OBJECTIVES::  In this study, we sought to assess whether the pictorial intervention would help to identify and improve ADR reporting in an ART clinic serving HIV patients in Northwest Ethiopia. METHODS::  A randomized controlled study on ART-naïve HIV-positive patients was conducted from July 15, 2015 to January 15, 2016. The patients were randomly categorized into intervention and control groups based on their identification number. Interventional group were then subjected to receive pictorial medication information and pictograms-enhanced tool to identify and report ADRs. However, control group did not receive any pictogram-enhanced intervention to identify the medications and to report ADRs. RESULTS::  Bivariate analysis showed that sociodemographic characteristics, age, sex, education, employment, and marital status were predictors of identifying and reporting ADRs. Males were twice more likely to identify ADRs than females. Univariate analysis revealed, intervention group showed a statistically significant association with the ability to identify ART medications using pictograms. Intervention group patients were more likely to identify 3TC [OR (95% CI)=7.536 (4.042-14.021), p=0.000], TDF [(OR (95% CI)=6.250 (2.855-13.682), p=0.000], NVP [(OR (95% CI)=5.320 (1.954-14.484), p=0.001], EFV [(OR (95% CI) =3.929 (1.876-8.228), p=0.000], and AZT [(OR (95% CI) =3.570 (1.602-7.960), p=0.002] using pictograms. Compared to control group, interventional group showed 4.3 times more likely to identify diarrhea as an ADR using pictogram. CONCLUSIONS::  We found that the use of pictogram-based intervention for ART medications resulted in increased identification of ADRs and improved ADR reporting among naïve HIV-positive patients with limited literacy in Northwest Ethiopia. This intervention provided promising innovation with the potential implications to improve ADR reporting and promote patients safety, particularly for HIV-positive patients with limited educational levels.