.3.1).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eDetermination of analytical sample\u003c/h2\u003e\u003cp\u003eAmong the 1,609 participants who consented to participate in the study, 837 (52%) individuals were initially excluded: 270 provided no responses, 253 self-reported having HIV, 22 were assigned female at birth, 29 identified as transgender or gender non-binary, and 236 reported no anal sex. Of the remaining 772 individuals, 240 submitted only partial responses limited to socio-demographic data. Individuals with incomplete responses were slightly younger (median age: 28.0 years [IQR: 22.0\u0026ndash;33.0] vs. 29.0 years [IQR: 24.0\u0026ndash;35.0], p\u0026thinsp;=\u0026thinsp;0.001) and less likely to reside in Lima or Callao (58.3% vs. 71.4%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) than participants with complete responses. No significant differences were observed in income, education level, or other key variables. Among the 532 individuals with full responses, 214 (40%) did not meet PrEP eligibility criteria. The final analytical sample consisted of 381 MSM eligible for PrEP.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eCharacteristics of MSM identified as eligible for PrEP\u003c/h3\u003e\n\u003cp\u003eThe median age in the analytical sample was 29 years (IQR: 25\u0026ndash;35), with 293 (76.9%) aged 25 years or older. Most participants had completed post-secondary education (78.7%, n\u0026thinsp;=\u0026thinsp;300), resided in Lima or the nearby city of Callao (75.1%, n\u0026thinsp;=\u0026thinsp;286). A majority (68.8%, n\u0026thinsp;=\u0026thinsp;262) reported a monthly income below 2,000 PEN (~\u0026thinsp;US\u003cspan\u003e$\u003c/span\u003e550, approximately twice the minimum wage) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In the past six months, 228 (59.8%) reported five or fewer anal sex partners, while condomless anal intercourse was highly prevalent (91.3%, n\u0026thinsp;=\u0026thinsp;348). A total of 249 (65.4%) reported recent sexual activity with partners of unknown HIV status or with known unsuppressed HIV. A suspected or diagnosed bacterial STI was reported by 159 (41.7%). Most participants either perceived themselves to be at risk for HIV or were unsure (79.8%, n\u0026thinsp;=\u0026thinsp;304). While PrEP awareness was high (91.6%, n\u0026thinsp;=\u0026thinsp;349), fewer participants knew where to obtain PrEP and the steps required to access it (53.3%, n\u0026thinsp;=\u0026thinsp;203), and 252 (66.1%) reported knowing someone in their social network who was using PrEP.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eResults of the exploratory factor analysis\u003c/h2\u003e\u003cp\u003eTo distill key constructs from the 19 items assessing participants\u0026rsquo; knowledge, attitudes, and experiences with PrEP, we conducted an EFA as described in the Methods. The data were well-suited for factor analysis (KMO\u0026thinsp;=\u0026thinsp;0.93; Bartlett\u0026rsquo;s test p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and principal axis factoring with \u003cem\u003ePromax\u003c/em\u003e rotation was applied. A four-factor model was selected as the best representation of the data (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The final factor structure included the following themes:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003ePositive attitudes \u0026amp; beliefs towards PrEP\u003c/em\u003e (8 items, Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.90) \u0026ndash; This factor captured participants' perceived benefits of PrEP, its acceptability, and the social support surrounding its use. Items included statements about feeling better while taking PrEP, believing it provides protection for both themselves and their partners, and perceiving social support for PrEP use.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003ePrEP self-efficacy\u003c/em\u003e (4 items, Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.92) \u0026ndash; This factor reflected participants' confidence in their ability to take PrEP consistently, manage daily adherence, and attend required medical visits.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eAccess to information about PrEP\u003c/em\u003e (5 items, Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.74) \u0026ndash; This factor encompassed participants' prior knowledge about PrEP, their awareness of access points in Peru, and their efforts to seek additional information.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eCost concerns related to PrEP\u003c/em\u003e (2 items, Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.82) \u0026ndash; This factor captured concerns about financial barriers, including the cost of PrEP pills and required medical exams.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eExploratory factor analysis of PrEP-related survey items\u003csup\u003ea\u003c/sup\u003e (N\u0026thinsp;=\u0026thinsp;381)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurvey items\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePositive attitudes \u0026amp; beliefs towards PrEP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrEP self-efficacy\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAccess to information\u003c/p\u003e\u003cp\u003e about PrEP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCost concerns related to PrEP\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\"I could use alarms or reminders to help me take PrEP.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\"I could adapt my daily routine in a way that makes it easier for me to take PrEP.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\"My sexual partner(s) would appreciate it if I used PrEP.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\"I would feel better about myself if I took PrEP every day.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\"I think that by using PrEP, I can also protect my partner(s) from HIV.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\"I think that PrEP can help me stay protected against HIV.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\"People close to me would support me in using PrEP.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\"I think that using PrEP is something currently accepted by society.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\"I believe I could take PrEP for a long time.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\"I feel capable of taking a daily PrEP pill.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\"I feel capable of attending appointments to receive the PrEP pills.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\"I think taking PrEP is good for me, rather than being a burden.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\"Before today, I already knew how and where to access PrEP in Peru.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\"I know other people who are taking PrEP.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\"I have searched for information online or asked other people about PrEP.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\"I believe I have enough information to decide whether or not to start PrEP.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\"Before today, I had already read or heard that PrEP can protect me from HIV.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\"I am concerned about the cost of PrEP pills.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\"I am concerned about the cost of the medical exams required to take PrEP.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003ea. Factor loadings\u0026thinsp;\u0026lt;\u0026thinsp;0.30 are not displayed for clarity. Items were grouped based on the highest loading on a given factor.