Capacity building and predictors of success for HIV-1 drug resistance testing in the Asia-Pacific region and Africa

Background

The TREAT Asia Quality Assessment Scheme (TAQAS) was developed as a quality assessment programme through expert education and training, for laboratories in the Asia-Pacific and Africa that perform HIV drug-resistance (HIVDR) genotyping. We evaluated the programme performance and factors associated with high-quality HIVDR genotyping.

Methods

Laboratories used their standard protocols to test panels of human immunodeficiency virus (HIV)-positive plasma samples or electropherograms. Protocols were documented and performance was evaluated according to a newly developed scoring system, agreement with panel-specific consensus sequence, and detection of drug-resistance mutations (DRMs) and mixtures of wild-type and resistant virus (mixtures). High-quality performance was defined as detection of ≥95% DRMs.

Results

Over 4.5 years, 23 participating laboratories in 13 countries tested 45 samples (30 HIV-1 subtype B; 15 non-B subtypes) in nine panels. Median detection of DRMs was 88–98% in plasma panels and 90–97% in electropherogram panels. Laboratories were supported to amend and improve their test outcomes as appropriate. Three laboratories that detected <80% DRMs in early panels demonstrated subsequent improvement. Sample complexity factors – number of DRMs (p<0.001) and number of DRMs as mixtures (p<0.001); and laboratory performance factors – detection of mixtures (p<0.001) and agreement with consensus sequence (p<0.001), were associated with high performance; sample format (plasma or electropherogram), subtype and genotyping protocol were not.

Conclusion

High-quality HIVDR genotyping was achieved in the TAQAS collaborative laboratory network. Sample complexity and detection of mixtures were associated with performance quality. Laboratories conducting HIVDR genotyping are encouraged to participate in quality assessment programmes.     

Towards more accurate HIV testing in sub‐Saharan Africa: a multi‐site evaluation of HIV RDTs and risk factors for false positives

Introduction : Although individual HIV rapid diagnostic tests (RDTs) show good performance in evaluations conducted by WHO, reports from several African countries highlight potentially significant performance issues. Despite widespread use of RDTs for HIV diagnosis in resource‐constrained settings, there has been no systematic, head‐to‐head evaluation of their accuracy with specimens from diverse settings across sub‐Saharan Africa. We conducted a standardized, centralized evaluation of eight HIV RDTs and two simple confirmatory assays at a WHO collaborating centre for evaluation of HIV diagnostics using specimens from six sites in five sub‐Saharan African countries. Methods : Specimens were transported to the Institute of Tropical Medicine (ITM), Antwerp, Belgium for testing. The tests were evaluated by comparing their results to a state‐of‐the‐art reference algorithm to estimate sensitivity, specificity and predictive values. Results : 2785 samples collected from August 2011 to January 2015 were tested at ITM. All RDTs showed very high sensitivity, from 98.8% for First Response HIV Card Test 1–2.0 to 100% for Determine HIV 1/2, Genie Fast, SD Bioline HIV 1/2 3.0 and INSTI HIV‐1/HIV‐2 Antibody Test kit. Specificity ranged from 90.4% for First Response to 99.7% for HIV 1/2 STAT‐PAK with wide variation based on the geographical origin of specimens. Multivariate analysis showed several factors were associated with false‐positive results, including gender, provider‐initiated testing and the geographical origin of specimens. For simple confirmatory assays, the total sensitivity and specificity was 100% and 98.8% for ImmunoComb II HIV 12 CombFirm (ImmunoComb) and 99.7% and 98.4% for Geenius HIV 1/2 with indeterminate rates of 8.9% and 9.4%. Conclusions : In this first systematic head‐to‐head evaluation of the most widely used RDTs, individual RDTs performed more poorly than in the WHO evaluations: only one test met the recommended thresholds for RDTs of ≥99% sensitivity and ≥98% specificity. By performing all tests in a centralized setting, we show that these differences in performance cannot be attributed to study procedure, end‐user variation, storage conditions, or other methodological factors. These results highlight the existence of geographical and population differences in individual HIV RDT performance and underscore the challenges of designing locally validated algorithms that meet the latest WHO‐recommended thresholds.     

