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Background. Timely antiretroviral therapy (ART) initiation requires early diagnosis of human immunodeficiency virus (HIV) infection with prompt enrollment and engagement in HIV care.Methods. We examined programmatic data on 334 557 adults enrolling in HIV care, including 149 032 who initiated ART during 2006–2011 at 132 facilities in Kenya, Mozambique, Rwanda, and Tanzania. We examined trends in advanced HIV disease (CD4+ count <100 cells/μL or World Health Organization disease stage IV) and determinants of advanced HIV disease at ART initiation.Results. Between 2006–2011, the median CD4+ count at ART initiation increased from 125 to 185 cells/μL an increase of 10 cells/year. Although the proportion of patients initiating ART with advanced HIV disease decreased from 42% to 29%, sex disparities widened. In 2011, the odds of advanced disease at ART initiation were higher among men (adjusted odds ratio [AOR], 1.4; 95% CI, 1.3–1.5), those on tuberculosis treatment (AOR, 1.6; 95% CI, 1.3–2.0), and those with a ≥12 month gap in pre-ART care (AOR, 2.0; 95% CI, 1.6–2.6).Conclusions. Intensified efforts are needed to identify and link HIV-infected individuals to care earlier and to retain them in continuous pre-ART care to facilitate more timely ART initiation.