Background: Pregnant women should be tested for HIV at least once to prevent mother-to-child transmission (MTCT) of HIV. In addition, there are unknown disparities in access to HIV services that result in HIV non-testing, leading to a high risk of MTCT. This study aimed to analyze trends of antenatal HIV testing coverage in Peru over the last 12 years and to perform a machine learning-based model to identify the most suitable predictors that increase the probability that a woman not being tested for HIV during pregnancy. Methods: Data compiled from annual Demographic and Health Surveys (2010 - 2021) were analyzed. Overall, 37526 women aged 15-45 years met the inclusion criteria. Evolution of HIV testing coverage was assessed according to education level and wealth index. Regarding machine learning models, three algorithms were included: XGBoost, Decision Tree, and LightGBM. Data from 2010 to 2019 was split into 80% (training and validation) and 20% (testing), further validation was conducted using 2021 data. Model performance was evaluated according to an f1 score, sensitivity, and specificity. Variable importance of the best model was estimated according to the Gain metric. All analyses were carried out using R software. Results: HIV testing coverage increased (from 73.3% to 90.5%) between 2010 and 2019, although it decreased (59.7%) in 2020, and increased moderately (83.8%) in 2021. This coverage varied by education level (47.8% of women with none/preschool education were tested for HIV, while 91.9% of women with higher education were tested), and wealth index (61.1% of poorest women were tested for HIV, while 94.5% of richest women were tested). The XGBoost model showed the best performance with an f1 score of 0.883, sensitivity of 68.7%, and specificity of 82.5%. Top five predictors for not getting tested for HIV were residing in an urban area, not knowing any sexually transmitted disease (STD), the poorest wealth index, not knowing any STD symptoms, and none/preschool education level. Conclusion: Over the last 12 years, antenatal HIV testing has reached high coverage; however, it is still below the UNAIDS goal of 95%. Efforts should be concentrated on pregnant women with lower levels of wealth, education, and knowledge about HIV/STD. [ABSTRACT FROM AUTHOR]