Background: The role of universal access to treatment in combination HIV prevention has been established. Estimation of coverage across steps in a continuum of care cascade (CCC), a key approach to monitor progress and identify barriers, is novel in Peru and most of Latin America. We aimed to build an estimation of the CCC for Peru, identify potential barriers defining losses across the process, and establish data gaps. Methodology: We assessed whether a single CCC estimate was appropriate, as opposed to subpopulation-specific CCC estimations. As data across the CCC estimates came from different sources, we sought to identify more than one source for each CCC step when possible. Where relevant, we sought to sub-classify numbers within each step (e.g. high or low CD4 counts among those newly positives). For MSM, we drew on existing data, from both peerreviewed publications and official estimates (i.e. Government bulletins) to estimate coverage for the CCC steps in Peru, including: total number of positives (1,2), % who know their status (3,4), % who have access to care (5), % who have started treatment (5), % who are adherent to ARV (6,7), and % who are virally suppressed (8).

References: 1) Ministerio de Salud. Informe Nacional sobre los progresos realizados en VIH en el país – Período 2009-2010 (UNGASS). Lima 2011. 2. 2) Dirección General de Epidemiología. Modos de Transmisión del VIH en el Perú: Resultados de la aplicación del modelo. MINSA 2010. Lima, Perú. 3) Dirección General de Epidemiología- IMPACTA. Vigilancia Epidemiológica en VIH en Población HSH 2011. MINSA 2011. Lima, Perú. 4) Caceres CF, et al. Comunidades Positivas: HIV Prevention intervention for MSM in Lima, Peru. Preliminary data. 5) Silva-Santisteban A, Segura E, Sandoval C, Giron M, Petrera M, Caceres CF. Determinants of unequal HIV care access among people living with HIV in Peru. Globalization and Health. 2013; 17;9(1):22. 6) Ministerio de Salud. Informe Nacional sobre los progresos realizados en VIH en el país – Período 2010-2011 (UNGASS). Lima 2012. 7) CARE Peru. Evaluación final del programa intervención en VIH VI Ronda. Lima, 2013. 8) Carina C, Shepherd BE, Krolewiecki AJ, et al. Rates and reasons for early change of first HAART in HIV-1-infected patients in 7 sites throughout the Caribbean and Latin America. PloS one. 2010 Jan;5(6):e10490.

Results: Of 75,000 adults estimated to be living with HIV in Peru in 2013, 22,000 were women. Tested primarily in connection with reproductive health services, they generally showed a better CCC profile than men, with earlier access to and higher retention in care, and more frequent viral suppression after 6 months. Among men, data are available primarily for MSM and male-to-female transwomen (TW). Key barriers across the CCC include: low HIV testing rates (only 27% of HIV+ know their status) and late registration in care (as reflected in CD4 counts around 100 at ARVT initiation) . Only 18% were virally supressed . Conclusions: The CCC for women in Peru shows progress towards universal access, reflecting success of programs to prevent mother to child transmission, and possibly better health seeking. For MSM/TW, active promotion and facilitation of biannual HIV testing is needed to improve serostatus awareness, linked with easier access to care, with strategies to avoid losses to follow up prior to ARVT initiation. Data for for other men are extremely limited. An integrated, reliable information system to monitor progress is needed.