Objective: To determine the baseline prevalence of tuberculosis (TB) in a cohort using a strategy of intensive pretreatment screening for TB and the subsequent incidence rate and temporal distribution of cases during the first year of antiretroviral therapy (ART). Design: Prospective observational community-based ART cohort in South Africa. Methods: Adults enrolling for ART and who did not have a current TB diagnosis were intensively screened for TB at baseline using culture of two sputum samples, chest radiography and investigations for extrapulmonary disease as required. Patients who developed symptoms consistent with incident TB during ART were similarly investigated. Results: Two hundred forty-one patients had a median CD4 cell count of 125 cells/μl (interquartile range 70–186) and 200 (83%) started ART. TB was diagnosed in 87 (36%) patients, with 82% of pulmonary cases being culture-proven. Most TB cases (87%) were prevalent disease detectable at baseline, whereas just 11 (13%) were incident cases that presented during the first year of ART. The incidence rate during 0–4 months of ART was similar to the rate during months 5–12 of ART [10.9 (95% confidence interval [CI] 4.6–23.3) cases per 100 person-years versus 8.1 (95% CI 3.6–18.0) cases per 100 person-years]. Conclusion: Systematic culture-based screening detected a very high burden of prevalent TB present at baseline. This intensified screening strategy was associated with an approximately two-fold lower incidence rate in the first 4 months of ART than previously observed in this cohort. This suggests that many incident cases of symptomatic TB presenting during early ART can be detected as prevalent disease prior to ART initiation using sensitive diagnostic tests.