This study showed a low prevalence (4%) of asymptomatic P. falciparum parasitemia among HAART-treated patients with sustained HIV-RNA viral suppression. The malaria parasite prevalence among HIV patients in this study is lower than the Kampala malaria parasite prevalence of 7.4% among under-five children as reported in the 2009 malaria indicator survey . It is important to note that the latter result is not directly comparable with the current study among HAART & cotrimoxazole-treated adults however it is one of the indicators of malaria endemicity in this urban setting. The findings of this study are consistent with previous reports of low prevalence of malaria infections among successfully treated HIV-infected adults [2, 8, 15]. All the study participants had received ongoing cotimoxazole prophylaxis, ITNs and malaria prevention education as recommended by the HIV/AIDS treatment guidelines . Results from this study imply that although HIV-infected individuals were previously considered among the special risk groups for malaria infections [3, 4], there is need to re-evaluate the risk of malaria infection after long-term successful HAART. The authors recommend parasite-based diagnosis of malaria in similar settings in order to avoid over-prescription of anti-malarial medicines. However, the choice between RDTs and microscopy to implement this depends on local circumstances that include the skills available, patient load, epidemiology of malaria and the possible use of microscopy for the diagnosis of other diseases.
The use of the simple rapid tests to detect malaria antigenaemia among PLHIV emphasizes the utility of RDTs in parasite-based malaria diagnosis (PMD) in this population. The findings of this study will contribute to the implementation of RDTs for PMD among PLHIV in areas where microscopy is not accessible . Moreover, use of RDT results to guide anti-malarial therapy is likely to reduce anti-malarial drug costs due to over-prescription [6, 17]. With the introduction of artemesinin-based combination therapy (ACT)  coupled with the high pill burden among HIV-infected individuals on HAART, cotrimoxazole and treatment for other co-morbidities, presumptive treatment of malaria is increasingly becoming clinically and economically inappropriate . With the declining incidence of malaria in Africa , plus the results from this study, there is need to scale up parasite-based malaria diagnosis in successfully treated HIV-infected adults in areas of low to moderate stable malaria transmission. Similarly, there is need to evaluate the utility of RDTs among successfully treated HIV-infected adults with febrile illnesses.
During follow up, none of the patients with asymptomatic parasitaemia reported development of clinical signs and symptoms of malaria infection during the subsequent six months. It is of interest to note that HIV-infected adults did not develop clinical symptoms of malaria despite the increased risk of malaria infections associated with the HIV-associated immune suppression [3, 4, 19]. The authors attribute this result partly to the fact that the parasite densities were low since the development of clinical symptoms correlates positively with parasite densities . It is also possible that long-term HAART restores the hosts' ability to control the infection. Similarly, the authors postulate that long-term cotrimoxazole prophylaxis could contribute to the hosts' response to the asymptomatic P. falciparum parasitaemia. However, there is need to study the recovery of the host's immunological responses to P. falciparum infection among PLHIV in the setting of long-term HAART and cotrimoxazole prophylaxis.