Presentation / Toxic Event / Responsible ARV / Comment / Alt. Drug
for Switching
Rash all over the body, Itchy /
  • Hypersensitivity reaction
/ NVP
(Note: Cotrimoxazole can also cause this picture) /
  • The rash is more common within the first 2 weeks of taking the drug and is dose-dependent.
  • Always start with ½ the dose of NVP when initiating a child on a NVP containing regimen, increase NVP to full dose if it is well tolerated after 2 weeks. A rash after 2 weeks of taking the drug is unlikely to be due to NVP -- look for another cause.
  • Severe cases may present with peeling and ulceration of the skin and mucous membranes (Steven’s Johnson Syndrome, Toxic Epidermal Necrosis). This is life threatening. Stop the drug immediately and consult/ refer.
/
  • EFV
  • PI
  • Stop all drugs if SJS or TEN occurs

Yellow eyes, feeling tired all the time /
  • Acute symptomatic hepatitis
/ NVP /
  • This is rare in children but look out for it nonetheless. Also look for other signs of liver disease such as itchy skin, swollen legs
/
  • EFV
  • PI

Patient is tired all the time, the conjuctiva and palms are pale /
  • Severe anemia (Hb <7.5)
  • Neutropenia (<500cells/mm3)
/ AZT /
  • Exclude malaria as another common cause of anemia
  • If child is anemic, use ABC or d4T instead.
/
  • ABC
  • d4T

Persistent nausea and vomiting /
  • Severe gastrointestinal intolerance
/ AZT /
  • This must be severe and refractory enough to prevent ingestion of ARV drug regimen
/
  • D4T
  • ABC

Nausea, vomiting, abdominal pain, lethargy, abnormal breathing, /
  • Lactic acidosis
/ AZT
d4T /
  • Though these are the clinical signs of lactic acidosis, please note that lactic acidosis is usually sub clinical
/
  • ABC

Hallucinations, abnormally vivid dreams, dizzy, depression /
  • Central Nervous toxicity
/ EFV /
  • It is best avoided in someone who has CNS disease
/
  • NVP
  • PI

Tingling or burning sensation in limbs, /
  • polyneuritus
/ D4T
3TC
DDI
DDC /
  • peripheral never damage can be permanent if not stopped early
/
  • ABC
  • AZT

Severe diarrhea /
  • Severe gastrointestinal intolerance
/ LPV/r /
  • Rule out an infectious cause of diarrhea

Swollen belly, big breasts, loss of fat on the face, loss of muscle in the arms and legs, buffalo hump, potato on matchstick appearance' /
  • Lipodystrophy
/ LPV/r
d4T
AZT /
  • Do not confuse with malnutrition.
  • Not reversible unless drugs are stopped early.
/
  • ABC

Foetal damage /
  • Foetal damage
/ EFV /
  • Avoid in pregnancy especially in 1st trimester
  • Do not give to sexually active adolescents because of the risk of getting pregnant
/
  • NVP