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Background  There is concern about the increasing rates of loss to follow-up (LTFU) among pre-antiretroviral therapy (pre-ART) patients in Ethiopia. Little information is available regarding the time when pre-ART patients are lost to follow-up in the country. This study assessed the time when LTFU occurs as well as the associated factors among adults enrolled in pre-ART care in an Ethiopian rural hospital.    Methods  Data of all adult pre-ART patients enrolled at the Sheka Zonal Hospital between 2010 and 2013 were reviewed. Patients were considered lost to follow-up if they failed to keep scheduled appointments for more than 90 days. The Cox proportional hazards regression model was used to assess factors associated with time until LTFU. The Kaplan-Meier survival table was used to compare the LTFU experiences of patients, segregated by significant predictors.    Results  A total of 626 pre-ART patients were followed for 319.92 person-years of observation (PYOs) from enrolment to pre-ART outcomes, with an overall LTFU rate of 55.8 per 100 PYOs. A total of 178 (28.4%) pre-ART patients were lost to follow-up, 93% of which occurred within the first six months. The median follow-up time was 6.13 months. The independent predictors included: not having been started on co-trimoxazole prophylaxis (adjusted hazard ratio [AHR] = 1.77, 95% confidence interval [CI], 1.12–2.79), a baseline CD4 count of or above 350 cells/mm3 (AHR = 1.87, 95%CI, 1.02–3.45), and an undisclosed HIV status (AHR = 3.04, 95%CI, 2.07–4.45).    Conclusion  A significant proportion of pre-ART patients is lost to follow-up. Not having been started on co-trimoxazole prophylaxis, presenting to care with a baseline CD4 cell count ≥350 cells/mm 3 , and an undisclosed HIV status were significant predictors of LTFU among pre-ART patients. Thus, close monitoring and tracking of patients during this period is highly recommended. Those patients with identified risk factors deserve special attention.    Electronic supplementary material  The online version of this article (doi:10.1186/s40249-015-0056-y) contains supplementary material, which is available to authorized users.

When are patients lost to follow-up in pre-antiretroviral therapy care? a retrospective assessment of patients in an Ethiopian rural hospital