This paper describes the incidence of immune reconstitution syndrome (IRS) from the developing world and implications for clinicians. Eleven of 144 HIVand tuberculosis (TB)-coinfected individuals followed for 72 person-years developed IRS within 6 months of initiating generic highly active antiretroviral therapy (HAART). All of the IRS patients were male, with a median age of 29 years; median CD4 at HAART initiation was 123 cells/mm3, and 6-month median CD4 rise was 124 cells/mm3. There was no statistical difference in CD4 rise or CD4 count and duration of TB treatment at HAART initiation between those who did and those who did not develop IRS (P = 0.8380). The median time to development of clinical IRS was 42 days (range 10-89 days). The incidence of IRS in this cohort is 15.2 cases per 100 patient-years. With increased coprevalence of opportunistic infections, especially TB, and increasing access to antiretroviral therapy in the developing world, clinicians in these countries must be able to identify IRS and relieve symptoms without compromising clinical care.