Fibrosing Cholestatic Hepatitis in HIV/HCV Co‐Infected Transplant Patients—Usefulness of Early Markers After Liver Transplantation

We characterized fibrosing cholestatic hepatitis (FCH) in a large cohort of HIV/HCV co‐infected patients. Between 1999 and 2008, 59 HIV infected patients were transplanted for end‐stage liver disease due to HCV. Eleven patients (19%) developed FCH within a mean period of 7 months [2–27] after liver transplantation (LT). At Week 1 post‐LT, the mean HCV viral load was higher in the FCH group: 6.13 log₁₀ IU/mL ± 1.30 versus 4.9 log₁₀ IU/mL ± 1.78 in the non‐FCH group, p = 0.05. At the onset of acute hepatitis after LT, activity was moderate to severe in 8/11 HIV+/HCV+ patients with FCH (73%) versus 13/28 (46%) HIV+/HCV+ non‐FCH (p = 0.007) patients. A complete virological response to anti‐HCV therapy was observed in 2/11 (18%) patients. Survival differed significantly between the two groups (at 3 years, 67% in non‐FCH patients versus 15% in FCH patients, p = 0.004). An early diagnosis of FCH may be suggested by the presence of marked disease activity when acute hepatitis is diagnosed and when a high viral load is present. The initiation of anti‐HCV therapy should be considered at this point.     

Finding a cure for HIV: will it ever be achievable?

Combination antiretroviral therapy (cART) has led to a major reduction in HIV‐related mortality and morbidity. However, HIV still cannot be cured. With the absence of an effective prophylactic or therapeutic vaccine, increasing numbers of infected people, emerging new toxicities secondary to cART and the need for life‐long treatment, there is now a real urgency to find a cure for HIV. There are currently multiple barriers to curing HIV. The most significant barrier is the establishment of a latent or “silent” infection in resting CD4+ T cells. In latent HIV infection, the virus is able to integrate into the host cell genome, but does not proceed to active replication. As a consequence, antiviral agents, as well as the immune system, are unable to eliminate these long‐lived, latently infected cells. Reactivation of latently infected resting CD4+ T cells can then re‐establish infection once cART is stopped. Other significant barriers to cure include residual viral replication in patients receiving cART, even when the virus is not detectable by conventional assays. In addition, HIV can be sequestered in anatomical reservoirs, such as the brain, gastrointestinal tract and genitourinary tract. Achieving either a functional cure (long‐term control of HIV in the absence of cART) or a sterilizing cure (elimination of all HIV‐infected cells) remains a major challenge. Several studies have now demonstrated that treatment intensification appears to have little impact on latent reservoirs. Some potential and promising approaches that may reduce the latent reservoir include very early initiation of cART and the use of agents that could potentially reverse latent infection. Agents that reverse latent infection will promote viral production; however, simultaneous administration of cART will prevent subsequent rounds of viral replication. Such drugs as histone deacetylase inhibitors, currently used and licensed for the treatment of some cancers, or activating latently infected resting cells with cytokines, such as IL‐7 or prostratin, show promising results in reversing latency in vitro when used either alone or in combination. In order to move forward toward clinical trials that target eradication, there needs to be careful consideration of the risks and benefits of these approaches, agreement on the most informative endpoints for eradication studies and greater engagement of the infected community.     

High acceptability of cognitive screening in HIV‐infected patients: a pilot study

With combined antiretroviral therapy (cART) life expectancy of HIV‐infected persons is close to the one of non‐infected persons. Identifying neurocognitive deficits in ageing HIV‐infected individuals is important. This study aimed to evaluate the acceptability of screening neurocognitive deficits in HIV‐infected patients. Thirty patients (26 men, 4 women) from the HIV clinic were examined with a new screening test and an in‐depth neuropsychological examination. The screening tests consisted of questions and examinations on cognition in everyday situations, mood and selected cognitive functions (word list memory, grooved pegboard, psychomotor speed, trail‐making test, psychomotor speed and executive functions, digit symbol test). Also, patients received a questionnaire to evaluate test acceptance. The mean age of the patients was 52.5 (30–74) years, mean education 12.5 (8–18) years. Seven patients had HIV‐stage CDC A, 12 B and 11 CDC stage C. The mean CD4 count was 657 cells/µl, the mean HIV viral load<20 cop./µl. All patients were treated with cART (7 with efavirenz). The screening test was done assisted by a nurse and lasted 26 minutes (mean). The screening indicated pathological signs of neurocognitive function in 11 (42%) patients. The in‐depth neuropsychological assessment revealed pathological conditions in 25 (83%) of patients; i.e. 16 (53%) patients had ANI (asymptomatic neurocognitive impairment), 8 (27%) had MND (mild neurocognitive disorder) and 1 (3%) had HAD (HIV‐associated dementia). Most patients (43.3%) judged the test as not too difficult and 56.6% as partly difficult. 96.6% of patients viewed the instructions of nurses as clear, 3.3% as unclear. 93.3% felt the test has not affected privacy and 83.3% estimated the screening as valuable and not worriesome. 83.4% of all patients were interested in their results and for none of the patients the test was too long. The test acceptability by the study nurses was also good. Only in 3.4% of tested persons they judged the test as too difficult for the patient. In 86.7% of tests they estimated the screening as valuable and in again 86.7% as not worrisome. For none of the nurses the test duration was too long. Only 16.6% of the patients had a completely normal neurocognitive testing. A short screening test lasting less than half an hour to search neurocognitive disorders assisted by a nurse is widely accepted by patients and nurses.     

