BACKGROUNDPre-exposure prophylaxis (PrEP) provision routes across Europe differ notably between governmental and non-governmental pathways. The introduction of long-acting (LA)-PrEP may further diversify provision dynamics.AIMWe investigated disparities in PrEP access and whether access pathways determine oral PrEP use patterns and LA-PrEP intention among PrEP-experienced men who have sex with men (MSM).METHODSUsing data from 7,505 PrEP-experienced MSM from a cross-sectional survey (PROTECT; 20 European countries, October 2023-April 2024), we used latent class analysis (LCA) to identify MSM's latent socioeconomic positions (SEPs), and logistic regression to compare the likelihood of accessing governmental/non-governmental pathways, and compare oral PrEP adherence, discontinuation and LA-PrEP intention between governmental/non-governmental pathways.RESULTSMost MSM accessed PrEP via governmental pathways (n = 6,671; 88.9%), 11.1% (n = 834) used non-governmental pathways. The LCA identified three groups: employed MSM with more advantaged SEPs, younger MSM with less advantaged SEPs, and older MSM with more advantaged SEPs. Compared with the first group, younger MSM with less advantaged SEPs were significantly more likely to access PrEP via non-governmental pathways (aOR = 1.27; 95% confidence interval (CI): 1.04-1.55). Accessing PrEP via non-governmental pathways was associated with suboptimal adherence (aOR = 1.28; 95% CI: 1.03-1.58), discontinuation (aOR = 3.55; 95% CI: 2.99-4.21), but also higher LA-PrEP intention (aOR = 1.28; 95% CI: 1.06-1.56).CONCLUSIONSInequalities exist in PrEP access among MSM in Europe. While non-governmental pathways offer opportunities to engage MSM with less advantaged SEPs, oral PrEP use patterns via this pathway were not optimal. Tailored efforts should ensure that PrEP is accessible and affordable to enhance current use and prepare for future LA-PrEP modalities.