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Gaining understanding of the period before antiretroviral therapy (ART) is needed to improve treatment outcomes and to reduce HIV transmission. This study describes the cascade of enrollment in HIV care, pre-ART follow-up, and predictors of mortality and lost to follow-up (LTFU) before ART initiation.We conducted a cohort study among HIV-infected adult patients not yet started on ART in 4 HIV Sub-Saharan African programs. Patient follow-up began at enrollment and ended at the earliest of death, transfer-out, ART initiation, last visit date, or 60 months postenrollment. Risk factors for death and LTFU were investigated during the periods 0–6 and 6–60 months.A total of 55,789 patients (65.4% women) were included as follows: 44.2% in clinical stage 3 or 4, with median CD4 of 261 cells per microliter [interquartile range (IQR): 125–447]. Patient care started with a median of 3 days (IQR: 0–11) after HIV diagnosis, and 31,104 of 55,789 (55.8%) patients had CD4 counts performed within 1 month of enrollment. Of 47,283 patients with known ART eligibility status at enrollment, 36,969 (78.2%) patients required ART and 27,798 of 36,969 (75.7%) patients initiated therapy. Median follow-up was 2.5 months (IQR: 0.9–13.1). Mortality and LTFU rates were 3.9 per 100 person-years [95% confidence interval (CI): 3.7 to 4.1] and 28.3 per 100 person-years (95% CI: 27.8 to 28.8), respectively. Regardless of period, increased mortality and LTFU were associated with male, lower body mass index, advanced clinical stage, and lower CD4 cell count.Short delays between HIV testing and care enrollment were observed in our HIV programs, but delays to determine ART eligibility were long. Interventions to initiate ART earlier, specifically targeted to men, are needed to improve patient retention in Africa.