HIV remains the leading cause of death among adults in South Africa despite the availability of antiretroviral therapy (ART) due to failure to initiate ART and failure to remain on ART. Among people living with HIV (PLWH) who are hospitalized, 17-26% die within 6 months of hospital discharge potentially contributing to more than half of all HIV-associated mortality in South Africa.

There are heterogenous reasons for mortality that include missed diagnoses, psychosocial barriers to completing treatment plans, and structural barriers that include food insecurity. To respond to the complexity of underlying causes of mortality we developed and piloted a disease neutral intervention to reduce posthospitalization mortality: HomeLink. This intervention consisted of structured posthospitalization home care visits with psychosocial counselling and nutritional supplementation and reduced posthospitalization mortality by 60%. These results raise important questions regarding reproducibility and scale-up of this intervention. In order to inform policy, the most feasible and cost- effective elements need to be identified. Here we are proposing a fully powered study of a refined HomeLink2 intervention to compare usual care to structured home visits or home visits plus nutritional supplementation. In addition, we will identify underlying mechanisms of the intervention effectiveness including the impact on timeliness of acute care, medical diagnoses, adherence to ART (through viral load testing), and psychosocial metrics. We will further assess implementation outcomes to guide future refinement of intervention delivery. Finally, we will use findings from the randomized trial to complete costing and cost-effectiveness analyses to inform policy makers regarding cost of HomeLink2 and cost-effectiveness of home visits alone or home visits plus nutritional support to inform potential scale-up and long-term sustainability. This project has the potential to generate considerable new knowledge on interventions that could dramatically reduce HIV-associated mortality in South Africa and other low- and middle-income settings. This proposed study is very likely to generate actionable knowledge to improve outcomes for PLWH and contribute to overall goals of HIV epidemic control.