Based on that one snapshot of a 54 ALT, I would not treat. I would monitor and collect more info.
It is a fair assumption that this friend (who I will call Sam) is in the immunoclearance phase towards eSeroconversion. This phase appears to be going well with a low viral count and reaching the silent phase where the eAntigen and EAntibody are both - (or + for that matter). Slight elevation of ALT is this phase is normal because the immune system is responding. If normal ALT then Sam would be still the tolerant phase with high DNA. So if all goes well, Sam (31) will reach the inactive phase of the disease early without doing a thing.
From what I learned, there is no reason to treat, especially with Lamivudine. I would very much be concern about helping the virus mutate. Although the chance of developing resistance to Lamivudine is low given Sam's low DNA, I still would not feel comfirtable.
The only scenerio where I would treat is, if the DNA remains very high during the immunoclearance phase with a very high ALT (like in the 2 to 3 hundreds) for 3-4 months. I may want combo treatment to cut down on replication and give the immune system some help. I'll be prepare to treat for 2-4 years and hope in that time, my immune system could take over on its own. In Sam's case, his immune system appears to be doing well on its own now.
You already know that there is no such thing as the virus not replicating as long as the surface antigen is still there.
If Sam's sono is fine. I suspect his biopsy result will show minimal damage. Given Sam's age and suspected phase of the disease, I think most doctors won't even order the biopsy.
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