Prevalence of helicobacter pylori and its relation to cytotoxin-associated gene a status in HIV positive and negative haematology patients

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In the Faculty of Health Sciences Department of Haematology and Cell Biology

At the University of the Free State Bloemfontein South Africa October 2007 ! " ! " ! "

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++ ! !! ! $ $ ! ! ! $ 6 . ?BBB7 + 9 6 / ? @ $ " . " ! ! = ! 6 ! 7. ! " "= ! ! ! " ! 6 & . +,,?7 8" ! ! = ! 3 ! " . ! ? ! +. ! ? 2 ! ! $ 6 & . +,,?7 ( 9 ! + L ! +) ++B " ! +/ CC> " 6H . +,,? 7 5 ! ! ! ! ?L ! ? ! " " 6H . +,,? 7 " ! ? ! ! 2 ! ! 6% . +,,,7. $ $ ! " ! " ! " " ! ! ! ! " ! 6 / . ?BBE7 2 / 6+,,,7 ! ? ! ! ! ! " ! ! " H 6+,,?7 ! ! ? ! ! 9 " . " $ / 6+,,,7. ! ! " ! ! ?. ! + ! & " ! $ " " " ! . 6H . +,,? 7 ( ! ! ! ! + 6% . +,,,7. $ $ ! ! + " 1 ! + " $ " " ! = ! " " 6 / . ?BBE7. ! ! " ! + " 6H . +,,? 7 ( ! ! + & 6H . +,,? 7

+C ! " ! ! ! " ! ! + $ 6H . +,,? 7 * $ ! + " $ " ! " & ! 6 $ 7. "" ! 6H . +,,? 7 ( " ! " ! 3 " ! 6H . +,,? 7 H 6+,,? 7 " 8" ! ! = ! + ! +) " " ! ! +/ " " " " ! ! ! ! " " ! + " 6H . +,,? 7. " " $ ! 3 " " ! ! " ! " " 6H . +,,? 7 ! ! " " 3" ! ! ! " ! ! " " 6H . +,,? 7 + - # ( ! ! ! " ! ! ! ! ! . " = " ! . $ " ! ! . ! ! $ . $ 6 &. +,,?7 ! ! " ! ! = $ $ $ $ ! ! " ! " ! ! 6 . ?BBE0 &. +,,?7 $ $ ! " ! " ( ! ! 3 . " 62#(7. ! " ! ! 6 )27 / ! 6 . +,,>7

+> = $ $ ! 6# (7. ! . ! " 6 ! . +,,+0 .+,,>0 H &&& . +,,@7 ! . " " $ "" " $ " & " "" ! !! 6 ! 1 . +,,-7 + - 5 8 ! " . . ! . " " ! ! 6 )27 + - 5 5 Endoscopy 8 ! " " 3" $ $ $ " !

& , ,,EA , >C+A 6R . . +,,,0 2 !! .

+,,-7 8 ! " ! $ $ . ! ! " ! ! ! ! " $ 3" 6H ! . +,,D0 # . +,,@7 " . . . 62 !! . +,,-7 ( ! ! ! " ! ! $ ! 62 !! . +,,-7 ! ; ! ! . ! ! $ ! . ! ! ! ! " 6 ! ! ! ! " " $ ! " 7 ! ! " ! . 62 !! . +,,-7 ( ! $ 3"

+D + - 5 + " " ! " . ! 3 ! " ! ! " ! 62 !! . +,,-7 ( 62 !! . +,,-7 5 $ ! ! " . $ 3" $ 61 . +,,+0 2 !! . +,,-7 $ . & . ! " " 61 . +,,+7 ! ! ! ! " 61 . +,,+7 ( $ 5 EDA " ! ! EBA % 5 ! " 61 . +,,+7

Picture 3: A histology slide of H. pylori infection

+@ + - 5 6 ) " " ! " ! ! " 62 !! . +,,-7 ! " $ ! ! 6H . +,,D7 ( $ ! . $ . ; " ! " " & . " " . ! 3" ! $ !& 3" ! 62 !! . +,,-7 / ! $ $ . ! " ! ! 62 !! . +,,-7 $ . ! ! " ! 62 !! . +,,-7

+ - 5 7 Rapid urease test

( 2 " 62#(7 ! " ! " ! 62 !! . +,,-7 ( " " ! " 62 !! . +,,-7 ( ! " " " $ " ! ! 62 !! . +,,-7 ( $ ! . $ . ! ! " " % ! " $ ?,> ! " 62 !! . +,,-7 " " ! . = $ ! 62 !! . +,,-7 ( " 6+,,-7 ! 2#(. " " = ! " = $ " ! 1 ! " $ $ . 2#( ! " ! " $ " ! ! 62 !! . +,,-7 $ . " = " 62 !! . +,,-7

+-+ - 5 8 0 " " ! . $ . ! ! $ " ! ! " ! )2. 6 . +,,D0 2 !! . +,,-7 " " ! $ ! ! . ! 2 3 ! )2 6 . +,,D7 ! ! ! ! $ ! ! . ! 6 . +,,D0 2 !! . +,,-7 # . " ! & ! " ! ! ( ! ! 3 =! . $ . ! & $ & $ ! ! 6H $ . +,,D7 % = $ $ & ! " " $ ! $ ! " . 6H . +,,D7 ! ! ! ! 3" $ ! " $ $ 62 !! . +,,-7 " ! $ ! " ! 6 " ! " ! $ 7. $ 6M & . ?BBE7. = ! "" 6H $ . +,,D7 + - + ) ) " . . + - + 5 Chromatography ( ! " ! 9 ! = ! & : ) ( (S " &< 6 ! ! . 8 " 7 6H &&& . +,,@7 ( ! " .