Improving early identification of HIV‐infected neonates with birth PCR testing in a large urban hospital in Johannesburg,South Africa: successes and challenges

Introduction : Timely diagnosis is necessary to avert early death in HIV‐infected neonates. Birth PCR testing may improve early identification and facilitate access to care. We implemented a birth HIV diagnosis programme in Johannesburg, South Africa and present successes and challenges of the first two and a half years of operation. Methods : Between June 2014 and December 2016, we sought to identify all HIV‐exposed births and offer newborn HIV PCR testing before discharge after delivery. The programme identified newly delivered women who had tested positive during pregnancy and provided post‐partum HIV antibody testing for women without recent negative results. HIV‐positive women were required to consent for neonatal birth testing and asked to return a week later to obtain their results. Neonatal venous blood was sampled and tested at the national laboratory using Roche COBAS® TaqMan® HIV‐1 Qualitative Test (Version 2.0). Non‐negative results triggered active follow‐up for confirmatory testing and appropriate treatment. Results : Of 30,591 women with live births, 6864 (22.4%) were known to be HIV positive and an additional 221 women (1.4% of those tested) were identified during maternal postnatal testing. Of 7085 HIV‐positive women, 6372 (89.9%) were interviewed and agreed to data collection, 6358 (99.8%) consented to birth testing for 6467 neonates and a blood sample was collected for 6377 (98.6%). If tested, 6210 (97.4%) tested negative, 91 (1.4%) positive, 57 (0.9%) revealed errors and 19 (0.3%) were indeterminate . Seven of the 19 neonates with indeterminate results and one with initial error result were found to be infected on subsequent testing yielding an intrauterine transmission rate of 1.6% (95% CI: 1.3–1.9). Sixteen (16%) of 99 infected infants were born to women (n = 221) identified during postnatal testing. With active outreach, 95/99 (96%) infected infants were initiated on antiretroviral therapy. Of 6261 neonates with negative results, 3251 (52%) returned to receive their test results. Conclusion : Our programme successfully achieved high coverage and uptake of birth PCR testing and was able, with active tracking, to start almost all identified HIV‐infected neonates on antiretroviral therapy. Implementation required additional staff for counselling, quality control and outreach. Return for negative results was low and neonates with indeterminate results required multiple repeat tests.     

The Importance of Quality Assurance/Quality Control of Diagnostics to Increase the Confidence in Global Foot‐and‐Mouth Disease Control

The last decade international trade in animals and animal products was liberated and confidence in this global trade can increase only if appropriate control measures are applied. As foot‐and‐mouth disease (FMD) diagnostics will play an essential role in this respect, the Food and Agriculture Organization European Commission for the Control of Foot‐and‐Mouth Disease (EUFMD) co‐ordinates, in collaboration with the European Commission, several programmes to increase the quality of FMD diagnostics. A quality assurance (QA) system is deemed essential for laboratories involved in certifying absence of FMDV or antibodies against the virus. Therefore, laboratories are encouraged to validate their diagnostic tests fully and to install a continuous quality control (QC) monitoring system. Knowledge of performance characteristics of diagnostics is essential to interpret results correctly and to calculate sample rates in regional surveillance campaigns. Different aspects of QA/QC of classical and new FMD virological and serological diagnostics are discussed in respect to the EU FMD directive (2003/85/EC). We recommended accepting trade certificates only from laboratories participating in international proficiency testing on a regular basis.     