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eComposite scores were calculated by summing item responses within each factor, with all items scored on a 0\u0026ndash;4 scale. Higher scores indicated stronger agreement or greater presence of the underlying construct. The possible score ranges were 0 to 32 for \u003cem\u003ePositive attitudes \u0026amp; beliefs towards PrEP\u003c/em\u003e, 0 to 16 for \u003cem\u003ePrEP self-efficacy\u003c/em\u003e, 0 to 20 for \u003cem\u003eAccess to information about PrEP\u003c/em\u003e, and 0 to 8 for \u003cem\u003eCost concerns related to PrEP\u003c/em\u003e.\u003c/p\u003e\u003cp\u003eAcross the full analytic sample, composite scores from the four EFA-derived factors reflected high motivation alongside persistent informational and structural barriers. \u003cem\u003ePositive attitudes \u0026amp; beliefs towards PrEP\u003c/em\u003e were strong (median: 29.0, IQR: 25.0\u0026ndash;32.0 out of 32), indicating broadly favorable perceptions. \u003cem\u003ePrEP self-efficacy\u003c/em\u003e was also high (median: 16.0, IQR: 13.0\u0026ndash;16.0 out of 16), suggesting participants felt confident in their ability to initiate and adhere to PrEP. In contrast, \u003cem\u003eAccess to information about PrEP\u003c/em\u003e showed greater variability (median: 16.0, IQR: 14.0\u0026ndash;18.0 out of 20), pointing to uneven levels of practical knowledge, information-seeking behavior, and perceived readiness to act. \u003cem\u003eCost Concerns\u003c/em\u003e were high overall (median: 8.0, IQR: 6.0\u0026ndash;8.0 out of 8), suggesting ongoing misconceptions or lack of clarity around the costs associated with PrEP, despite its availability free of charge through the public health system.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eThe HIV Prevention Cascade and Implementation Gaps:\u003c/h2\u003e\u003cp\u003eInterest in PrEP was high, with 341 (89.5%) expressing willingness to use it, 322 (84.5%) self-identifying as good candidates based on the PrEP summary provided, and 316 (82.9%) were ready to initiate PrEP. However, only 154 (40.4%) participants knew of a clinic likely to offer PrEP, and only 132 (34.6%) had ever sought it. Ultimately, 73 participants (19.2%) reported ever initiating PrEP, and only 30 (7.9%) were currently using at least four PrEP doses per week and were classified as adherent to daily oral PrEP. The two most relevant implementation gaps in the HIV prevention cascade involve the transition from deciding to start PrEP to actively seeking PrEP, and from seeking PrEP to actual PrEP uptake (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Notably, among those who had ever initiated daily oral PrEP, adherence over the past 30 days remained suboptimal, with only 30 of 73 (41.1%) reporting current use of at least four doses per week.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eCorrelates of PrEP seeking and PrEP initiation\u003c/h2\u003e\u003cp\u003eComparisons between different sub-groups are included in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Compared to those who had never sought PrEP, individuals who had sought PrEP were more likely to be older (84.1% vs. 73.1% aged\u0026thinsp;\u0026ge;\u0026thinsp;25, p\u0026thinsp;=\u0026thinsp;0.015), live in Lima or Callao (82.6% vs. 71.1%, p\u0026thinsp;=\u0026thinsp;0.018), and report higher positive beliefs and attitudes towards PrEP (median: 31.0 vs. 28.0, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), greater access to PrEP information (median: 18.0 vs. 15.0, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and higher self-efficacy (median: 16.0 vs. 15.0, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Individuals who had sought PrEP were also more likely to have requested HIV PEP (19.7% vs. 5.2%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similar patterns were observed among those who had ever initiated PrEP versus those who had not. PrEP initiators had higher rates of post-secondary education (87.7% vs. 72.4%, p\u0026thinsp;=\u0026thinsp;0.039), lived more frequently in Lima or Callao (86.3% vs. 74.1%, p\u0026thinsp;=\u0026thinsp;0.015), and had greater access to PrEP information (median: 19.0 vs. 15.0, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). They also reported higher self-efficacy (median: 16.0 vs. 16.0, with tighter IQRs among initiators, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and were more likely to report incomes\u0026thinsp;\u0026ge;\u0026thinsp;2,000 soles (45.2% vs. 27.9%, p\u0026thinsp;=\u0026thinsp;0.005). Prior HIV PEP use was more common among PrEP initiators (17.8% vs. 8.4%, p\u0026thinsp;=\u0026thinsp;0.029).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of respondents eligible for PrEP (N\u0026thinsp;=\u0026thinsp;381), organized by domains of the Behavioral Model for Vulnerable Populations, and stratified by the two largest gaps in the HIV Prevention Cascade\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eSought PrEP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eEver initiatied PrEP\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes, n\u0026thinsp;=\u0026thinsp;132\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo, n\u0026thinsp;=\u0026thinsp;249\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eYes, n\u0026thinsp;=\u0026thinsp;73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo, n\u0026thinsp;=\u0026thinsp;308\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003ep-value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePredisposing Factors\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, years\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29.0 (26.0\u0026ndash;34.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29.0 (24.0\u0026ndash;36.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30.0 (26.0\u0026ndash;35.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e29.0 (25.0\u0026ndash;35.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge category\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;25 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21 (15.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67 (26.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13 (17.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e75 (24.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;25 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e111 (84.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e182 (73.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e60 (82.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e233 (75.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt; Post-secondary\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21 (15.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60 (24.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9 (12.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e72 (23.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePost-secondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e111 (84.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e189 (75.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e64 (87.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e223 (72.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCity of residence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther provinces\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23 (17.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72 (28.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10 (13.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e85 (27.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLima \u0026amp; Callao\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e109 (82.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e177 (71.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e63 (86.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e258 (74.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePositive beliefs/attitudes towards PrEP\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31.0 (28.0\u0026ndash;32.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.0 (24.0\u0026ndash;31.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e31.0 (29.0\u0026ndash;32.