+E & ! % . -- EA $ . -B CA " ! ! . E+ >A " $ " ! $ $ -> +A $ " ! $ $ 6H &&& . +,,@7 2 ! H &&& 6+,,@7 "" : " . " . " " ! " ! !! ! " < 6H &&& . +,,@7 ) " ! ! !& 3" ! # $ % + - + + ! ! ! " ! ! = " 5 " J 8 9 & 68 7 6 &. +,,?7 ! !! ! " ! " 6 !& . ?BBB0 . +,,C7 8 $ " ! ! . ! $ " ( $ = !! !

$ -EA 6 @EA = E+A7. 6 &. +,,?7 !

!! " ! 6 ! . +,,+7 ( ! " " & = $ $ ! ! ! " ! ! ! 6 . +,,C7 9 6+,,@7 $ ! " ! ! $ ! = ! ! ! " ! ! " ! 9 6+,,@7. " " =" 6 9 . +,,@7 $ . ! =" $ $ & " $ ! 62 !! . +,,-7

+B ) 3 = ! & " ! ! $ ! ! ! " ! 6 . ?BBE0 . +,,D7 $ 6+,,D7 " ! 5 ) . $ ! ! & $ " ! ! ! . ! 6 . +,,D7 ( 8 . 5 =) . ) " ! 6 . +,,D0 M 9 . +,,@0 9 . +,,-7 $ EDA " ! ! E, A 6M & . ?BBE 7 + - + 6 ! ( 9 ! ! ! " ! " " ! 6 &. +,,?7 " ! = " ! " ! ! ! $ 6 &. +,,?7 " " $ $ 6# (7

$ EBA BEA " ! ! $ B,A 65 R .

+,,?7 3" $ . 8 " " " ! # ( " ! # ( ! 6 ! . +,,D0 . +,,D7 ! # ( " ! $ ! . ! $ ! " " ! 6 &. +,,?7 $ . ! $ ! $ ! " " " . " " ! " 6 ! . +,,+0 ! . +,,D7

C, + - + 7 . * ( ?C) 6# (7. ! 5 ?BE- ! ! = $ $ " ! " : < ! ! 65 . ?BB-0 ( 8 " " 5 ". ?BB-0 . +,,-7 # & $ . ! ! ! ! " " " ! ! . 65 . +,,@7 ( " = $ ! $ ! ( ?C) ?>) ! ?C) ?>) )*+ 3" " ! $ 6 &. +,,?7 ( $ ! ! $ ! $ " ! ! B> -A BD -A " ! $ 6 . ?BBE0 &. +,,?7 ( ! " ?>) ?C) . ?> ) ?C) ?>) ?C) ! " ) " = # (. ! " ?>)= ?C)= $ $ . 4 6 7 ! " & $ ! . 6 7 " $ 6* . +,,>7 ( $ . " ! !

!! ! = B- -A. BE >A BEA. " ! $

! ! * 6+,,>7 ( ! ?C) ?>) ! ?C) = ! $ " ?+ ) " ! " ! ! ! ?>) 6* . +,,>7 ! ! " " $ ! ! $ 3 ! $ 6* . +,,>7. ?C) " ?C)= " ! $ . = " ! ! " & ?C)*+ 6T?C)7 "" " =" $ 6 . +,,?7 " . =

C? ! ?C)= . " $ =" $ ! =" ! $ 6* . +,,>7 6+,,>7 1 ! # ( ! ! $ . $ 3" $ ! " ! . ,A ! CBA 8 " . ! " ! " 6 . +,,C7 + , ! ! " ! " ! " ! 6 . +,,+7 1 ! " ! " ! ! ! ! ! " ! ! & " " ! ! . ! ! ! . ! " 6 . ?BBB7 ! ! " ! ! ! 6 . ?BB-7 . ! $ $ = ! ! $ ! ! ! 6 . +,,?7 # " ! " ! # 9 ! 3 . " " $ $ ! ! 6 . +,,?7 % . " U ! " ! ! . . ! ! " " ! 61 & . +,,,7 ( " ! " $ " " 3 6 . +,,@7 ! ! " ! ! $ ! ! " 6 9= 9 . ?BEE7 " ! ! " " ! ! 6M & . ?BB-7 ( " ! ! " ! 6M & . ?BB-7 ( " ! ! ; = ! " =! " 3 6 )7 ! ! !

C+ " ! . ! " " 6M & . ?BB-7 ! " . ! $ 3" ! ! " & ! " " ! 61 . ?BB@7 H & 6+,,@7. !! " " ! ; ! " ! ! ! ! *$ = 3" ! 6 7. ! ! = 3 =+ 6)*G=+7 = " " " ! " ! $ $ ! =+. " " ! ! . 3! $ . " " ! 6 ! . +,,?7 ! ! " " " $ $ ! ! $ " ! ! ! & ! " " ! ! 6 !% . +,,,7 ( 6+,,?7 " ! ! " ! ! ! $ . "" " " $ " ! ! ! ! " 3 V$ ! ! " " ! ! $ " 6 . +,,?7 3 6+,,@7 " 9 : ! " ! " ! " $ ! " $ ! $ < ( " " $ ! ! ! ! $ & " ! " +,, 6 3 . +,,@7

CC 7" ( " ! " ! + : $ & " 6 .?BBC. 5 . ?BBE0 . +,,+.0 ) ! . +,,+0 ) " . +,,+0 $ . +,,+0 % ! . +,,C0 . +,,C0 2 . +,,C0 / . +,,D0 9 . +,,@7. " ! ! = ! " 6 (7 " . ! " ! " " 6 ( 7 ! ! + : 5 ? ' @ ! ! & . ! " 6 ø . ?BBB7 ! ! " ! ! = ! " 6 ( 7 " ! ! !! 6 . ?BBB7 Mucus Layer ₂ UREA + H2O NH3 + C2O NH3 neutralize s the gastric acid Mucus Layer 3 Mucus Layer 1 Gastric fluid 4 MUCOSAL DAMAGE

