Prevalence and Risk Factors of HIV, HBV, and HCV Among Women Who Inject Drugs in Five Mozambican Cities: A Cross-Sectional Biological and Behavioral Survey, 2023–2024

Background Women who inject drugs (WWID) are disproportionately affected by HIV and viral hepatitis, yet data on prevalence and risk factors in Mozambique remain scarce. This study aimed to estimate the prevalence of Human Immunodeficiency Virus (HIV), Hepatitis B surface antigen (HBsAg), and Hepatitis C (HCV) among WWID and to identify associated sociodemographic and behavioral risk factors. Methods A cross-sectional biological and behavioral survey was conducted among 524 WWID in five Mozambican cities (Maputo, Beira, Tete, Quelimane, Nampula) between July 2023 and March 2024, using respondent-driven sampling (RDS). Participants completed structured questionnaires and underwent rapid testing for HIV, HBV, and HCV. RDS-weighted prevalence estimates were calculated for all outcomes. Modified Poisson regression with robust standard errors was used to identify factors associated with HIV infection. Results The weighted prevalence was 28.5% (95% CI: 23.3–33.9) for HIV, 4.3% (95% CI: 2.2–6.4) for HBsAg positivity, and 17.9% (95% CI: 13.9–22.0) for HCV. HIV prevalence increased markedly with age and duration of injection and was highest in Maputo City. In adjusted analyses, compared to those aged 16–17, older age (≥ 35 years; aRR = 13.8; 95% CI: 4.7–40.8), longer injecting duration (≥ 7 years), and residence in Maputo were independently associated with HIV infection, while secondary or higher education and absence of recent STI symptoms were protective. Among WWID living with HIV, 85.0% were aware of their status, 86.6% of those aware were on antiretroviral therapy, and 75.7% of those on treatment were virally suppressed. Conclusion WWID in Mozambique face a high burden of HIV and HCV, with significant geographic disparities. Losses along with the HIV care continuum, particularly gaps in retention and viral suppression, highlight critical issues in sustained treatment and adherence access rather than initial diagnosis. Urgent interventions integrating harm reduction, gender-sensitive HIV/HCV services, and targeted prevention in high-burden areas are needed.