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e29.0 (25.0\u0026ndash;32.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEnabling Resources\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMonthly income\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;2000 soles\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e86 (65.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e176 (70.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e40 (54.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e222 (72.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;2000 soles\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46 (34.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e73 (29.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e33 (45.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e86 (27.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAccess to information about PrEP\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18.0 (16.0\u0026ndash;19.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15.0 (13.0\u0026ndash;17.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19.0 (17.0\u0026ndash;20.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e15.0 (13.0\u0026ndash;17.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e***\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConcerns for associated costs\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.0 (6.0\u0026ndash;8.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.0 (6.0\u0026ndash;8.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.0 (6.0\u0026ndash;8.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e8.0 (6.0\u0026ndash;8.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNeed factors in past 6 months\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of anal sex partners\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;5 partners\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e64 (48.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e164 (65.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e35 (47.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e193 (62.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;5 partners\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e68 (51.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e85 (34.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e38 (52.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e115 (37.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCondom use during anal sex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlways\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (6.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (10.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6 (8.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e27 (8.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInconsistent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e124 (93.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e224 (90.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e67 (91.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e281 (91.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHIV status of sex partner(s)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHIV- or with undetectable HIV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48 (36.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e84 (33.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e28 (38.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e104 (33.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnknown or detectable HIV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e84 (63.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e165 (66.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e45 (61.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e204 (66.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-perception of HIV risk\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot at risk\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27 (20.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50 (20.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15 (20.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e62 (20.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAt risk or unsure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e105 (79.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e199 (79.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e58 (79.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e246 (79.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTransactional sex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e103 (78.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e214 (85.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e60 (82.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e257 (83.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29 (22.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (14.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13 (17.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e51 (16.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAny bacterial STI diagnosed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e69 (52.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e153 (61.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e40 (54.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e182 (59.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e63 (47.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e96 (38.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e33 (45.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e126 (40.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRequested HIV PEP\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e106 (80.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e236 (94.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e60 (82.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e282 (91.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26 (19.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (5.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13 (17.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e26 (8.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrEP Self-efficacy\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16.0 (15.0\u0026ndash;16.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15.0 (12.0\u0026ndash;16.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16.0 (16.0\u0026ndash;16.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e16.0 (12.0\u0026ndash;16.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e***\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003e\u003csup\u003ea\u003c/sup\u003eWilcoxon rank sum test; Pearson's Chi-squared test; Fisher's exact test. \u003csup\u003eb\u003c/sup\u003emedian (IQR). \u003csup\u003ec\u003c/sup\u003ePost-exposure prophylaxis\u003c/p\u003e\u003cp\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01. ***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eFactors associated with seeking PrEP:\u003c/h2\u003e\u003cp\u003eIn multivariable analyses, several factors across the domains of the Behavioral Model for Vulnerable Populations were associated with seeking PrEP (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Among predisposing factors, older age was significantly associated with a greater likelihood of seeking PrEP, while no other variables in this domain remained in the final model. Within the need factors domain, individuals who reported inconsistent condom use, had a recent history of a suspected or diagnosed bacterial STI, or had previously requested HIV PEP were more likely to seek PrEP. Higher self-efficacy was also positively associated with PrEP-seeking behavior. Enabling resources emerged as the most consistent and actionable drivers of PrEP engagement: participants with greater access to actionable PrEP information were significantly more likely to seek PrEP, whereas those reporting higher cost concerns were less likely to do so.