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ABSTRACT Background As direct acting antiviral (DAA) therapy is progressively rolled out for patients with hepatitis C virus (HCV) infection, careful scrutiny of HCV epidemiology, diagnostic testing, and access to care is crucial to underpin improvements in delivery of treatment. Methods We performed a retrospective study of HCV infection in a UK teaching hospital to evaluate the performance of different diagnostic laboratory tests, to describe the population with active HCV infection, and to determine the proportion of these individuals who access clinical care. Results Over a total time period of 33 months between 2013 and 2016, we tested 38,510 individuals for HCV infection and confirmed a new diagnosis of active HCV infection (HCV-Ag+ and/or HCV RNA+) in 359 (positive rate 0.9%). Our in-house HCV-Ab test had a positive predictive value of 87% when compared to repeat HCV-Ab testing in a regional reference laboratory, highlighting the potential for false positives to arise based on a single round of antibody-based screening. Of those confirmed Ab-positive, 70% were HCV RNA positive. HCV-Ag screening performed well, with 100% positive predictive value compared to detection of HCV RNA. There was a strong correlation between quantitative HCV-Ag and HCV RNA viral load (p<0.0001). Among the 359 cases of infection, the median age was 37 years, 85% were male, and 36% were in prison. Among 250 infections for which genotype was available, HCV genotype-1 (n=110) and genotype-3 (n=111) accounted for the majority. 117/359 (33%) attended a clinic appointment and 48 (13%) had curative treatment defined as sustained virologic response at 12 weeks (SVR 12 ). Conclusions HCV-Ab tests should be interpreted with caution as an indicator of population prevalence of HCV infection, both as a result of the detection of individuals who have cleared infection and due to false positive test results. We demonstrate that active HCV infection is over-represented among men and in the prison population. A minority of patients with a diagnosis of HCV infection access clinical care and therapy; enhanced efforts are required to target diagnosis and providing linkage to clinical care within high risk populations. ABBREVIATIONS <jats:def-list><jats:def-item> DAA Direct Acting Antiviral <jats:def-item> ELISA Enzyme linked immunosorbent assay <jats:def-item> HCV Hepatitis C Virus <jats:def-item> HCV-Ab IgG antibody to Hepatitis C virus <jats:def-item> HCV-Ag Hepatitis C virus core antigen <jats:def-item> HCV RNA Hepatitis C ribonucleic acid (viral load) <jats:def-item> MSM men who have sex with men <jats:def-item> NAT nucleic acid testing <jats:def-item> PCR polymerase chain reaction (test for viral load) <jats:def-item> PPV positive predictive value <jats:def-item> PWID people who inject drugs <jats:def-item> SDG Sustainable Development Goals <jats:def-item> SVR sustained virologic response <jats:def-item> WHO World Health Organisation

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