Inflammation and cell apoptosis Gastric fluid Mucus Layer ₂ UREA + H2O NH3 + C2O NH3 neutralize s the gastric acid Mucus Layer ₂ UREA + H2O NH3 + C2O NH3 neutralize s the gastric acid Mucus Layer 3 Mucus Layer 3 Mucus Layer 3 Mucus Layer 1 Gastric fluid Mucus Layer 1 Gastric fluid 4 MUCOSAL DAMAGE

Inflammation and cell apoptosis Gastric fluid

4 MUCOSAL DAMAGE

Inflammation and cell apoptosis Gastric fluid

C> " ! 3 " . ( =! " ! ! 6 ø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

CD 6+,,@7 ; ! " . " ! " ( " ! . ! $ ! ! " " ! " = ! 6 9 . +,,@7 $ . ! ! ( K " " . " ! ! ! ! " (= " " ! 3 6* 7 " 6% . +,,@7 % = ! " ( " 6 ( 7 & ! ! 3" 6 . +,,@7 " ! " 61 . ?BB>0 ) " . ?BB@7. ! ! . " " " " ! " ! " ! " ! . 6 . ?BBD7 "" ! . " " 6 = ( " 7 & ! " $ " ! " ! " ! ) =?, . L =H L 6??0?E7. 6 " . +,,,. . +,,? 0 . +,,? 0 & . +,,+0 . +,,> 0 . +,,D7 . ! ! $ . 3 ! ! " 6) . +,,C7. ! = " " " ! ! " ! " . " !! $ " ! 6 !& . ?BB-7

C@ + : + ? @ ! " ! " " 6 ( 7 ! ! " ! =" 6( . +,,D7 # ! ! =" $ ". " 6 . +,,>7 ( ! ( ! ! ! ! " " ! @ 6 . +,,D0 . +,,@7 $ " " ! " " . " ! ( 65 . ?BBE0 ) ! . +,,+0 $ . +,,+0 % ! . +,,C0 . +,,C0 2 . +,,C7 ! $ ! ! " " ! ! ( . 6 . +,,@7 $ ! 6 . +,,>0 . +,,>0 % ; . +,,D0 % ; . +,,D0 . +,,D0 9 & . +,,D0 ( . +,,D0 . +,,D 0 . +,,D 7 ( " ! " " ( " $ ! " ! " ! ! ( 6 . +,,>0 . +,,>0 % ; . +,,D0 % ; . +,,D0 . +,,D0 9 & . +,,D0 ( . +,,D0 . +,,D 0 . +,,D 0 $ ;9 ! . +,,@0 H . +,,-7 ! ! $ ! " " ( " " ! " " " " 6 7 " $ . . " ! " . ! " ! " . ! $ 6N = . +,,@7 $ . " ! ( " ! " ! . $ " ! ! ! ! ! ! ( 0 ! ! ! ! ! ! ! 0 6 !

C-! 7 " ! ! " 6 . +,,@7 $ . ! ! 6+,,@7 . ?+ +> & " ! . =5 L " "" ! " ! " =" " ! + : 6 ? # @ ! ! 6 /7 ! ! ! 6/ . ?BEB7 ! ! . ! " " . ! $ . " ! $ ! 6/ . ?BEB7 ! / ?BEB. ! ! $ " 4 ?7 " . +7 = ! " C7 ! ! 6 / 7 6/ . ?BEB7 . ! ! ! " ! " ! " ! ! ! ! ! ! 6 /7 / 6) " . +,,+0 . +,,+0 / . +,,D7 6+,,+7 " 9 ! $ " = $ ! . ! " ! = " ! " . ! ! ! $ 6 . +,,+7 $ $ ->@+ " ! " # ! 6# 7. ) 6+,,@7 " 9 ?C @A ! / " C+ +A ! / " # ! " ! % ! ! " ! ! ! " ! L ! " & " " / / . " ! $ . ! " ! / / " " " ! ! . ! " " " " 6) . +,,@7

CE ) 6+,,@7 ! " ! ! ! " 3 " " . : ! . & . " " ! . ! ! ! !=;! ! ! ! ! " " < 6) . +,,@7 . ! $ . ! " " ! . ! " $ ! ! ! / 6) . +,,@7 "" " " " ! ! / / ! " ! $ / / ! ! $ " ! " 6H &! . +,,D0 $ $ . +,,D7 " . 6+,,D7 ! ! "" " ! ! ! $ / / ! " ! " ! 6 . +,,D7 . 6+,,D7 . $ . ! ! $ " ! " " " ! " ! 6+,,D7 ! : 3" $ . ! ! ; ! < "" 3" L = " ! ! ! ! ! 6 . +,,D7 + 5; / ! " $ $ 9 $ " ! ( " ! 3" " ! )/>I ( " 6( 7 ! . ( ? ( + 6 . ?BBB7 ( ? ! " " ! & 6 7=+. =?+ 6 %=γ7 ! ! . ( + ! $ " ! =>. =D. =@. =?, =?C " " ! 8= " ! ! " 6 . ?BBB7

CB ( ( ? " ! ! ! = ! ! . " 9 . 3 ! " ! ( + " 6 ! . +,,+7 9 ! " ! . ! " 3 ! ! . ( ? ! "" " =+. =?+. ( %=α % =γ " " ! ! " ;! 6/ . ?BBE7 ( ( + ! & => =D $ $ " ! ;! 9 ! . $ " =?, " ! ! ;! " ! $ . 6 . ?BBE7 $ . $ " ! ! " "" ) " 6+,,+7 5 ! $ " ( + " " ! 3" ! ! ! " H +,,C ! = & " " " . " $ ! " ! . ! $ ! ! " ! " " " C, $ ! 6+,,+7 ! " ! $ " ! " " $ " ! " ! ! ! . " " !! ! " 6% 3 . +,,,7 6+,,?7 " 6! 9 ! 7 3" " ( ! ! " $ 9 ! ( ? ! & " ! 6+ &7 " ( + " 6@ &7 ! 6 . +,,?7 ( ! " ! " = " ! ! )/>6I7 ( ! . ! " ! ! = $ = H 6 H7. H6I7 ( ? = $ H6=7 6" ( +7 ! ! 6 . +,,?7 ( ! ?,,= ! 9 $ " @ & + & = $ ( ? ! 6 . +,,?7 & ( " =? 6( ?7 " ! " . % =γ ! " "