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFactors associated with seeking PrEP among Peruvian MSM eligible for PrEP (N\u0026thinsp;=\u0026thinsp;381)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eUnadjusted\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eAdjusted\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eaOR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePredisposing Factors\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u0026thinsp;\u0026ge;\u0026thinsp;25 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.15\u0026ndash;3.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.13\u0026ndash;4.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePost-secondary education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.98\u0026ndash;2.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLives in Lima or Callao\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.15\u0026ndash;3.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHas positive beliefs \u0026amp; attitudes towards PrEP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.05\u0026ndash;1.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEnabling Resources\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMonthly income\u0026thinsp;\u0026ge;\u0026thinsp;2000 soles\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.82\u0026ndash;2.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHave access to information about PrEP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.29\u0026ndash;1.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.31\u0026ndash;1.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e***\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHas concerns for associated costs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.70\u0026ndash;0.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.60\u0026ndash;0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNeed factors in past 6 months\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;5 partners anal sex partners\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.33\u0026ndash;3.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInconsistent condom use during anal sex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.79\u0026ndash;4.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.50\u0026ndash;10.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePartner(s) of unknown HIV status / detectable HIV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.57\u0026ndash;1.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-perceived at risk for HIV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.58\u0026ndash;1.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTransactional sex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.99\u0026ndash;2.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.90\u0026ndash;3.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAny bacterial STI diagnosed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.95\u0026ndash;2.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.15\u0026ndash;3.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRequested HIV post-exposure prophylaxis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.24\u0026ndash;9.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.92\u0026ndash;9.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e***\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrEP Self-efficacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.07\u0026ndash;1.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01. ***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eFactors associated with initiating PrEP:\u003c/h2\u003e\u003cp\u003eIn multivariable analyses, fewer variables were significantly associated with PrEP initiation compared to the earlier stage of seeking PrEP (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Within predisposing factors, positive beliefs and attitudes toward PrEP exhibited a negative association in the adjusted model, suggesting that while favorable perceptions are common, they may not sufficiently drive initiation in the absence of other enabling conditions. Within the need factors domain, higher PrEP self-efficacy was positively associated with initiation, underscoring its role in facilitating the transition from intention to action. Enabling resources once again emerged as key drivers of progression in the HIV prevention cascade. Individuals with higher income and greater access to PrEP-related information were significantly more likely to have initiated PrEP.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFactors associated with initiating PrEP among Peruvian MSM eligible for PrEP (N\u0026thinsp;=\u0026thinsp;381)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eUnadjusted\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eAdjusted\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eaOR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePredisposing Factors\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u0026thinsp;\u0026ge;\u0026thinsp;25 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.79\u0026ndash;2.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePost-secondary education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.08\u0026ndash;4.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLives in Lima or Callao\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.23\u0026ndash;5.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHas positive beliefs \u0026amp; attitudes towards PrEP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.06\u0026ndash;1.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.73\u0026ndash;0.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEnabling Resources\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMonthly income\u0026thinsp;\u0026ge;\u0026thinsp;2000 soles\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.26\u0026ndash;3.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.19\u0026ndash;3.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHave access to information about PrEP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.36\u0026ndash;1.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.35\u0026ndash;1.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e***\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHas concerns for associated costs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.78\u0026ndash;1.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNeed factors in past 6 months\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;5 partners anal sex partners\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.09\u0026ndash;3.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInconsistent condom use during anal sex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.45\u0026ndash;2.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePartner(s) of unknown HIV status / detectable HIV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.49\u0026ndash;1.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-perceived at risk for HIV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.53\u0026ndash;1.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTransactional sex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.54\u0026ndash;2.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAny bacterial STI diagnosed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.71\u0026ndash;1.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRequested HIV post-exposure prophylaxis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.11\u0026ndash;4.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrEP Self-efficacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.24\u0026ndash;1.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.17\u0026ndash;1.