INTRODUCTION: Central Asia has one of the fastest-growing HIV epidemics globally. Suboptimal anti-retroviral treatment (ART) coverage and viral suppression among people who inject drugs (PWID) and are living with HIV increase transmission risk to injection and sexual partners. Men and women may have distinct patterns of HIV transmission risk behaviors, but little is known about how these behaviors co-occur. This paper identifies HIV transmission risk typologies among PWID and examines associated health outcomes by sex. METHODS: Between February 2017 and June 2019, we recruited 450 men and 166 women (N = 616) PWID living with HIV in Kazakhstan. Latent class analysis identified heterogenous patterns of injection and sexual risk behaviors. Multinomial logistic regression examined how criminal-justice involvement, drug use and health outcomes varied by risk patterns. RESULTS: ART coverage was 71 % and viral suppression was 43 %, with little variation by sex. Among men, latent classes included: No injection & Low Sexual Risk (41.8 %), Injection & Sexual Risk (36.4 %), and Low Injection & High Injection Risk (21.8 %) behaviors. Both injection risk classes were associated with higher odds of detention, drug use, and overdose. Among women, classes included: Low Injection & Sexual Risk (60.7 %), Sex Work Behaviors & Injection Risk (8.4 %), High Injection & Sexual Risk (30.7 %) behaviors. Sex Work Behaviors & Injection Risk was associated with higher odds of detention, heroin use, and verbal police harassment. CONCLUSION: PWID living with HIV in Kazakhstan exhibit high-risk behaviors and low viral suppression. Distinct patterns by sex underscore the need for tailored harm reduction strategies and retention in HIV care.