A federal judge in Texas ruled that a provision of the Affordable Care Act (ACA) mandating that private insurance plans cover drugs that prevent HIV infection at no cost to patients violates both federal law and the Constitution.

The ruling, made in Fort Worth by U.S. District Judge Reed O’Connor, came in response to a lawsuit filed in 2020 by Jonathan Mitchell, a former Texas solicitor general, on behalf of Braidwood Management Inc. and other self-described Christian employers and employees across Texas.

The plaintiffs argued that the mandate to provide total coverage of the HIV drugs Truvada and Descovy, as well as contraceptives and the HPV vaccine, compels business owners to pay for services that “encourage homosexual behavior, prostitution, sexual promiscuity, and intravenous drug use” despite their religious beliefs.

Truvada and Descovy are known as pre-exposure prophylaxis (PrEP) drugs, they reduce the chance of getting HIV from sex or intravenous drug use. Daily use of PrEP reduces the risk of acquiring HIV by more than 99% among men who have sex with men and by at least 90% among women. In 2019, the U.S. Preventive Services Task Force granted PrEP an “A rating,” which under the ACA means that the vast majority of insurers were mandated to cover it for free starting in January 2021.

O’Connor, who in a 2018 case ruled that the ACA was unconstitutional, sided with Braidwood Management, writing that the government has no “compelling interest in forcing private, religious corporations to cover PrEP drugs with no cost-sharing and no religious exemptions.”

The government defendants in the suit “outline a generalized policy to combat the spread of HIV, but they provide no evidence connecting that policy to employers such as Braidwood, nor do they provide evidence distinguishing potential religious exemptions from existing secular exemptions” the judge wrote. “Thus, defendants have not carried their burden to show that the PrEP mandate furthers a compelling governmental interest.”

The American Cancer Society Cancer Action Network said the ruling could have a broader impact and jeopardize other preventive care coverage under the ACA, including routine cancer screenings.

“This ruling threatens to erode more than a decade of progress reducing cancer deaths and suffering,” the group said in a statement. “Having guaranteed, no-cost coverage of proven preventive and screening services — like those for breast, colorectal, cervical, and lung cancer — has enabled more people to get timely, life-saving screenings without facing potentially unaffordable out-of-pocket costs.”

“We strongly urge the government to swiftly appeal this ruling.”

U.S. Department of Health and Human Services (HHS) spokeswoman Rachel Seeger declined to say whether the government would appeal the ruling but affirmed that HHS “continues to work to ensure that people can access health care, free from discrimination.”

The plaintiffs in the case also challenged the ACA’s free coverage requirements for “contraception, the HPV vaccine, and the screenings and behavioral counseling for STDs and drug use” under the same religious grounds.

“They say neither they nor their families require such preventive care,” the judge wrote in his ruling. “They also claim that compulsory coverage for those services violates their religious beliefs by making them complicit in facilitating homosexual behavior, drug use, and sexual activity outside of marriage between one man and one woman.”

O’Connor, an appointee of Republican former President George W. Bush, did not rule on the contraceptive mandate challenge and rejected the challenge to the HPV vaccine mandate. The judge also did not specify how his new ruling on PrEP coverage would be enforced.

Jonathan Saenz, president and attorney for Texas Values, characterized the matter as “a very simple case.”

“Christian employers should not be forced to pay for drugs that violate their right of conscience,” Saenz told The Dallas Express. “If the Biden admin[istration] chooses to continue this case, they will lose again at the taxpayer’s expense.”