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01. ***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study is the first to examine factors associated with key stages of the PrEP prevention cascade among MSM in Peru, offering insights into implementation gaps during the initial phase of the national rollout of free PrEP. Consistent with findings from other settings [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], we observed high levels of awareness and interest in PrEP. Nonetheless, substantial drop-offs in seeking and initiating PrEP were identified, pointing to missed opportunities for better implementation. By organizing findings according to the Behavioral Model for Vulnerable Populations, we identified actionable predisposing, enabling, and need-related factors that inform targeted implementation strategies.\u003c/p\u003e\u003cp\u003eOur findings highlight that a lack of practical, actionable information, such as where and how to obtain PrEP, is a major barrier to uptake. While PrEP awareness was high, only one-third of participants had ever sought it, and less than one in five had initiated it. These findings point to the urgent need for patient-centered strategies that directly address this information gap. While access to information was a key enabler of both seeking and initiating PrEP, our findings show that not all positive perceptions translate into action. For example, although favorable beliefs about PrEP were widely endorsed, they were not significantly associated with uptake after seeking PrEP, and in adjusted models, were inversely associated with PrEP initiation. This highlights a gap between motivation and follow-through, reinforcing the need for strategies that not only educate but also facilitate decision-making, reduce friction in service navigation, and support the behavioral shift from intention to action.\u003c/p\u003e\u003cp\u003eLingering cost concerns were negatively associated with seeking PrEP, suggesting that perceived financial barriers may still deter individuals from engaging with PrEP services in the first place. In addition, higher income was positively associated with PrEP initiation. Although this may reflect earlier access to PrEP through private providers prior to the public rollout, it nonetheless points to structural inequities in who is most likely to navigate the PrEP cascade. These findings underscore the need for equity-focused implementation efforts and improved communication strategies to correct cost-related misconceptions, especially given that PrEP is now available free of charge through the public health system.\u003c/p\u003e\u003cp\u003eA human-centered implementation research approach is essential to understanding and addressing the complex and context-specific barriers that hinder PrEP uptake among MSM in Peru. Unlike top-down interventions, human-centered strategies begin with the perspectives, needs, and lived experiences of end-users [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], including potential PrEP users, current clients, and healthcare providers. This approach recognizes that MSM in Peru often face overlapping barriers such as stigma, discrimination, fear of being outed, and logistical constraints like long wait times or lack of privacy in clinics [\u003cspan additionalcitationids=\"CR26 CR27\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. By involving users in the design and iteration of solutions, human-centered approaches foster trust, improve usability, and ensure that interventions are aligned with real-world needs.\u003c/p\u003e\u003cp\u003eHuman-centered approaches, particularly low-intensity social media campaigns (SMCs), are well-suited to reach younger MSM who are less engaged in traditional health systems. In this study, we were able to reach over 1,600 MSM in just a few weeks through online outreach alone, underscoring the potential of digital platforms to rapidly connect with key populations. Prior studies show that targeted SMCs can effectively increase awareness and uptake of clinical services, especially when messages are culturally tailored, platform-specific, and delivered by peer influencers [\u003cspan additionalcitationids=\"CR30 CR31\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In Peru, access to the internet and smartphones have increased substantially over the past decade [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. As of 2023, nearly all young MSM report access to both [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], with their primary digital environments including Whatsapp, Instagram, Facebook, sex-partnering apps, YouTube, and TikTok\u0026mdash;offering key opportunities for strategic messaging. A national SMC that clearly communicates that PrEP is available free of charge through the public health system, along with information on eligibility, where to access services (e.g., a PrEP clinic locator with hours of operation), and any associated requirements, such as lab tests or follow-up visits, could directly address the core informational barriers and cost-related misconceptions identified in this study. These strategies align with the Expert Recommendations for Implementing Change (ERIC), such as \u0026ldquo;distribute educational materials\u0026rdquo; and \u0026ldquo;use mass media,\u0026rdquo; and could be enhanced by including peer-driven testimonials and real-time Q\u0026amp;A through WhatsApp or chatbot platforms [\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBeyond awareness, individual-level enablers such as PrEP self-efficacy and prior experience with HIV prevention (e.g., PEP use) were positively associated with PrEP uptake, indicating that digital decision-support tools (DSTs) that describe PrEP options and how to access care could reinforce motivation and help translate intention into action [\u003cspan additionalcitationids=\"CR40 CR41\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Such DSTs might include PrEP decision aids, which have been found to be successful elsewhere [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Integration of such tools into mHealth platforms, like the \u003cem\u003eJomPrEP\u003c/em\u003e app in Malaysia, has shown promise to increase the uptake of PrEP [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. These tools also offer potential for supporting adherence once PrEP is initiated, but may be especially valuable in helping users translate high motivation into actual uptake, particularly among those who have already engaged with health services but face uncertainty or concerns about navigating the logistics of receiving PrEP.\u003c/p\u003e\u003cp\u003eAt the clinical and system level, our findings also suggest a mismatch between demands on patients and providers and the healthcare system\u0026rsquo;s capacity to deliver. This mismatch is particularly evident in the second major drop-off of the cascade\u0026mdash;between seeking and initiating PrEP\u0026mdash;where readiness alone was insufficient. Even when individuals had discussed PrEP with a provider, the lack of progression may reflect system-level barriers, such as limited provider time, inadequate follow-up processes, or unclear pathways to initiation. This underscores the need not only to create demand through patient-centered interventions, but also to promote enabling conditions within the health system to absorb and sustain that demand. Strengthening provider capacity, clinic workflows, and service delivery infrastructure will be essential to closing the gaps observed in the PrEP cascade. As PrEP awareness and motivation grow, especially among MSM with higher self-efficacy and access to information, health systems must be prepared to respond effectively and equitably.\u003c/p\u003e\u003cp\u003eTo this end, ERIC implementation strategies, such as audit and feedback and educational meetings, can help address barriers related to provider knowledge, competing priorities, and workflow inefficiencies [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Incorporating these strategies into Peru\u0026rsquo;s national PrEP rollout could reinforce provider engagement and alignment with updated PrEP protocols. For instance, audit and feedback can be used to highlight missed opportunities for PrEP counseling and initiation, while educational meetings can provide structured, evidence-based training for providers to build confidence and competence in PrEP delivery.