Background Districts in coastal Andhra Pradesh, south India have the highest burden of HIV in both rural and urban areas. A comprehensive care program focused on improving clinical care and community outreach, complemented by a computerised management information system (CMIS), was implemented under the USAID supported Samastha project.

Methods Four community care centres covering 19 mandals were chosen as project sites. A mandal covers about 25 villages. Doctors, nurses and other members of the care teams were trained using the adapted “Integrated Management of Adult Illness” package and followed up with clinical mentorship visits every quarter. All on-site staffs were trained on infection prevention procedures. At the community level, people living with HIV (PLHIV) were involved in community outreach focused on treatment adherence, accompanied referrals for management of opportunistic infections and social linkages for livelihood options and basic nutrition. Small support groups of 10–12 individuals were formed at village or cluster level. Minor ailments and illnesses were treated at the local primary healthcare centers. Each community outreach worker maintained individual line-lists and prioritised outreach and follow-up for an average of 125 PLHIV, including children infected or affected by HIV. 6–8 outreach workers were supervised by a counsellor.

Results By the fourth year of implementation, 3257 PLHIV were registered with the project, of whom 1269 (38.9%) were initiated on Government supplied free ART. 2845 (87.3%) received nutrition support through education, supplementation and government schemes. 2085 (64%) were linked to social schemes such as widow pensions, bank loans or alternative livelihood options. Psychosocial support was provided to 2964 (91%) of the individuals registered. Loss to follow-up among those on ART reduced from 17% to <1% and annual death rates among those registered decreased from 21% to 4%. Success stories document the increased quality of life and ability to cope with stigma and discrimination.

Conclusions People living with HIV can be engaged in effective outreach when they function as spokes from the hub of a community care centre. Community outreach complements facility based clinical care and a comprehensive approach that includes both a bio-medical and social focus can improve quality of life and minimise death.