Hepatitis C virus (HCV) infection is a major source of morbidity and mortality among substance users and persons living with human immunodeficiency virus (HIV) infection. Treatment for chronic HCV infection involves complex decision-making. These decisions are even more complicated in persons with HIV and substance use related problems. A secondary analyses of qualitative data collected in the United States (2004-2005) with 31 HIV/HCV coinfected adults (48% women; mean age 44.7 years) revealed three themes related to substance use (substance use evolution, revolving door: going back out and reconstructing life) and two HCV treatment decision-making themes (HCV infection treatment issues: not a priority, fear, misinformation and get clean and try it). Study limitations and implications are discussed.