Options for Decentralized Testing of Suspected Secondary Outbreaks of Foot‐and‐mouth Disease

This article reviews the options for use of virus detection techniques for decentralized testing of samples from suspected secondary outbreaks of foot‐and‐mouth disease (FMD). These options have been expanded by the advent of new tests including disposable lateral flow devices (LFDs) that detect viral proteins and portable RT‐PCR equipment that detects viral RNA. LFDs have been developed with similar sensitivity to antigen detection ELISA but with the ability to provide a result 1–30 min after the addition of epithelium or vesicular fluid. Portable RT‐PCR platforms are being developed that can detect FMD viral RNA in blood, epithelium or other materials with minimal sample processing and with high sensitivity, in as little as 60 min in some cases. These devices may be used on infected farms as pen‐side tests, in regional, local or mobile laboratories, or in National Reference Laboratories (NRL). Advantages and disadvantages of different testing options are considered to inform decisions on the optimal strategies for different national circumstances. Issues include validation and quality control, containment needs, availability of test devices and reagents, the decision tree for declaring an outbreak, training issues and provision of samples for subsequent viral characterization. Tests to confirm the diagnosis of the index case of an outbreak of FMD should continue to be carried out in the NRL.     

HIV treatment for prevention

“No virus, no transmission.” Studies have repeatedly shown that viral load (the quantity of virus present in blood and sexual secretions) is the strongest predictor of HIV transmission during unprotected sex or transmission from infected mother to child. Effective treatment lowers viral load to undetectable levels. If one could identify and treat all HIV‐infected people immediately after infection, the HIV/AIDS epidemic would eventually disappear. Such a radical solution is currently unrealistic. In reality, not all people get tested, especially when they fear stigma and discrimination. Thus, not all HIV‐infected individuals are known. Of those HIV‐positive individuals for whom the diagnosis is known, not all of them have access to therapy, agree to be treated, or are taking therapy effectively. Some on effective treatment will stop, and in others, the development of resistance will lead to treatment failure. Furthermore, resources are limited: should we provide drugs to asymptomatic HIV‐infected individuals without indication for treatment according to guidelines in order to prevent HIV transmission at the risk of diverting funding from sick patients in urgent need? In fact, the preventive potential of anti‐HIV drugs is unknown. Modellers have tried to fill the gap, but models differ depending on assumptions that are strongly debated. Further, indications for antiretroviral treatments expand; in places like Vancouver and San Francisco, the majority of HIV‐positive individuals are now under treatment, and the incidence of new HIV infections has recently fallen. However, correlation does not necessarily imply causation. Finally, studies in couples where one partner is HIV‐infected also appear to show that treatment reduces the risk of transmission. More definite studies, where a number of communities are randomized to either receive the “test‐and‐treat” approach or continue as before, are now in evaluation by funding agencies. Repeated waves of testing would precisely measure the incidence of HIV infection. Such trials face formidable logistical, practical and ethical obstacles. However, without definitive data, the intuitive appeal of “test‐and‐treat” is unlikely to translate into action on a global scale. In the meantime, based on the available evidence, we must strive to provide treatment to all those in medical need under the current medical guidelines. This will lead to a decrease in HIV transmission while “test‐and‐treat” is fully explored in prospective clinical trials.     

Utilisation of pathology procedures in the South African private pathology sector between 2003 and 2005.

OBJECTIVE: To analyse the patterns of pathology procedures performed in the private pathology sector in South Africa. To determine what the differences between the individual practices are and to attempt to explain any differences. DESIGN: A retrospective analysis of claims from pathology laboratories submitted by electronic interface to a medical aid administrator between January 2003 up to December 2005 were analysed. The data were sorted according to the practice number of the pathology laboratory and referring doctor, account number, laboratory number, beneficiary number and the origin of the claim (in hospital or out of hospital). The number of claims for every procedure was compared across different laboratories. RESULTS: Sufficient data were available on 5.4 million claim lines over the 3-year period (92% of the total lines submitted over the period). The total amount claimed increased by 2.5% and 9.9%, the number of test procedures increased by 1.4% and 17.7%, and the number of accounts increased by 4.8% and 0.9% in 2004 and 2005 respectively. These increases occurred despite a decrease in active beneficiaries of 1.6% and 4.0% in 2004 and 2005. The average cost per active beneficiary per month varied between R494 and R611 in 2005. A relatively few common test procedures (30) contributed disproportionately to the total number of procedures (67.8%) and cost (56.9%) of laboratory testing. The utilisation of individual procedures varied between laboratories with large differences in the performance of common tests such as erythrocyte sedimentation rate, reticulocyte count, protein electrophoresis and creatinine. CONCLUSION: The differences in the cost of pathology claims between individual laboratories were larger than expected. There was evidence of inappropriate test utilisation. Part of the differences between laboratories under control of the laboratories and are a result of request form design, test profile content and reflexing of tests.     

