INTRODUCTION: Antiretroviral therapy (ART) has significantly reduced HIV infections, but late initiation remains a major issue. This study aimed to identify predictors of ART initiation among newly diagnosed HIV-positive patients in Adama town. METHOD: A retrospective cohort study was conducted, with 396 newly diagnosed HIV-positive patients. This study used a survival analysis approach, including Kaplan-Meier plots, the log-rank test, and the Cox proportional hazards model. RESULT: The incidence rate was 152 per 1000 person-days for early initiation after HIV positive confirmed. In the adjusted model, gender, VCT test, disclosure status, having children in the home, opportunistic infections, and HIV/TB co-infections were significantly associated with time to ART initiation. CONCLUSION: To enhance early ART initiation, healthcare programs should prioritize support for women patients, promote HIV serostatus disclosure, and improve access to VCT testing. Targeted interventions for those with comorbidities and support for families with children are also essential.