\u003c/p\u003e\u003cp\u003eMore intensive strategies, such as guided facilitation and practice transformation approaches, should also be considered in high-volume clinics [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. These strategies, which include collaborative learning, workflow redesign, and coaching, are especially effective when layered with lower-intensity interventions. Differentiated PrEP delivery models, such as community-based initiation, telehealth, pharmacy pick-up, or multi-month dispensing, can further enhance accessibility and retention by reducing logistical barriers. As interest in PrEP grows among MSM, these adaptations will be key to ensuring that health services are not only available, but also responsive, person-centered, and scalable.\u003c/p\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eDespite its many important findings, this analysis has limitations. First, reliance on self-reported data may have introduced recall and social desirability biases, particularly in responses related to sexual behaviors, PrEP use, and healthcare engagement. Second, the cross-sectional nature of the analysis precludes causal inference between individual-level factors and PrEP-seeking or initiation behaviors. Third, although the sample includes a diverse group of MSM, it was largely urban and recruited online, potentially limiting generalizability to rural or more marginalized populations who may face different structural barriers or have lower levels of internet access. It is important to note, however, that Peru\u0026rsquo;s HIV epidemic among MSM is primarily concentrated in urban areas, where internet penetration is high.\u003c/p\u003e\u003cp\u003eIn addition, while data were collected during the very initial rollout phase of the national PrEP program (July\u0026ndash;August 2023), public awareness and service delivery were still in early development and may not reflect the intended scale of PrEP access. As of February 2025, PrEP is available at 120 public primary health centers nationwide; however, uptake remains critically low, with only an estimated 4,000 MSM receiving PrEP, representing less than 3% of the approximately 140,000 who could benefit from its use. Notably, use is still heavily concentrated in Lima and Callao, which account for approximately 80\u0026ndash;85% of these MSM users. This persistently low uptake highlights that the barriers identified in our study remain highly relevant and continue to limit the reach and impact of the national PrEP program.\u003c/p\u003e\u003cp\u003eFinally, transgender women were not included in the analysis due to small numbers in the sample. While this limitation was necessary to maintain analytic clarity, it is important to acknowledge that transgender women represent a distinct population with unique health needs and structural barriers that warrant focused study and tailored interventions [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. As of February 2025, fewer than 200 transgender women in Peru had initiated PrEP, further underscoring the need for dedicated research and programmatic attention.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eFuture Directions\u003c/h2\u003e\u003cp\u003eFuture research should prioritize longitudinal studies to better understand transitions across the PrEP cascade and the sustainability of PrEP use over time. Additionally, implementation science research is needed to evaluate the real-world impact of tailored, human-centered interventions, including digital tools, social media campaigns, and differentiated service delivery models. By addressing both structural and behavioral barriers identified in this study, Peru can enhance the effectiveness of its national PrEP program and extend its reach to MSM who remain underserved.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eDespite high levels of interest and willingness to use PrEP among MSM in Peru, our analysis of the HIV Prevention Cascade reveals substantial implementation gaps. While 82.9% of participants expressed readiness to initiate PrEP, only 34.6% had ever sought it, and just 19.2% had initiated use, underscoring critical barriers to PrEP engagement. Informational barriers remain a key obstacle to PrEP engagement, particularly in the early stages of the cascade. However, our findings also underscore that motivation and awareness do not guarantee uptake: actionable knowledge, psychological readiness, and system navigation support are equally essential for helping individuals move from intention to initiation.\u003c/p\u003e\u003cp\u003eThese findings indicate that national availability of PrEP through the public health system is not sufficient on its own to drive meaningful uptake, as evidenced by the fact that, more than a year into the rollout, fewer than 3% of MSM who could benefit are currently receiving it. To close the gaps identified along the PrEP cascade, implementation strategies must be both targeted and multi-level. Beyond addressing awareness, strategies must support users in translating intention into behavior through digital outreach, social media campaigns, decision-support tools, and person-centered service navigation. At the same time, system-level adaptations, including audit and feedback, educational outreach to providers, and differentiated service delivery, will be essential to strengthen clinical readiness and ensure that individuals who express interest are supported through to PrEP initiation. By aligning these strategies with the ERIC framework and prioritizing human-centered design, Peru can optimize its PrEP program and make meaningful progress toward its HIV prevention goals.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eThe authors did not receive support from any organization for the submitted work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests:\u003c/em\u003e\u003c/strong\u003e The authors have no competing interests to declare that are relevant to the content of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval:\u003c/em\u003e\u003c/strong\u003e The study protocol, survey, and informed consent were approved by the Via Libre Bioethics Committee (Approval No. 9008, 2023a).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent to participate:\u003c/em\u003e\u003c/strong\u003e Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAckowledgments:\u0026nbsp;\u003c/strong\u003eWe thank David Vel\u0026aacute;squez, Hugo S\u0026aacute;nchez, Mar\u0026iacute;a del Rosario (MaR) Le\u0026oacute;n, Felipe Vilcachagua, Yamir Salazar, and Jos\u0026eacute; Luis Castro of the Community Engagement Team at the Peru Clinical Trials Unit (CTU) for their invaluable support. We are also grateful to Patricia Alarc\u0026oacute;n and Dora Germ\u0026aacute;n for their coordination efforts. Finally, we extend our sincere thanks to all study participants for their time and contributions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Sharing:\u0026nbsp;\u003c/strong\u003eResearch data can be made available upon reasonable request\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMinisterio de Salud del Per\u0026uacute;, Centro Nacional de Epidemiolog\u0026iacute;a, Prevenci\u0026oacute;n y Control de Enfermedades (CDC MINSA). Situaci\u0026oacute;n epidemiol\u0026oacute;gica del VIH-SIDA en el Per\u0026uacute; n.d. https://www.dge.gob.pe/vih/uploads/nacional_vih.html (accessed November 13, 2024).\u003c/li\u003e\n\u003cli\u003eNachega JB, Musoke P, Kilmarx PH, Gandhi M, Grinsztejn B, Pozniak A, et al. Global HIV control: is the glass half empty or half full? Lancet HIV 2023;10:e617\u0026ndash;22. https://doi.org/10.1016/S2352-3018(23)00150-9.