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Background: The Tracks survey of people who inject drugs (PWID) collected data in 14 sentinel sites across Canada (2017–2019). Objective: To describe the prevalence of human immunodeficiency virus (HIV) and hepatitis C and associated risk behaviours and to examine trends over time. Methods: Information regarding socio-demographics, social determinants of health, use of prevention services and testing, drug use, risk behaviours, and HIV and hepatitis C testing, care and treatment was collected through interviewer-administered questionnaires. Biological samples were tested for HIV, hepatitis C antibodies and hepatitis C ribonucleic acid (RNA). Descriptive statistics were calculated and trends over time were assessed. Results: Of the 2,383 participants, 65.6% were cisgender male, 42.2% were Indigenous, 48.0% completed some high school or less, 62.6% lived in unstable housing and 75.7% had ever been incarcerated. Average age was 40.1 years. The majority experienced stigma and discrimination (88.7%) and physical, sexual and/or emotional abuse in childhood (85.0%) or with a sexual partner (75.9%). The majority reported use of a needle/syringe distribution program (90.1%) and tested for HIV (90.5%) and hepatitis C (90.9%). Among participants who had ever had sex, the majority (59.2%) reported inconsistent condom use during vaginal and/or anal sex with a casual sex partner. Prevalence of HIV was 10.3% (82.9% were aware of infection status) and many (36.9%) were hepatitis C RNA-positive (50.1% were aware of infection status). Most surveillance indicators remained relatively stable from Phase 1 to Phase 4. Changes were found in substances used, and improvements were noted related to HIV and hepatitis C prevalence and care cascade indicators. Conclusion: Many PWID in Canada were living in unstable housing and experienced high levels of stigma and discrimination. Prevalence of HIV and hepatitis C was high in some areas. These findings contribute to the evidence base used to inform targeted prevention and control measures.