Approximately 30% of patients with chronic HCV infection have persistently normal ALT. Although earlier guidelines referred to them as “healthy” or “asymptomatic” HCV carriers, antiviral therapy was not considered. However, it is now clear that the majority of such patients have some degree of liver histologic damage, with approximately 20% of these patients having significant damage and likely to progress to more severe liver fibrosis. Most patients experience periods of elevated serum ALT, which accelerates disease progression. However, the definition of “persistent normal ALT” in clinical practice and the “virologic, histologic profile” of these patients is an ongoing debate that requires liver tissue biopsy. Non-invasive tests are now critical in assessing “liver fibrosis”, “natural history” and “effectiveness of antiviral therapy”. Newer therapies (pegylated interferon + ribavirin) have adjusted the treatment goal to clear the underlying infection, with treatment depending on age, disease severity and likely response rather than ALT levels. This review takes aim at these unanswered questions and gives some evidence-based answers to those from patients and their physicians. In clinical practice, “sustained ALT normal” is actually repeatedly normal ALT over a period of time (every 2-3 months for 3 years), or “repeatedly normal ALT”, as it should be, with evidence of transient fluctuations in ALT over several months. Therefore, 1) for HCV with normal ALT, liver biopsy is used to decide whether to treat or not, and 2) in terms of future cancer and liver disease incidence, at least such patients should not be excluded from antiviral therapy. The simple fact is that young, low viral load, easily curable, and patients with a strong willingness to treat can be treated. In Italy there is a recommendation: 1, ALT normal HCV to decide whether to treat should analyze the characteristics of individual cases, such as the need for pregnancy, possible disease progression, other comorbid diseases, good viral genotype response, etc. 2, the possibility of obtaining SVR may not be biopsied, such as: less than 50 years old + easily treatable genotype + low viral load. 3, patients aged 50-65 years need to be biopsied to decide, >65- Biopsy and treatment are not recommended for patients >65-70 years old. The following characteristics determine the timing of treatment: age, risk of disease progression, likelihood of response, degree of liver damage, willingness to treat, need for pregnancy. . The patient is informed about the treatment methods, course of treatment, and efficacy of each genotype. 1. other relevant tests for antiviral, such as: coagulation, HIV, etc. 2. screening of relatives. 3. viral load and liver damage. 4. normal ALT, 30 U/L for men and 20 U/L for women. 5. comparison of liver biopsy and non-invasive tests. 6. follow-up of patients without antiviral therapy