I've had hepatitis C for about 30 years. My liver counts are almost normal now, but my viral load has jumped from 236,000 to 695,000. I took the treatment of ribavirin and interferon for about two months, but I was so depressed that my doctor decided that I should stop taking the medicine. How can my ALT and AST be almost normal and the viral load level just so high? Is the virus doing more damage?

E.L.

Hepatitis C is a viral infection of the liver. It can cause acute hepatitis, but most of the problems result from chronic (persistent) infection. Unfortunately, most people who become infected will fail to clear the virus from the body and will develop chronic infection. Over 20-30 years, about 20-50 percent of people with chronic hepatitis C virus (HCV) infection will develop cirrhosis (widespread destruction of the liver).

The course of chronic HCV infection can be difficult to predict. In people who are infected with HIV (the virus that causes AIDS), the amount of virus in the blood (viral load) is the best predictor of the progression of the disease. In hepatitis C, however, the best predictor by far of disease progression is the amount of liver damage seen on liver biopsy (a procedure in which a sample of tissue -- in this case, liver tissue -- is removed for examination). Obviously, the more damage already present, the worse the prognosis.

I assume that you had a liver biopsy before undergoing treatment. If your biopsy showed minimal inflammation and damage to the liver, then your overall prognosis is pretty good. I am not sure how you know for sure that you have had hepatitis C for 30 years, but if that is true, then clearly your rate of progression is slow. Aside from liver biopsy, there are other, less reliable predictors of progression of disease. If you drink alcohol, the rate of progression is higher. The same is true if you have HIV infection, which I assume you do not.

The liver function tests that you mentioned measure alanine aminotransferase (ALT) and aspartate aminotransferase (AST), enzymes that are released into the blood when liver cells are damaged. ALT and AST levels are important, but they do not have the same predictive value as the biopsy. There are many people with hepatitis C who have persistently normal liver function tests, and these people tend to do better than those with abnormal tests. The level of the viral load is also somewhat predictive, but only because an elevated viral load correlates somewhat with the abnormalities found on liver biopsy. Your viral load is not in the very high range that is associated with a higher risk of damage seen on biopsy. Unfortunately, however, there is no way to know for sure how your liver is doing without doing a liver biopsy. If you have a biopsy and it shows only minimal disease, you are probably not losing much by not receiving treatment.

For now, I would suggest you avoid all alcohol. You also might consider taking vitamin E, because a few studies have found that doses of 1,200 units a day may have some beneficial effect in patients with hepatitis C. I would consult with your doctor before starting such a regimen of vitamin E, however, because it could affect your liver tests and confuse further readings.