We wholeheartedly agree with Paul Farmer and colleagues [1] that it is vitally important to examine social, as well as molecular, causes of disease. Unless we carefully consider the full range of factors that underlie a given problem, we may produce “solutions” with unintended and deleterious consequences. In this light we express our concern about the infant feeding approach advocated in their article to reduce mother-to-child transmission of HIV in Rwanda.

While exclusive replacement feeding reduces the risk of transmission between HIV-positive mothers and their infants, it does not adequately address the specters of infection and undernutrition that accompany avoidance of breast-feeding. We are convinced by data from regions that are similar to Rwanda and even from African countries with higher standards of living that replacement feeding from birth is a dangerous and inappropriate approach for HIV-affected families in countries like Rwanda.

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