Abstract Objectives To investigate the relationship between time to antiepileptic drug (AED) treatment (TTT) and seizure outcome in a high treatment gap sub-Sahara African setting. Methods Clinical and demographic characteristics of 72 adults with epilepsy aged 18–75 years were obtained. We estimated TTT as the difference between the duration of epilepsy and the duration of treatment. Indices of clinical outcome including seizure severity and 6-month disease remission were documented. The effects of TTT and other clinical and demographic characteristics on clinical outcomes were tested using bivariate and logistic regression analyses. Results Forty (55.6%) of the participants initiated treatment within 5 years of seizure onset (TTT ≤ 5 years) while 32 (44.4%) initiated treatment after 5 years (TTT > 5 years). There was moderate to strong correlation between TTT and age of onset (p = .009), age at treatment initiation (p = .026), duration of epilepsy (p = .000), and seizure severity (p = .020). The TTT > 5 years group had an earlier mean age of onset (p = .015) and higher seizure severity score (p = .001) and were less likely to be in 6-month disease remission (p = .014). Time to treatment ≤5 years was the only independent predictor of lesser seizure severity (OR = 0.163, 95% CI = 0.041–0.649) and better 6-month remission (OR = 0.154, 95% CI = 0.031–0.770) after adjusting for age of onset, duration of epilepsy, and number of AEDs. Conclusion Delayed treatment initiation is common in our sample and independently associated with poor seizure outcome.