“They Should Lay It All on the Table”: Oral PrEP Perceptions Among Men Who Have Sex with Men in Portugal

Abstract Portugal is among the Western European countries with the highest rates of new HIV diagnoses. Despite pre-exposure prophylaxis (PrEP) efficacy in reducing HIV transmission, adherence rates remain below UNAIDS targets, even among key populations. A qualitative study was conducted with 17 semi-structured interviews with men who have sex with men (MSM) living in Portugal, both PrEP users and non-users. Data were analyzed using content analysis combined with elements of consensual qualitative research, informed by the PrEP care continuum as an organizing framework. Findings showed that interconnected structural, psychosocial, and individual factors across the care continuum shape PrEP engagement. Specifically, community-based services and peer networks are central in facilitating awareness and uptake, although their limited availability outside urban areas creates barriers for individuals living in rural areas. Stigma related to PrEP use emerged as a cross-cutting barrier, particularly among individuals with intersecting marginalized identities, and was associated with concerns about sexual identity and disclosure. Perceived HIV risk influences engagement with PrEP, with higher perceived risk facilitating awareness, uptake, and adherence, whereas lower perceived risk was associated with reduced interest and PrEP discontinuation. The study contributes to understanding PrEP implementation among MSM in Portugal and supports ongoing efforts to integrate PrEP into primary healthcare following models already established for other prophylactic interventions.