>, " " " 6 ! . +,,?7 ! ! $ % =γ $ $ " " ! 6 . ?BBB0 H . +,,,7 5 ! " ! ! & ( " ! " . % =γ $ " " ! 5+ ! 6H . ?BB>7 $ $ = " 5? 5+ ! " =" $ $ 9 ! " 5? ! " 6 . ?BBE7 ! " $ ! 6+,,+7 ! . ! . ;! $ " 5? " 6 5?L 5+ W?7. 5 ;! 5+ " " 6 5?L 5+ O ?7 $ ( $ ! " " " $ " ! ! 9 ! $ . " $ " ! . ( ? ! & " " 5+ ! " " " ! 6 . ?BBE7 ( 6+,,C7 $ " ! " ! ! " " = " ! ! ( 6+,,C7. 5 $ ! ! " ? 6 % 52?7 P ! ! ? =γ 6 % =γ7 ! " Q" " ( % 52? $ ! ! ! ! ! " " ! " " " ! " ! ! " " ! . " ! ! 6 !& . ?BB>7

>? ! ! ! ! " 6+,,-7 ! " " $ ! $ ! ! " ! ! $ +,,D " ! 5 ) . $ ! ! & $ " ! ! ! . ! 6 . +,,D7 ( " :! 9 " " " ! " ) " $ ! " " ) = $ " " < 6 . ?BBB7 "" 6+,,D7 " ! " ! 6H . +,,D7 ! ! H 6+,,D7. " ! $ . ! ;! " 5 " 6H . +,,D7 ( & " . " $ ! ! ! ! ! ! " / ! ! ! " 3 " $ ! . " $ ! ;! " ! 6H . +,,D7 " . " " ! ! ! ! " ! 8 " ! " 6H " ; . +,,,7 + 55 " ( " ( ! $ ! 6 ! . +,,+7 ( ! ! ! = "" $ ! 6 . ?BBE7 ( " " " ! " =" " 3 ! . ! ! . 9 $ $ ! ! "" 6 .

>+ ?BBE7 8 ! " ! $ ! $ . 6 . ?BBD7 ( " ! ! " ! ! $ ! 6 *J . ?BB-7 8 ! ! = " . ! " " ! " ! $ " ! ! 6 ! . +,,+7 ! = " ! 6 ! . +,,+7 % = " ! " =" "= " = " +, " 9 $ ? 3 ! D,, ! ! >,, 9 +D, ! ! 6 ! . +,,+7 * ! = " ! "" ! " ! ! & 6 . ?BB@7 ! = " ! ?, K ?> ! ( " ! 6 ! . +,,+7 ) " ! $ ! ! = " 6 99 . +,,?7 ( ! $ " . $ ! $ ?@ ! ! " " 6 . +,,C7 =! " " . ! " " " ! - ?> . $ 3 $ $ . $ $ "" $ % / 6%/ 7 # " " . " " " . ! ! 3 ! ! ! " ! 6 . +,,C7 = " " 6 ! 9 ! ! 7 ! $ " " =" " ! . $ ! - 6 . ?BBB7 ( " = "

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

>> 2 ! ; ! = " 6 % ; . +,,C7 2 ! 9 ! ! & 9 ! 6 % ; . +,,C7 ! " ! " " ! " ! & ! ! ! " " " $ ! 6 % ; . +,,C7 6?BB+7 " " $ ! 3 ! . ! ! 9 ! ! " $ 8 " ( " 9 $ $ ! " 9 6 $ . ?BB>7 9 ! $ " " ! ! ! 68 " " ! ! " " . ?BB+0 . +,,,7 5 = 6+,,-7 ! " ! " ! " ! $ ! ! ! " ! = " ( " ! ! ! 3" 4 6?7 ( 6 % ; . +,,C70 6+7 ( ! ! " " $ !! = " 6 % ; . +,,C70 6C7 " ! " ! 61 . +,,-70 6>7 / ! " ! 61 . +,,-70 6D7 ! ! ! $ " ! 61 . +,,-70 6@7 ! " 6 % ; . +,,C0 ; 5 ! . +,,-7 ! ". 1 8 6+,,-7 3" " ! ! $ $ " " ! ! " ! . ! ! . ! ! . 6 ; 5 ! . +,,-7

>D . " ! ) " & !! ! 6 9 &. . +,,@ 7 ( . $ . " ! 6?7 ) " $ ! $ ! ! 6 . +,,D0 . +,,D7. ! ! ! " " ! 6 9 & . +,,@ 7. 6+7 $ ) =" $ ) = $ . ) =" $ " ! 6 9 &. . +,,@ 7 . $ ! ! ! ! ! 3 "" $ ! " ! 61 . +,,>7 "" ! ! = ! ! 6 = 7 " $ ! " 61 . +,,>7 2 & ! ?+ D ! ! $ "" " ! 61 . +,,>7 . $ " $ $ ! ! L = $ ! " 6*J . +,,D7 *J 6+,,D7 3" " = $ " " ! " $ " $ " " ! . ! $ ! " ! ! ! ! 6*J . +,,D7 ) " $ ! & " . ! 4 ( ! 6 ! 7. ! . . ! . . !&! . ! 6*J . +,,D7 % . 3 ! !. " $ " ! 6*J . +,,D7 . ! ! $ " " 3 ! . *J 6+,,D7 $ . " 3 ! ! " " $ $ . & ! $ " & " 3 ! ! " 6*J . +,,D7 / ! ! ! 3 ! . $ ! ! $ $ 6*J . +,,D7