Clinical and public health implications of acute and early HIV detection and treatment: a scoping review

Introduction : The unchanged global HIV incidence may be related to ignoring acute HIV infection (AHI). This scoping review examines diagnostic, clinical, and public health implications of identifying and treating persons with AHI. Methods : We searched PubMed, in addition to hand‐review of key journals identifying research pertaining to AHI detection and treatment. We focused on the relative contribution of AHI to transmission and the diagnostic, clinical, and public health implications. We prioritized research from low‐ and middle‐income countries (LMICs) published in the last fifteen years. Results and Discussion : Extensive AHI research and limited routine AHI detection and treatment have begun in LMIC. Diagnostic challenges include ease‐of‐use, suitability for application and distribution in LMIC, and throughput for high‐volume testing. Risk score algorithms have been used in LMIC to screen for AHI among individuals with behavioural and clinical characteristics more often associated with AHI. However, algorithms have not been implemented outside research settings. From a clinical perspective, there are substantial immunological and virological benefits to identifying and treating persons with AHI – evading the irreversible damage to host immune systems and seeding of viral reservoirs that occurs during untreated acute infection. The therapeutic benefits require rapid initiation of antiretrovirals, a logistical challenge in the absence of point‐of‐care testing. From a public health perspective, AHI diagnosis and treatment is critical to: decrease transmission via viral load reduction and behavioural interventions; improve pre‐exposure prophylaxis outcomes by avoiding treatment initiation for HIV‐seronegative persons with AHI; and, enhance partner services via notification for persons recently exposed or likely transmitting. Conclusions : There are undeniable clinical and public health benefits to AHI detection and treatment, but also substantial diagnostic and logistical barriers to implementation and scale‐up. Effective early ART initiation may be critical for HIV eradication efforts, but widespread use in LMIC requires simple and accurate diagnostic tools. Implementation research is critical to facilitate sustainable integration of AHI detection and treatment into existing health systems and will be essential for prospective evaluation of testing algorithms, point‐of‐care diagnostics, and efficacious and effective first‐line regimens.     

Rapid and simple detection of foot‐and‐mouth disease virus: Evaluation of a cartridge‐based molecular detection system for use in basic laboratories

Highly contagious transboundary animal diseases such as foot‐and‐mouth disease (FMD ) are major threats to the productivity of farm animals. To limit the impact of outbreaks and to take efficient steps towards a timely control and eradication of the disease, rapid and reliable diagnostic systems are of utmost importance. Confirmatory diagnostic assays are typically performed by experienced operators in specialized laboratories, and access to this capability is often limited in the developing countries with the highest disease burden. Advances in molecular technologies allow implementation of modern and reliable techniques for quick and simple pathogen detection either in basic laboratories or even at the pen‐side. Here, we report on a study to evaluate a fully automated cartridge‐based real‐time RT ‐PCR diagnostic system (Enigma MiniLab^®) for the detection of FMD virus (FMDV ). The modular system integrates both nucleic acid extraction and downstream real‐time RT ‐PCR (rRT ‐PCR ). The analytical sensitivity of this assay was determined using serially diluted culture grown FMDV , and the performance of the assay was evaluated using a selected range of FMDV positive and negative clinical samples of bovine, porcine and ovine origin. The robustness of the assay was evaluated in an international inter‐laboratory proficiency test and by deployment into an African laboratory. It was demonstrated that the system is easy to use and can detect FMDV with high sensitivity and specificity, roughly on par with standard laboratory methods. This cartridge‐based automated real‐time RT ‐PCR system for the detection of FMDV represents a reliable and easy to use diagnostic tool for the early and rapid disease detection of acutely infected animals even in remote areas. This type of system could be easily deployed for routine surveillance within endemic regions such as Africa or could alternatively be used in the developed world.     

