Co-treatment of acid mine drainage (AMD) with municipal wastewater (MWW) using the activated sludge process is a novel treatment technology offering potential savings over alternative systems in materials, proprietary chemicals and energy inputs. The impacts of AMD on laboratory-scale activated sludge units (plug-flow and sequencing batch reactors) treating synthetic MWW were investigated. Synthetic AMD containing Al, Cu, Fe, Mn, Pb, Zn and SO4 at a range of concentrations and pH values was formulated to simulate three possible co-treatment processes, i.e., (1) adding raw AMD to the activated sludge aeration tank, (2) pre-treating AMD prior to adding to the aeration tank by mixing with digested sludge and (3) pre-treating AMD by mixing with screened MWW. Continuous AMD loading to the activated sludge reactors during co-treatment did not cause a significant decrease in chemical oxygen demand (COD), 5-day biochemical oxygen demand, or total organic carbon removal; average COD removal rates ranged from 87-93%. Enhanced phosphate removal was observed in reactors loaded with Fe- and Al-rich AMD, with final effluent TP concentrations<2 mg/L. Removal rates for dissolved Al, Cu, Fe and Pb were 52-84%, 47-61%, 74-86% and 100%, respectively, in both systems. Manganese and Zn removal were strongly linked to acidity; removal from net-acidic AMD was <10% for both metals, whereas removal from circum-neutral AMD averaged 93-95% for Mn and 58-90% for Zn. Pre-mixing with screened MWW was the best process option in terms of AMD neutralization and metal removal. However, significant MWW alkalinity was consumed, suggesting an alkali supplement may be necessary.