This is a randomised controlled trial involving 500 HIV-infected adults who have been hospitalized in public or non-profit hospitals in Mwanza region. Participants will be enrolled and randomized 2-3 days prior to hospital discharge, to either receive the DARAJA intervention (N=250) or the standard of care (N=250). HIV-infected adults randomised to the DARAJA intervention will have 5 sessions with a trained social worker over a 3-month period, the first meeting being in the hospital on the morning of discharge, the second at the patient’s home, and the three subsequent visits either in the patient’s home or outpatient HIV clinic. The control group will not receive the DARAJA intervention. All other aspects of care in the two groups will be the same and follow current standard practice.