A commentary suggest that in settings where chest X-ray is affordable and widely available, its use before initiation of tuberculosis preventive therapy adds value; however, most such high-resource settings already use chest X-rays routinely for this purpose. By contrast, in the countries where the burden of tuberculosis is greatest and the need for preventive therapy most acute, it is likely that a recommendation to require chest X-ray before initiation of preventive therapy will do more harm than good. In these settings, scarce resources would be better used to increase the uptake of preventive therapy among people living with HIV on ART by ensuring a reliable supply of such therapy, political support, clear guidelines, clinician training, and patient support.