>@ ( " ! " " $ ! " $ % 6+,,D7 " ! $ $ ! ;! ! . ! ! " = ! " 6% . +,,D7 / 3 " $ ! " ! " " ! . " " "" ! " ! ! " ! 6 . ?BBE7 ( ! ; $ " " . ! . " ! 6 . ?BBE7 $ ! ! " ! " ! " " ! "" 6% !& . +,,C7 ( ! "" ! " 6% !& . +,,C7 " . $ . " ! "" ! " ! " " ! $ L !! ! 6 . +,,C7 9 & 6+,,-7 ! ! " " ! ! ! ! ! ! ! " " " ( " =! " ! ! ! ! ! =! : ! < 6 . +,,C7 . & ! " ! "" . ! " ! " ! ! ! ! . ! ! " =! " ! " ! " ! 6 . +,,C7 ( !& ! " "" = !& ! ! ! $ ! ! " ! !& ! " " . = " " ! 6*JH . +,,?7

>-( ! ! . . ! " " ! $ !! 9 " " ! " " ! ! ! 65 . +,,>7 !! $ ! ! " $ $ !! " $ " 6)9 . ?BBB0 / 5 ! . +,,?0 / 5 ! . +,,?7

>E 6 ?7 ( ! " " $ ! " $ " $ " ! ! " ! " 3 % " $ ! +7 ( " ! ) " $ " ! =) 5 6 57 " " $ " C7 ( ! " " $ ! ) " $ " $ " $ " ! ! " ! " 3 % " $ ! >7 ( " " ) 6 " " $ " 7 " ! ! . . . 3. ! = ! ! D7 ( " " ) 6 " " $ " 7 $ " ! ! . . ! . " . !

>B 7 7 5 ! ( ! " $ ! " $ ! " ! . " $ $ " " ! ! " ! " 3 % ! . ! ( ! $ ! . ) " " $ " . ) " " $ " . . 3. ! . ! = ! ! . ! 6 ! ! 7. " 6 ! ! 7. 6 ! ! 7. ! " 6 ! ! 7. ! 6 ! ! 7 ! 7 + ( " " " $ ! ! " ! " 3. +B C,. " 0 " $ ! ! # $ " ( ! " " ! ! " ! " 3 $ $ " " ! " ( " " $ . " " ! ! " % ! ! "

D, 7 6 ! " ! ! ! ! ! " ! " 3 % " $ ! . ! ! " ! 3! ! ! " ! " ! " " $ ! 3! " ! " ! ( ! " ! "" ! ! ! " ! 3! ! $ ( " ! & " & " % " ( $ ! " ! = " ! ! :M . " < : . " < " . ! " ! ! . $ ! ! ( ! 6 "" 3 ?7 ! " " ! " ! & " ( ! " $ . 8 . & . ! $ ; " & 7 7 7 7 5 ?7 " " $ ! ! 7 7 + / ?7 ?E

D? +7 $ ! C7 ! $ ! $ ! >7 @ D7 @7 ! ! . " C, " -7 ! " " " " & " E7 ! "" ! B7 & " " ! ! 3! ! ! 7 8 & " ! . $ " ! 6 7 3 ! " 6 7 & " ?>)=# 6!7 & " )

D+ " & ! " 6 "" 3 7 ! . . $ ! ! = ! ! ! ( " ! ! ! " ! " ! L ! . " " * " ! " ! ! ! " ( ! ! ! " ! " 3 ) ! ?>)=# " ! . " 3" / " ! ! . # $ % ( =) 5 8 " ! / " ) . # $ % 7 8 5 57 . ( ?>)=# " " ! " ! ( $ / " ! ! . # $ % 6 . +,,?7 7 8 5 5 # A 57 . ?7 ( ! & 6 7 + ! " " ! " ( ! " ? ) 3 ! " . ? " $ " ? " " " ! ! " ? ) +

DC +7 ( C7 ! =?>= ! " ? & C- & 6? ) 7?>) 7 8 5 + ?7 ! " " ! ! " " ! ( ! ! ! ? )*+ $ +7 ( " ?>) ! " +, 1 ! ! " C7 C +, ! ( ! ! " ! ! " >7 ?, " = ( " ! ! . . ! ! " " ! ?, !! " ! ?, ! " $ 3" ! . . D7 +, " = ( " ! . . ! ! " " ! 7 8 5 6 ( " = ! ! " ! " 3. % . ! . " / " ! ! . # $

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DD ( ! 4 - Y?BB / X $ " - W?BB / X" $ " 7 8 + /'! 5 ) " ! " =) 5 8 & ? " >#66B> ( (. 4 @ !! ! ! ( =) 8 " ! " " $ " !! $ ! = E,°) " ?4+,, " ! C, ! ) " ! ! " . = 5 ! ; " 3 ( " U ! ) " ( ! ; ! ( 6 " 3 7 ! "" , +D " ! ! " ! , @+D. ?+ D. +D. D, ?,, #L = " ! $ ! 5 " J !

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D-8 0 8 5 ! ! +- +,,@ ++ +,,-" ( ! ! ! ,B *! +,,@ ++ +,,@ ! ! 8 5 5 ) C +: 6; 0 % " 9 " ! ?E " ! . . . " $ & ( 3" ! " 3! ! 3" ! ( ! ! ! ! ! ! " " " ( ! " ! ! ! " ! ! &. ( ( L ! $ " ! ! 3! ! " ( " ! ! ! 3 6Z,> C, 7 ! ! $ $ ! . " ! " ! " ! ( . ! ! !! ! ! ! 3" ! . ! ! ! ! "

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DB % ! ! $ D 6?C $ +,,@7 6+, $ +,,@. > / ! +,,@. ?? / ! +,,@. ?D +,,@ ++ +,,@7. " 6?7 " $ " $ $ !! 6 ! ! ! 7 6+7 " 6C7 " $ ! % $ . " J $ ! ! , + > @ E ?, ?+ B =* ! =, @ + C =* ! =, @ C , =* ! =, @ @ = $ =, @ ? C = $ =, @ + , = $ =, @ > =/ != , @ ? ? =/ != , @ ? D = =, -+ + = =, -) 3 +" " " $ . ! ! % % + ! ! " ! ! ! " ?D +,,-. $ ++ +,,- " % ! ! ! " 8 + ! @E " " . C, " CE ! ! " DB " ! * "

