Abstract Background and Aims Whether the HCV test‐and‐treat strategy impacted on the rate of new HCV infections among PLWH in Italy is unknown. Methods Prospective study of PLWH in the ICONA network. At baseline, PLWH were tested for HCV‐Ab; HCV‐RNA (if HCV‐Ab positive) and, if positive, treated with DAA. SVR12 indicated eradication. Seroconversions and re‐infections were evaluated yearly in HCV‐Ab neg and HCV‐RNA neg at first screening. We estimated the following: HCV seroconversions, incidence of HCV reinfections, and access to DAA and SVR12 rates tighter with factors associated with each outcome. Data were analysed by Cox regression, Poisson regression and logistic regression models. Results Sixteen thousand seven hundred and forty‐three PLWH were included; 27.3% HCV‐Ab positive; of these, 39.3% HCV‐RNA positive. HCV seroconversion incidence: .48/100 PYFU (95% CI: .36–.65); re‐infections incidence: 1.40/100 PYFU (95% CI: .91–2.04). The risk factor for HCV re‐infection was young age: aIRR 1.85, 95% CI: 1.17–2.95) per 10 years younger. 86.4% of HCV viremic in follow‐up started DAA. PWID vs. heterosexuals (aHR .75, 95% CI .62–.90), HIV‐RNA >50 copies/mL (aHR .70, 95% CI .56–.87), HCV genotype other than G1, G2, G3, G4 or with multiple/missing HCV genotype and post‐COVID‐19 calendar periods were associated with lower DAA access. 922/965 (95.5%) PLWH achieved SVR12. We estimated 72% reduction of chance to achieve SVR12 in PLWH with a CD4 count <200/mm 3 (vs. CD4 ≥200/mm 3 aOR .18, 95% CI: .07–.46). 95.5% of DAA‐treated individuals eradicated HCV, but they represent only 53.2% of HCV viremic PLWH and 66.4% of those in follow‐up. HCV‐RNA positivity by year decreased from 41.7% in 2017 to 11.7% in 2022. Conclusions The screening‐and‐treat campaign implemented in Italy, even if only partially effective, resulted in a dramatic drop in HCV circulation in our cohort.