Abstract Background In Western settings, the relationship between trauma history, posttraumatic stress disorder, substance use, and HIV risk behavior, is well established. Although female fish traders in Zambia are affected by HIV at rates estimated to be 4–14 times higher than the national prevalence, no studies have examined the co-occurring issues of trauma, substance use and HIV risk behavior among this vulnerable population. The current study examined: 1) trauma history, trauma symptoms and HIV risk behaviors and 2) the relationship between these co-occurring issues among female fish traders from the Kafue Flatlands in Zambia. Methods Twenty individual semi-structured qualitative interviews and a focus group discussion (n = 12 participants) were conducted with female fish traders in the Kafue Flatlands of Zambia. Template analysis was used to examine the data. Results The findings indicate that female fish traders in Zambia are at risk of multiple and ongoing traumatic events and daily stressors, severe mental health symptoms (including western conceptualizations of disorders such as anxiety, depression, post-traumatic stress disorder (PTSD) and complicated grief, as well as local idioms of distress), substance abuse, and HIV sexual risk behaviors. The results suggest a relationship between trauma and HIV sexual risk behavior in this population. Conclusions The indication of these co-occurring issues demonstrates the need for HIV prevention intervention efforts, which account for trauma, mobility, and psychosocial outcomes in order to reduce HIV sexual risk behavior among female fish traders in Zambia.