@, ! " . ! " & - " $ ! 3 6" " " $ ! % C . ! " ! % = $ " ?- " $ " ! ! " ) " 3 % $ ! . ! . " ! ?>)=# $ " . $ " " " $ " ) 6% C7 ?>)=# HIV + 28.81% N = 17 HIV – 72.19% N = 42 H. Pylori + 45.24% N = 8 H. pylori – 54.76% N = 9 H. pylori + 47.06% N = 19 H. pylori – 52.94% N = 23 CagA + 50.00% N = 4 CagA – 50.00% N= 4 CagA + 31.58% N = 13 CagA – 68.42% N = 6

@? 8 6 % > ! ; " $ , +, >, @, E, $ $ > ! " $ ! 3 7" " $ ! " ( " $ ! " $ " " " +E EA 6BDA ) ! $ P) Q. ?BA = >?A7 ( ! " $ ! " $ $ " ! ! 6 X, ,,?E7. 6% >7 8 7 % D "

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0 25 50 75 100 125 0 1 2 3 U/ml O D ( 45 0n m )

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@@ , ?, +, C, >, D, @, -, E, $ $ =) " $ =) $ 3 :" $ ) " ! ( ! =) $ " $ " " $ " $ $ ". ! $ . % B ( ! $ . ! ! 6 X, C@D>7 8 9 ! ( ! = ! ! ! ! " ( " !! # $ " 6 C7 6" ! = ! ! # $ " D 3 ; 5 + 6 7 ( ! " # " 2 ? K 2 CDBBB 2 C@,,, K 2 -?BBB I 2 -+,,,, ! $ " ( ! # " 2 ? K 2 >BBBB 2 D,,,, K 2 BBBBB I 2 ?,,,,, ! $ "

@-( > . " =) " ! ! = ! ! 7" ! = ! ! . " =) " ) 2 5 + 6 7 " $ ?- +C DC A @> -? A , A , A ?? -@ A $ >+ CC CC A D- ?> A + CE A , A - ?> A " " $ +- >> >> A >> >> A , A , A ?? ?? A " $ C+ ?@ -D A -? EE A C ?C A , A @ +D A =) " $ ?, >, ,, A D, ,, A , A , A ?, A =) $ ?- >- ,E A >? ?E A , A , A ?? -@ A . " =) " " $ ; " $ ? 6( >7 ( ! 2 ? K 2 CDBBB $ 2 ? K 2 >BBBB 6( C7 ( , ! . " ! 6( >7 > . " ! ! $ 6( C7 " + C % ?, ! = ! ! . " =) "

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@B ( D ! ! ! " & " & =) 8" ! = ! ! " & " & =) ) 2E 5E +E 6E 7 E " $ " " $ E C- D A @+ D A , A , A , A " $ " $ B ?? ?? A @@ @- A , A , A ++ ++ A $ " " $ ?B >- C- A C@ @> A , A , A ?D -B A $ " $ +C +? -> A -C B? A > CD A , A , A " $ =) " $ > , A ?,, A , A , A , A " $ =) $ > -D A +D A , A , A , A $ =) " $ @ @@ @- A ?@ @- A , A , A ?@ @- A $ =) $ ?C CE >@ A >@ ?D A , A , A ?D CE A [ C % ?? ! = ! ! " & " & =) , +, >, @, E, ?,, ?+, " $ " " $ " $ " $ $ " " $ $ " $ " $ = ) " $ " $ = ) $ $ = ) " $ $ = ) $ > * ? + C > 3 55" ! = ! ! " & " & =)

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-? =) " $ " " D- 6( @7 $ . =) $ " D> 6( @7 ( ! ! ! 6 X, ->>,7. % @ ( - " & " & =) -" " & " & =) " $ " " $ C, +> >> " $ " $ CE +> @@ $ " " $ @C +, E+ $ " $ D+ ?E " $ =) " $ +E +C C@ " $ =) $ C? +C >> $ =) " $ @- D, E+ $ =) $ DD +, -C ( " " $ " " $ 6C,7 " " $ " $ 6CE7. 6( -7 ( ! " " ! ! 6 X , ,C>+7 ( " $ " " $ 6@C7 " $ " $ 6D+7. 6( -7 ( ! " " ! ! 6 X , ,-,-7 1 " " $ ! ! " " $ =) " $ +E. " " $ =) $ . C?. 6( -7

-+ " $ =) " $ @-. " $ =) $ . DD. 6( -7 $ . " $ =) ". ! ! ! ! ! " 8 , ! ( +, " CB " ! ( 3 . " =) " E " " ; " " 6( E7 ," 3 . " =) " ) 3 ?F @ ?F @ " $ ?- -@ >- +C DC $ >+ @? B, CE ?, " " $ +- @@ @- CC CC " $ C+ @D @C C> CE =) " $ ?, E, ,, +, ,, =) $ ?- DE E+ >? ?E % ?+ 3 . " =) "

-C , ?, +, C, >, D, @, -, E, B, " $ $ " " $ " $ =) " $ =) $ % 3 5+" 3 . " =) " ( ! " $ $ " 3 ! ! 6 X , +E>>7. 6% ?+7 ( ! " " $ $ " 3 ! ! 6 X , BC+B7. 6% ?+7 ( ! =) " $ $ " 3 ! ! 6 X, >,DB7. 6% ?+7 ( B 3 " & " & =)

