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In 2018, Brazilian guidelines changed to recommend tuberculosis (TB) preventive therapy for all people with HIV and a CD4+ cell count 350 cells/μl or less, but only for those with a positive tuberculin skin test (TST) if CD4+ cell count is than 350 cells/μl. We determined the potential effectiveness of CD4+-based guidelines for TB testing and preventive therapy.Secondary analysis of the stepped-wedge, cluster-randomized THRio trial for isoniazid preventive therapy (IPT).We analyzed data from 4114 newly registered patients with HIV in 29 clinics followed until TB diagnosis, death, or administrative censoring. We compared incidence rates of TB and TB/death between CD4+, TST, IPT, and antiretroviral therapy categories.Initial CD4+ cell count was 350 cells/μl or less in 2138 (52%) and more than 350 cells/μl in 1976 (48%) patients. TST was performed for 2922 (71%), of whom 657 (16%) were TST-positive [278 (13%) CD4+ ≤ 350 vs. 379 (19%) CD4+ > 350]. A total of 619 (15%) received IPT and 2806 (68%) received antiretroviral therapy. For patients with CD4+ cell count 350 cells/μl or less who did not receive IPT, the incidence rate of TB was 1.79/100 person-years (pys) and TB/death was 3.89/100 pys. For patients with CD4+ cell count more than 350 who did not receive IPT, the incidence rates of TB and TB/death were 0.57/100 and 1.49/100 pys for TST-negatives, and 1.05/100 and 1.64/100 pys for TST-unknowns.TB incidence was high among all patients who did not receive IPT, including those with CD4+ cell count more than 350 cells/μl and negative or unknown TST results. TB preventive therapy should be provided to all people living with HIV in medium burden settings, regardless of CD4+ cell count and TST status.