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Among adults started on antiretroviral treatment (ART) in a rural district hospital (a) to determine the cumulative proportion of deaths that occur within 3 and 6 months of starting ART, and (b) to identify risk factors that may be associated with such mortality.A cross-sectional analytical study set in Thyolo district, Malawi.Over a 2-year period (April 2003 to April 2005) mortality within the first 3 and 6 months of starting ART was determined and risk factors were examined.A total of 1507 individuals (517 men and 990 women), whose median age was 35 years were included in the study. There were a total of 190 (12.6%) deaths on ART of which 116 (61%) occurred within the first 3 months (very early mortality) and 150 (79%) during the first 6 months of initiating ART. Significant risk factors associated with such mortality included WHO stage IV disease, a baseline CD4 cell count under 50 cells/μl and increasing grades of malnutrition. A linear trend in mortality was observed with increasing grades of malnutrition (χ2 for trend = 96.1, P ≤ 0.001) and decreasing CD4 cell counts (χ2 for trend = 72.4, P ≤ 0.001). Individuals who were severely malnourished [body mass index (BMI) < 16.0 kg/m2] had a six times higher risk of dying in the first 3 months than those with a normal nutritional status.Among individuals starting ART, the BMI and clinical staging could be important screening tools for use to identify and target individuals who, despite ART, are still at a high risk of early death.