-> :" 3 " & " & =) > ) 3 ?F @ ?F @ " $ " " $ E -D ,, +D ,, " $ " $ B -- -E ++ ++ $ " " $ ?B @C ?@ C@ E> $ " $ +C @, E- CB ?C $ =) " $ > 100 0 $ =) $ > 50.00 50.00 " $ =) " $ @ 66.67 33.33 " $ =) $ ?C 61.54 38.46 % ?C 3 " & " 0 10 20 30 40 50 60 70 80 90 " $ " " $ " $ " $ $ " " $ $ " $ patient Groups P er ce n ta g e Female Male 3 56" 3 " & " ( ! 3 " " $ " " $ " " $ " $ ! ! 6 X, >+CD7. 6% ?C7

-D . ! 3 " $ " " $ " $ " $ ! ! 6 X, E-B+7. 6% ?C7 % ?> 3 " & =) , +, >, @, E, ?,, ?+, $ =) " $ $ =) $ " $ =) " $ " $ =) $ > % 3 57" 3 " & =) ( " $ =) " $ . " $ =) $ D,A D,A ( " . " $ =) " $ " " $ =) $ . $ . = ! ! / " $ =) ". ! ! ! ! ! 3 "

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--( ! ! " $ $ " ! ! 61 X , +@C,. !& X , D?@> 3 ! X ? ,,,,7 6% ?D7 ( ! ! " " $ $ " ! ! 61 X , >@--. !& X , @,CB 3 ! X? ,,,,7. 6% ?D7 ( =) " $ " " ! " . =) $ " " ! !&. 3 ! " ( ! ! =) " $ $ " ! ! 61 X , +-CD. !& X ? ,,,, 3 ! X , DCD,7.6% ?D7 ( ?? ! " & " & =) 55" 2 ! " & " & =) ) C ?F @ * $ ?F @ ?F @ " $ " " $ E , ?,, , " $ " $ B ?? ?? @@ @- ++ ++ $ " " $ ?B ?D -B @@ >+ ?D -B $ " $ +C +? -> -C B? > CD $ =) " $ > , ?,, , $ =) $ > , ?,, , " $ =) " $ @ , @@ @- CC CC " $ =) $ ?C _{+C ,E @B +C - @B} % ?@ ! ; " & " !&

-E , +, >, @, E, ?,, ?+, " $ " " $ 6) 7 " $ " $ 6) 7 " $ " " $ 6) 7 " $ " $ 6) 7 > 1 !& 3 2 ! 3 59" 2 ! " & " ( ! ! " " $ " " $ " " $ " $ ! ! 61 X ? ,,,,. !& X , +,DB 3 ! X , >-,@7. 6% ?@7 ( ! ! " $ " " $ " $ " $ ! ! 61 X , -,B+. !& X , @BD, 3 ! X , C?+B7. 6% ?@7 % ?- ! " & =)

-B 0 20 40 60 80 100 120 HIV negative and Cag A positive (current) HIV negative and Cag A negative (current) HIV negative and Cag A positive (childhood) HIV negative and Cag A negative (childhood) Patient Groups P er ce n ta g e _White Black Mixed Race 3 5-" 2 ! " & =) % " " " $ =) " $ $ =) $ . " !&6% ?-7 $ . " " $ =) " $ ! $ !& 3 ! 0 ! " " $ = ) $ $ !&. 3 ! 6% ?-7 / " " $ =) " $ " $ =) $ . ! ! ! ! ! ! " 6% ?-7

E, 8 5; C % = " ?? " ! 3 ! ( ! ? " ! ! &. ? " ! ! $ B " ! ! " / ! +D " C> " ! ! ! ! 6B " 7. & 6? " 7. $ 6> " 7. 6D " 7. 6? " 7 " 6?@ " 7 8 " ! ! " @ " " ! ( ?+ ! . " =) " ( : < ! " ! : < " 5+" 1 ! . " =) " . ! ! ) % ?F @ % ?F @ * ?F @ $ ?F @ 0 ?F @ # ?F @ 2 ?F @ " $ 6) ! 7 ?- -, DB ?- @D , D EE D EE , , $ 6) ! 7 >+ ED -? ?> +B , , , , , " $ 6) ! 7 ?- >? ?E >? ?E D EE D EE , ?? -@ , $ 6) ! 7 >+ >+ EE +? >C ?B ,D , B D+ - ?> + CE " " $ 6) ! 7 +- @@ @- +B @C , C -, , , , " $ 6) ! 7 C+ BC -D C ?C , , C ?C , , " " $ 6) ! 7 +- C- ,> ?E D+ ?> E? C -, ?? ?? ?E D+ C -" $ 6) ! 7 C+ >@ EE C> C ?D EC , C ?C , , =) " $ 6) ! 7 ?, -, ,, +, ,, , ?, , , , =) $ 6) ! 7 ?- @> -? CD +B , , , , , =) " $ 6) ! 7 ?, >, ,, , C, ,, ?, ?, C, , =) $ 6) ! 7 ?- C+ +B +B >? D EE , ?? -@ ?? -@ D EE

E? % ?E " " $ $ " ! . ! ! , ?, +, C, >, D, @, -, E, B, " $ 6) ! 7 $ 6) ! 7 " $ 6) ! 7 $ 6) ! 7 > ( " " 6A7 ( " ! ! 6A7 6A7 ( & 6A7 2 $ 6A7 / 6A7 3 5," 1 ! ! ! ( ! ! ! " $ $ " ! ! 6( " " X , +@-?. ( "

! ! X , -,E,. X . ( & X , +EE?. 2 $ X , +EE?.