\u003c/li\u003e\n\u003cli\u003eUNAIDS. Per\u0026uacute; - Country Factsheets (2023) n.d. https://www.unaids.org/es/regionscountries/countries/peru (accessed November 13, 2024).\u003c/li\u003e\n\u003cli\u003eTorres TS, Teixeira SLM, Hoagland B, Konda KA, Derrico M, Moreira RI, et al. Recent HIV infection and annualized HIV incidence rates among sexual and gender minorities in Brazil and Peru (ImPrEP seroincidence study): a cross-sectional, multicenter study. Lancet Reg Health Am 2023;28:100642. https://doi.org/10.1016/j.lana.2023.100642.\u003c/li\u003e\n\u003cli\u003eCorey L, Gilbert PB, Juraska M, Montefiori DC, Morris L, Karuna ST, et al. Two Randomized Trials of Neutralizing Antibodies to Prevent HIV-1 Acquisition. N Engl J Med 2021;384:1003\u0026ndash;14. https://doi.org/10.1056/NEJMoa2031738.\u003c/li\u003e\n\u003cli\u003eFonner VA, Dalglish SL, Kennedy CE, Baggaley R, O\u0026rsquo;Reilly KR, Koechlin FM, et al. Effectiveness and safety of oral HIV preexposure prophylaxis for all populations. AIDS Lond Engl 2016;30:1973\u0026ndash;83. https://doi.org/10.1097/QAD.0000000000001145.\u003c/li\u003e\n\u003cli\u003eChou R, Evans C, Hoverman A, Sun C, Dana T, Bougatsos C, et al. Preexposure Prophylaxis for the Prevention of HIV Infection: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2019;321:2214\u0026ndash;30. https://doi.org/10.1001/jama.2019.2591.\u003c/li\u003e\n\u003cli\u003eMenacho L, Konda KA, Lecca L, Cabello R, Lankowski A, Benites C, et al. Optimising PrEP uptake and use in Peru: no time to lose! Lancet HIV 2024;11:e204\u0026ndash;6. https://doi.org/10.1016/S2352-3018(24)00038-9.\u003c/li\u003e\n\u003cli\u003eVeloso VG, C\u0026aacute;ceres CF, Hoagland B, Moreira RI, Vega-Ram\u0026iacute;rez H, Konda KA, et al. Same-day initiation of oral pre-exposure prophylaxis among gay, bisexual, and other cisgender men who have sex with men and transgender women in Brazil, Mexico, and Peru (ImPrEP): a prospective, single-arm, open-label, multicentre implementation study. Lancet HIV 2023;10:e84\u0026ndash;96. https://doi.org/10.1016/S2352-3018(22)00331-9.\u003c/li\u003e\n\u003cli\u003eMinisterio de Salud del Per\u0026uacute;. Norma T\u0026eacute;cnica de Salud \u0026ldquo; Prevenci\u0026oacute;n Combinada del Virus de la Inmunodeficiencia Humana para Poblaciones en Alto Riesgo\u0026rdquo; 2023.\u003c/li\u003e\n\u003cli\u003eGelberg L, Andersen RM, Leake BD. The Behavioral Model for Vulnerable Populations: application to medical care use and outcomes for homeless people. Health Serv Res 2000;34:1273\u0026ndash;302.\u003c/li\u003e\n\u003cli\u003eSmall LFF. Use of Mental Health Services among People with Co-Occurring Disorders and other Mental Health co-morbidities: Employing the Behavioral Model of Vulnerable Populations. Ment Health Subst Use Dual Diagn 2010;3:81\u0026ndash;93. https://doi.org/10.1080/17523281003717871.\u003c/li\u003e\n\u003cli\u003eBabitsch B, Gohl D, von Lengerke T. Re-revisiting Andersen\u0026rsquo;s Behavioral Model of Health Services Use: a systematic review of studies from 1998-2011. Psycho-Soc Med 2012;9:Doc11. https://doi.org/10.3205/psm000089.\u003c/li\u003e\n\u003cli\u003eChen NE, Meyer JP, Avery AK, Draine J, Flanigan TP, Lincoln T, et al. Adherence to HIV treatment and care among previously homeless jail detainees. AIDS Behav 2013;17:2654\u0026ndash;66. https://doi.org/10.1007/s10461-011-0080-2.\u003c/li\u003e\n\u003cli\u003eMaru DS-R, Bruce RD, Walton M, Mezger JA, Springer SA, Shield D, et al. Initiation, adherence, and retention in a randomized controlled trial of directly administered antiretroviral therapy. AIDS Behav 2008;12:284\u0026ndash;93. https://doi.org/10.1007/s10461-007-9336-2.\u003c/li\u003e\n\u003cli\u003eKrishnan A, Wickersham JA, Chitsaz E, Springer SA, Jordan AO, Zaller N, et al. Post-release substance abuse outcomes among HIV-infected jail detainees: results from a multisite study. AIDS Behav 2013;17 Suppl 2:S171-180. https://doi.org/10.1007/s10461-012-0362-3.\u003c/li\u003e\n\u003cli\u003eParsons JT, Rendina HJ, Lassiter JM, Whitfield THF, Starks TJ, Grov C. Uptake of HIV Pre-Exposure Prophylaxis (PrEP) in a National Cohort of Gay and Bisexual Men in the United States. J Acquir Immune Defic Syndr 1999 2017;74:285\u0026ndash;92. https://doi.org/10.1097/QAI.0000000000001251.\u003c/li\u003e\n\u003cli\u003eFabrigar LR, Wegener DT, MacCallum RC, Strahan EJ. Evaluating the use of exploratory factor analysis in psychological research. Psychol Methods 1999;4:272\u0026ndash;99. https://doi.org/10.1037/1082-989X.4.3.272.\u003c/li\u003e\n\u003cli\u003eShrestha N. Factor Analysis as a Tool for Survey Analysis. Am J Appl Math Stat 2021;9:4\u0026ndash;11. https://doi.org/10.12691/ajams-9-1-2.\u003c/li\u003e\n\u003cli\u003eMinisterio de Trabajo y Promoci\u0026oacute;n del Empleo del Per\u0026uacute;. Decreto Supremo N.\u0026deg; 003-2022-TR n.d. https://www.gob.pe/institucion/mtpe/normas-legales/2890811-003-2022-tr (accessed May 26, 2025).\u003c/li\u003e\n\u003cli\u003eAssaf RD, Konda KA, Torres TS, Vega-Ramirez EH, Elorreaga OA, Diaz-Sosa D, et al. Are men who have sex with men at higher risk for HIV in Latin America more aware of PrEP? PloS One 2021;16:e0255557. https://doi.org/10.1371/journal.pone.0255557.\u003c/li\u003e\n\u003cli\u003eSun Z, Gu Q, Dai Y, Zou H, Agins B, Chen Q, et al. Increasing awareness of HIV pre-exposure prophylaxis (PrEP) and willingness to use HIV PrEP among men who have sex with men: a systematic review and meta-analysis of global data. J Int AIDS Soc 2022;25:e25883. https://doi.org/10.1002/jia2.25883.\u003c/li\u003e\n\u003cli\u003eYi S, Tuot S, Mwai GW, Ngin C, Chhim K, Pal K, et al. Awareness and willingness to use HIV pre-exposure prophylaxis among men who have sex with men in low- and middle-income countries: a systematic review and meta-analysis. J Int AIDS Soc 2017;20:21580. https://doi.org/10.7448/IAS.20.1.21580.\u003c/li\u003e\n\u003cli\u003eG\u0026ouml;ttgens I, Oertelt-Prigione S. The Application of Human-Centered Design Approaches in Health Research and Innovation: A Narrative Review of Current Practices. JMIR MHealth UHealth 2021;9:e28102. https://doi.org/10.2196/28102.\u003c/li\u003e\n\u003cli\u003eCalabrese SK. Understanding, Contextualizing, and Addressing PrEP Stigma to Enhance PrEP Implementation. Curr HIV/AIDS Rep 2020;17:579\u0026ndash;88. https://doi.org/10.1007/s11904-020-00533-y.\u003c/li\u003e\n\u003cli\u003eDubov A, Galbo P, Altice FL, Fraenkel L. Stigma and Shame Experiences by MSM Who Take PrEP for HIV Prevention: A Qualitative Study. Am J Mens Health 2018;12:1843\u0026ndash;54. https://doi.org/10.1177/1557988318797437.\u003c/li\u003e\n\u003cli\u003eFeyissa GT, Lockwood C, Woldie M, Munn Z. Reducing HIV-related stigma and discrimination in healthcare settings: A systematic review of quantitative evidence. PloS One 2019;14:e0211298. https://doi.org/10.1371/journal.pone.0211298.\u003c/li\u003e\n\u003cli\u003eOliveros G\u0026oacute;mez D, Machavariani E, Altice FL, G\u0026aacute;lvez de Le\u0026oacute;n S, Earnshaw V, Montenegro-Idrogo JJ, et al. Influence of Stigma on Engagement in HIV Care and Adherence to Antiretroviral Therapy in Specialized HIV Clinics Targeting Men Who Have Sex with Men and Transgender Women in Lima, Peru. AIDS Behav 2024;28:2755\u0026ndash;68. https://doi.org/10.1007/s10461-024-04401-3.\u003c/li\u003e\n\u003cli\u003ePatel VV, Ginsburg Z, Golub SA, Horvath KJ, Rios N, Mayer KH, et al. Empowering With PrEP (E-PrEP), a Peer-Led Social Media-Based Intervention to Facilitate HIV Preexposure Prophylaxis Adoption Among Young Black and Latinx Gay and Bisexual Men: Protocol for a Cluster Randomized Controlled Trial. JMIR Res Protoc 2018;7:e11375. https://doi.org/10.2196/11375.\u003c/li\u003e\n\u003cli\u003eKudrati SZ, Hayashi K, Taggart T. Social Media \u0026amp; PrEP: A Systematic Review of Social Media Campaigns to Increase PrEP Awareness \u0026amp; Uptake Among Young Black and Latinx MSM and Women. AIDS Behav 2021;25:4225\u0026ndash;34. https://doi.org/10.1007/s10461-021-03287-9.