Association Between Duration of Human Immunodeficiency Virus (HIV)–1 Viral Suppression Prior to Renal Transplantation and Acute Cellular Rejection

Renal transplant has become an important option for human immunodeficiency virus (HIV)–infected patients with end‐stage renal disease; however, these patients experience a high rate of acute cellular rejection (ACR). Guidelines do not currently exist for the optimal duration of viral suppression prior to transplantation. In a retrospective cohort analysis of 47 HIV‐infected renal transplant recipients, we compared the rate of ACR between patients based on the length of time of viral suppression prior to transplantation. Of the patients who achieved viral suppression for >6 months but less than 2 years prior to transplantation (n = 15), 60% experienced ACR compared to 41% of patients suppressed at least 2 years or more (n = 32) prior to transplant (p = 0.21). Patients suppressed <2 years experienced ACR at 2.48 times the rate of those suppressed 2 years or longer. Induction immunosuppression, HLA mismatch and panel‐reactive antibodies (PRAs) did not significantly differ between the two groups.     

A prospective evaluation of lower extremity ulcers in a Zimbabwean population

Aetiological factors and their frequencies, causes, level and impact of immunosuppression on outcome of lower extremity ulcers were prospectively recorded. A total of 100 patients were evaluated. Consent for HIV testing was given by 68 patients and 31 (46%) of these were HIV infected. Thirty patients were diabetic. CD 4+ T‐lymphocyte count was assessed in 41 patients. Eleven were HIV infected with a mean CD 4+ count of 229 ± 137 cells/µl. Six had non insulin‐dependent diabetes mellitus (NIDDM) with a mean CD 4+ count 430 ± 308 cells/µl. Five had both HIV infection and NIDDM with a mean CD 4+ count of 299 ± 120 cells/µl. All three groups differed from the normal 707 ± 285 cells/µl found in 17 non HIV‐infected non diabetic patients (P < 0· 05). The main aetiologies were bacterial infection, arterial disease, trauma and neuropathy. Ulcer healing and limb salvage were noted in 71%. Mortality was 10%; seven in HIV‐infected and three in non HIV‐infected non diabetic patients (P = 0· 06). Amputation rate was 9%. Persisting ulcers were noted in 8% and 2% were lost to follow‐up. Our evaluation shows that wound aetiologies in Zimbabwe differ from those in the West. Immunosuppression because of HIV infection and NIDDM was noted in more than half of the patients. HIV infection may increase mortality in this group of patients.     

Clinical utility of HCV core antigen detection and quantification using serum samples and dried blood spots in people who inject drugs in Dar‐es‐Salaam,Tanzania

Introduction : A lack of access to hepatitis C virus (HCV) diagnostics is a significant barrier to achieving the World Health Organization 2030 global elimination goal. HCV core antigen (HCVcAg) quantification and dried blood spot (DBS) are appealing alternatives to conventional HCV serology and nucleic acid testing (NAT) for resource‐constraint settings, particularly in difficult‐to‐reach populations. We assessed the accuracy of serum and DBS HCVcAg testing in people who inject drugs in Tanzania using HCV NAT as a reference. Method : Between May and July 2015, consecutive HCV‐seropositive patients enrolled in the local opioid substitution treatment centre were invited to participate in the study. All had HCV RNA detection (Roche Molecular Systems, Pleasanton, CA, USA), genotyping (NS5B gene phylogenetic analysis) and HCVcAg on blood samples and DBS (Architect assay; Abbott Diagnostics, Chicago, IL, USA). Results : Out of 153 HCV‐seropositive individuals, 65 (42.5%) and 15 (9.8%) were co‐infected with HIV (41 (63%) were on anti‐retroviral therapy (ARVs)) and hepatitis B respectively. In total, 116 were viraemic, median viral load of 5.7 (Interquartile range (IQR); 4.0–6.3) log iU/ml (75 (68.2%) were genotype 1a, 35 (31.8%) genotype 4a). The median alanine transaminase (ALT) (iU/l), aspartate transaminase (AST) (iU/l) and gamma‐glutamyl transferase (GGT) (iU/l) were 35 (IQR; 23–51), 46 (32–57) and 69 (35–151) respectively. For the quantification of HCV RNA, serum HCVcAg had a sensitivity at 99.1% and a specificity at 94.1%, with an area under the receiver operating curve (AUROC) at 0.99 (95% CI 0.98–1.00). DBS HCVcAg had a sensitivity of 76.1% and a specificity of 97.3%, with an AUROC of 0.87 (95% CI 0.83–0.92). HCVcAg performance did not differ by HIV co‐infection or HCV genotype. Conclusions : Our study suggests that HCVcAg testing in serum is an excellent alternative to HCV polymerase chain reaction in Africa. Although HCVcAg detection and quantification in DBS has a reduced sensitivity, its specificity and accuracy are good and it could therefore be used for scaling up HCV testing and care in resource‐limited African settings.