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E+ , ?, +, C, >, D, @, -, E, B, ?,, " " $ 6) ! 7 " $ 6) ! 7 " " $ 6) ! 7 " $ 6) ! 7 > ( " " 6A7 ( " ! ! 6A7 6A7 ( & 6A7 2 $ 6A7 / 6A7 * 3 5:" 1 ! " . ! ! ( ! ! ! " " $ $ " ! ! " " " ! ! 1 " " 6 X , ,,-E7 " " " $ $ " " . $ . " ! " " $ " " ! ! 6 X, ,,@C7 ( . &. $ ! ! ! . 6 X . & X , >D-@. $ X ? ,,,, X 7. 6 X " " 7. 6% ?B7 ( ! " ! ! ! " " $ $ " ! ! ! . 6/ X , ,?@?7 " " $ " ?E E+A " ! ! " $ " ! ! ( ! ! ! 6( "

EC " X , >>@?. " ! ! X , ?-+C. X ? ,,,,. & X, >D-@. $ X, C+C+ X, >D-@7. 6% ?B7 % +, ! =) . ! ! , ?, +, C, >, D, @, -, E, =) " $ 6) ! 7 =) $ 6) ! 7 =) " $ 6) ! 7 =) $ 6) ! 7 > ( " " 6A7 ( " ! ! 6A7 6A7 ( & 6A7 2 $ 6A7 / 6A7 3 +;" 1 ! =) . ! ! ( ! " ! ! ! =) " $ $ " ! ! 6( " " X ? ,,,,. " ! ! X, @@DD. X . ( & X, C-,>. $ X X 7. 6 X " " 7. 6% +,7 . ! " ! ! ! = ) " $ $ " ! ! 6( " " X ? ,,,,. " ! ! X , ?+>,. X , ?+E+. & X , C-,>. $ X ? ,,,,. X , C+@? X ? ,,,,7.6% +,7

E> ( ?C ! " & " & =) . ! ! 56" 1 ! " " ! " 0 ! =) . ! ! ) % ?F @ % ?F @ * ?F @ $ ?F @ 0 ?F @ # ?F @ 2 ?F @ " $ " " $ 6) ! 7 E D, C- D , ?+ D , , , " $ " $ 6) ! 7 B EE EB , , , ?? ?? , , " $ " " $ 6) ! 7 E +D C- D ?+ D ?+ D , +D , " $ " $ 6) ! 7 B DD D@ >> >> , , , , , $ " " $ 6) ! 7 ?B -C @E +@ C+ , , , , , $ " $ 6) ! 7 +C BD @D > CD , , , , , $ " " $ 6) ! 7 ?B >+ ?? ?, DC ?D -B , ?D -B ?D -B D +E $ " $ 6) ! 7 +C >C >E C, >C +? -> , > CD , , " $ =) " $ 6) ! 7 > _{D, +D , +D , , ,} " $ =) $ 6) ! 7 > _{D, D, , , , , ,} " $ =) " $ 6) ! 7 > D, , +D +D , +D , " $ =) $ 6) ! 7 > _{, -D , , , +D ,} $ =) " $ 6) ! 7 @ _{EC CC ?@ @- , , , , ,} $ =) $ 6) ! 7 ?C @B +C C, -- , , , , , $ =) " $ 6) ! 7 @ CC CC , CC CC , ?@ @- CC CC , $ =) $ 6) ! 7 ?C _{>@ ?D ?D CE - @B , ?D CE - @B - @B} % +? ! " " ! " . ! ! ( ! " ! ! ! " " $ " " $ " " $ " $ ! ! 6( " " X , ?C?+. " ! ! X, ,@+>. X . & X, >-,@. $ X? ,,,, X 7. 6 X " " 7. 6% +?7 ( ! " ! ! ! " " $

ED " " $ " " $ " $ ! ! 6( " " X , CC>@. " ! ! X? ,,,,. X, >-,@. & X, >-,@. $ X X , +,DB7. 6 X " " 7. 6% +?7 ( ! " ! ! ! " $ " " $ " $ " $ ! ! 6( " " X , ,-D>. " ! ! X , ,-D>. X . $ X . X 7. 6 X " " 7. 6% +?7 ( ! " ! ! ! " $ " " $ " $ " $ ! ! 6( " " X ? ,,,,. " ! ! X , ?>B>. X , -,B+. & X . $ X , C?+B. X , ,E>> X , >D+>7. 6 X " " 7. 6% +?7 % ++ ! " " ! =) . ! ! % " " $ =) " $ ! ! " " . " ! ! & 3 ( " " $ =) $ ! ! $ ! ! " " " ! ! 6% ++7 / ! . ! " " $ =) " $ " " . " " $ =) $ ! " ! ! 6% ++7 % " . $ =) " $ . " $ =) $ ! " " 3 ! " !

E@ ! ! ! " " 6% ++7 $ . " " $ =) " $ " $ = ) $ . ! ! ! ! ! ! "

E-0 20 40 60 80 100 120 HIV positive and H. pylori positive (Current Source) HIV positive and H. pylori negative (Current Source) HIV positive and H. pylori positive (Childhood Source) HIV positive and H. pylori negative (Childhood Source) HIV negative and H. pylori positive (Current Source) HIV negative and H. pylori negative (Current Source) HIV negative and H. pylori positive (Childhood Source) HIV negative and H. pylori negative (Childhood Source) Patient Groups P er ce n ta g e

Tap w ater on premises (%)

Tap w ater from communal source (%) Bore Hole (%) Tanks (%) River (%) Dam (%) Other (%) 3 +5" 1 ! " " ! " . ! !

EE , ?, +, C, >, D, @, -, E, B, " $ =) " $ 6) ! 7 " $ =) $ 6) ! 7 " $ =) " $ 6) ! 7 " $ =) $ 6) ! 7 $ =) " $ 6) ! 7 $ =) $ 6) ! 7 $ =) " $ 6) ! 7 $ =) $ 6) ! 7 > ( " " 6A7 ( " ! ! 6A7 6A7 ( & 6A7 2 $ 6A7 / 6A7 * 6A7 3 ++" 1 ! " " ! =) . ! !

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B, , ?, +, C, >, D, @, -, " $ 6) 7 $ 6) 7 " $ 6) 7 $ 6) 7 > !& 6A7 ! 6A7 5 6A7 / 6A7 3 +6" 1 " . ! ! ( ! ! " " $ $ " ! ! 6 !& X, >+>?. " ! X . X X 7. 6 X " " 7. 6% +C7 . ! " ! " $ $ " ! ! 6 !& X , --@,. " ! X, +EE. X? ,,,, X, >B@E7 % +> " " . ! !

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