\u003c/li\u003e\n\u003cli\u003eLi C, Xiong Y, Muessig KE, Tang W, Huang H, Mu T, et al. Community-engaged mHealth intervention to increase uptake of HIV pre-exposure prophylaxis (PrEP) among gay, bisexual and other men who have sex with men in China: study protocol for a pilot randomised controlled trial. BMJ Open 2022;12:e055899. https://doi.org/10.1136/bmjopen-2021-055899.\u003c/li\u003e\n\u003cli\u003eMulawa MI, Rosengren AL, Amico KR, Hightow-Weidman LB, Muessig KE. mHealth to reduce HIV-related stigma among youth in the United States: a scoping review. mHealth 2021;7:35. https://doi.org/10.21037/mhealth-20-68.\u003c/li\u003e\n\u003cli\u003eKrishnan A, Ferro EG, Weikum D, Vagenas P, Lama JR, Sanchez J, et al. Communication technology use and mHealth acceptance among HIV-infected men who have sex with men in Peru: implications for HIV prevention and treatment. AIDS Care 2015;27:273\u0026ndash;82. https://doi.org/10.1080/09540121.2014.963014.\u003c/li\u003e\n\u003cli\u003eMobile internet use in Peru by age 2023. Statista n.d. https://www.statista.com/statistics/982795/mobile-internet-user-penetration-rate-peru-age-group/ (accessed May 6, 2025).\u003c/li\u003e\n\u003cli\u003eEncuesta Nacional de Hogares (ENAHO) 2022 - [Instituto Nacional de Estad\u0026iacute;stica e Inform\u0026aacute;tica \u0026ndash; INEI] | Plataforma Nacional de Datos Abiertos n.d. https://datosabiertos.gob.pe/dataset/encuesta-nacional-de-hogares-enaho-2022-instituto-nacional-de-estad%C3%ADstica-e-inform%C3%A1tica-%E2%80%93 (accessed May 6, 2025).\u003c/li\u003e\n\u003cli\u003ePowell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci 2015;10:21. https://doi.org/10.1186/s13012-015-0209-1.\u003c/li\u003e\n\u003cli\u003eYakovchenko V, Chinman MJ, Lamorte C, Powell BJ, Waltz TJ, Merante M, et al. Refining Expert Recommendations for Implementing Change (ERIC) strategy surveys using cognitive interviews with frontline providers. Implement Sci Commun 2023;4:42. https://doi.org/10.1186/s43058-023-00409-3.\u003c/li\u003e\n\u003cli\u003eLovero KL, Kemp CG, Wagenaar BH, Giusto A, Greene MC, Powell BJ, et al. Application of the Expert Recommendations for Implementing Change (ERIC) compilation of strategies to health intervention implementation in low- and middle-income countries: a systematic review. Implement Sci IS 2023;18:56. https://doi.org/10.1186/s13012-023-01310-2.\u003c/li\u003e\n\u003cli\u003eLiu AY, Vittinghoff E, von Felten P, Rivet Amico K, Anderson PL, Lester R, et al. Randomized Controlled Trial of a Mobile Health Intervention to Promote Retention and Adherence to Preexposure Prophylaxis Among Young People at Risk for Human Immunodeficiency Virus: The EPIC Study. Clin Infect Dis Off Publ Infect Dis Soc Am 2019;68:2010\u0026ndash;7. https://doi.org/10.1093/cid/ciy810.\u003c/li\u003e\n\u003cli\u003eLi C, Xiong Y, Maman S, Matthews DD, Fisher EB, Tang W, et al. An instant messaging mobile phone application for promoting HIV pre-exposure prophylaxis uptake among Chinese gay, bisexual and other men who have sex with men: A mixed methods feasibility and piloting randomized controlled trial study. PloS One 2023;18:e0285036. https://doi.org/10.1371/journal.pone.0285036.\u003c/li\u003e\n\u003cli\u003eLin B, Liu J, He W, Pan H, Ma Y, Zhong X. Effect of a Reminder System on Pre-exposure Prophylaxis Adherence in Men Who Have Sex With Men: Prospective Cohort Study Based on WeChat Intervention. J Med Internet Res 2022;24:e37936. https://doi.org/10.2196/37936.\u003c/li\u003e\n\u003cli\u003ePalmer L, Wickersham JA, Gautam K, Maviglia F, Bruno B-D, Azwa I, et al. User preferences for an mHealth app to support HIV testing and pre-exposure prophylaxis uptake among men who have sex with men in Malaysia. PLOS Digit Health 2024;3:e0000643. https://doi.org/10.1371/journal.pdig.0000643.\u003c/li\u003e\n\u003cli\u003eMeyer J, Price C, Tracey D, Sharpless L, Song Y, Madden L, et al. Preference for and Efficacy of a PrEP Decision Aid for Women with Substance Use Disorders. Patient Prefer Adherence 2021;15:1913\u0026ndash;27. https://doi.org/10.2147/PPA.S315543.\u003c/li\u003e\n\u003cli\u003eCelum C, Seidman D, Travill D, Dehlendorf C, Gumede S, Zewdie K, et al. A decision support tool has similar high PrEP uptake and increases early PrEP persistence in adolescent girls and young women in South Africa: results from a randomized controlled trial. J Int AIDS Soc 2023;26:e26154. https://doi.org/10.1002/jia2.26154.\u003c/li\u003e\n\u003cli\u003eShrestha R, Wickersham JA, Khati A, Azwa I, Ni Z, Kamarulzaman A, et al. Clinic-Integrated Mobile Health Intervention (\u0026ldquo;JomPrEP\u0026rdquo; App) to Improve Uptake of HIV Testing and Pre-exposure Prophylaxis Among Men Who Have Sex With Men in Malaysia: Protocol for an Intervention Development and Multiphase Trial. JMIR Res Protoc 2022;11:e43318. https://doi.org/10.2196/43318.\u003c/li\u003e\n\u003cli\u003eShrestha R, Altice FL, Khati A, Azwa I, Gautam K, Gupta S, et al. Clinic-Integrated Smartphone App (JomPrEP) to Improve Uptake of HIV Testing and Pre-exposure Prophylaxis Among Men Who Have Sex With Men in Malaysia: Mixed Methods Evaluation of Usability and Acceptability. JMIR MHealth UHealth 2023;11:e44468. https://doi.org/10.2196/44468.\u003c/li\u003e\n\u003cli\u003eGoorts K, Dizon J, Milanese S. The effectiveness of implementation strategies for promoting evidence informed interventions in allied healthcare: a systematic review. BMC Health Serv Res 2021;21:241. https://doi.org/10.1186/s12913-021-06190-0.\u003c/li\u003e\n\u003cli\u003eKovacs E, Strobl R, Phillips A, Stephan A-J, M\u0026uuml;ller M, Gensichen J, et al. Systematic Review and Meta-analysis of the Effectiveness of Implementation Strategies for Non-communicable Disease Guidelines in Primary Health Care. J Gen Intern Med 2018;33:1142\u0026ndash;54. https://doi.org/10.1007/s11606-018-4435-5.\u003c/li\u003e\n\u003cli\u003ePantoja T, Opiyo N, Lewin S, Paulsen E, Ciapponi A, Wiysonge CS, et al. Implementation strategies for health systems in low-income countries: an overview of systematic reviews. Cochrane Database Syst Rev 2017;9:CD011086. https://doi.org/10.1002/14651858.CD011086.pub2.\u003c/li\u003e\n\u003cli\u003eReisner SL, Apedaile D, Silva-Santisteban A, Huerta L, Aguayo-Romero R, Perez-Brumer A. The PrEP cascade in a sample of HIV-negative or unknown status adolescent and young adult transgender women in Peru. Int J STD AIDS 2025;36:141\u0026ndash;50. https://doi.org/10.1177/09564624241272940.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"HIV prevention, Pre-exposure prophylaxis (PrEP), Men who have sex with men (MSM), Implementation science, Health behavior, Peru","lastPublishedDoi":"10.21203/rs.3.rs-7843241/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7843241/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eIn 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.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eBetween 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.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAmong 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.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eDespite 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.\u003c/p\u003e","manuscriptTitle":"Identifying Implementation Gaps in the HIV Prevention Cascade Among Peruvian Men Who Have Sex with Men","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-14 06:27:00","doi":"10.21203/rs.3.rs-7843241/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"314b32c6-d2f6-42ed-9cfb-edf3e7d5eb97","owner":[],"postedDate":"October 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":56163401,"name":"Infectious Diseases"},{"id":56163402,"name":"Preventive Medicine"}],"tags":[],"updatedAt":"2025-10-14T06:27:00+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-14 06:27:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7843241","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7843241","identity":"rs-7843241","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}