Objectives: To calculate annual tuberculosis incidence rates, and investigate risk factors for tuberculosis, among heterosexual adults living with diagnosed HIV in England and Wales. Design: Analyses of comprehensive national records of persons seen for HIV care between 2002 and 2010 linked to the national tuberculosis database (1999-2010) for England and Wales. Methods: Annual incidence rates of tuberculosis among heterosexual adults living with diagnosed HIV were calculated on the basis of the number of heterosexual adults seen for HIV care in a given year and the number, in that same year, with a first episode of tuberculosis at the time of, or subsequent to, their HIV diagnosis. Results: Between 2002 and 2010, almost one in 10 (4266/45 322) heterosexual adults living with HIV were diagnosed with tuberculosis, of whom the majority (92%) were diagnosed at the time of, or after, their HIV diagnosis; 84% (3307) were black African. The annual tuberculosis incidence rate decreased from 30 per 1000 in 2002 to 8.8 per 1000 in 2010 (P< 0.01). The annual tuberculosis incidence rate among those not on antiretroviral therapy (ART) was significantly higher than among those using ART (2010: 36 versus 3 per 1000; P<0.01). Conclusions: The annual tuberculosis incidence rate among heterosexual adults living with diagnosed HIV in England and Wales has declined significantly over the past decade. However, the 2010 rate remains significantly higher than in the general population. Our findings support routine HIV testing in tuberculosis clinics, screening for latent tuberculosis in HIV diagnosed persons, and the prompt initiation of ART where appropriate.