In a recent study led by the Yale School of Public Health, researchers found that the Sept. 2022 Texas ruling in Braidwood Management v. Becerra could potentially result in more than 2,000 predictable cases of human immunodeficiency virus in the U.S. in the coming year. 

Pre-exposure prophylaxis, or PrEP, is a medication that can dramatically reduce the patient’s odds of contracting or transmitting HIV if taken either regularly or before sexual intercourse. Since 2019, the U.S. Preventive Services Task Force — an independent volunteer panel of experts in disease prevention — has given PrEP a Grade A “strongly recommended” rating, reflecting significant evidence that PrEP has crucial health benefits that outweigh any harms. 

Under the 2010 Patient Protection and Affordable Care Act, this rating requires all employers and insurers to provide PrEP coverage without cost sharing. 

However, in Braidwood Management v. Becerra, U.S. District Judge Reed O’Connor ruled in favor of the plaintiffs — a group of Christian-owned businesses and six individuals — who argued that the ACA’s requirement for private insurance policies to cover PrEP violated their religious freedom under the Religious Freedom Restoration Act. 

“Depending on whether the ruling is upheld and broadly interpreted, there are lots of people who are currently eligible and receiving incredibly effective and cost effective pre-exposure prophylaxis for HIV [who can] be denied care,” said A. David Paltiel, a YSPH professor and one of the lead authors of the study. “In fact, if it is interpreted even more broadly, [coverage] for other incredibly important services could be curtailed.”

This ruling relied on the 2014 Supreme Court case Burwell v. Hobby Lobby Stores, Inc., which held that requiring employers to provide coverage for contraceptives burdened religious exercise. O’Connor ruled that the coverage of PreP under insurance would do the same, since the plaintiffs believe that PreP helps to facilitate sex between same-sex partners.

Meredithe McNamara, an author of the study and an assistant professor of pediatrics at the Yale School of Medicine, described the Braidwood Management v. Becerra ruling as more “sinister” than the decision in Burwell v. Hobby Lobby Stores, Inc., since there is no “immediate workaround” for PreP coverage, unlike contraceptives. 

“Per Braidwood, anyone with an objection to LGBTQ identity can claim that providing healthcare for LGBTQ people harms their religious beliefs,” McNamara wrote in an email to the News. “In a time when the rights of transgender people are debated in state legislatures throughout the U.S., Braidwood is a clear example of a judicial attack meant to embolden those with prejudice to further harm LGBTQ people.”

In the study, the researchers tried to estimate how many new HIV infections would result from the outcome of this court ruling, focusing on men who have sex with men.

According to Palitiel, it is estimated that out of all the MSM who are eligible for PreP treatment, about 28 percent of these men are actually receiving PreP. If PreP is no longer covered by insurance, this number — which Paltiel referred to as coverage — will almost certainly drop.

“We assembled data on the efficacy of PreP, its current coverage and current rates of HIV transmission, and then said, ‘what if coverage actually drops?’” Paltiel said. “What if coverage drops 1 percent? 2 percent? 3 percent? How many new infections would we expect to observe in this population?”

The researchers estimated that for every 1 percent decrease in the number of PrEP eligible MSM receiving PrEP, there would be approximately 114 new HIV infections the following year. Infections occurring after the one-year period and all secondary transmissions were ignored in this estimate. In addition, the researchers estimated that coverage would drop from 28 percent to 10 percent after the Braidwood Management v. Becerra decision. 

Based on these statistics, the researchers estimate that the ruling will lead to more than 2,000 new entirely preventable HIV infections in MSM in the following year. 

However, according to Paltiel, this number is almost certainly an underestimate.

“Our number is conservative … in terms of base inputs we chose, conservative in terms of [only considering] the coming year and not what happens further down the road, conservative in the sense that we only consider primary infections … and not all the secondary transmission that happens once a person is infected and conservative only in the sense that we only consider MSM,” Paltiel said. 

In addition, the paper was also “conservative” in the sense that it did not take into account outsized effects of the ruling on specific racial and social demographic groups who are disproportionately impacted by HIV, particularly Black and Latino gay and bisexual men, as well as transgender women.

According to Paltiel, the most worrisome outcome of this ruling would be if the court chooses to strike down the U.S. Preventative Service Force’s authority to issue binding recommendations, something that is currently guaranteed due to the ACA.  

“That is an incredibly powerful safeguard that we have here in this country to insure people actually get access to preventative services,” Paltiel said. “The Brainwood case challenges that part of the Affordable Care Act. If this is upheld and interpreted broadly, it isn’t just HIV prevention, it’s all preventative services which are only required to be paid for because the U.S. Preventative Service Force said they were Grade A.”

While the plaintiffs also requested a nationwide religious exemption for PrEP insurance coverage, Judge O’Connor has yet to rule on this; this outcome is expected to be determined in the coming weeks.

Nick Fisk GRD ’23, the current president of the Graduate and Professional Student Senate, described the outcome of the Braidwood case “infuriating.”

“The relative selectiveness of the filing and ruling seems so carved out, as if in malice, to target those disproportionately affected–namely poor folk, racially marginalized, and men who have sex with men,” Fisk wrote in an email. “Their claim [that homosexual behavior violates their religious freedom] not only makes painfully clear how they view LGBT folk as less human, but also the demonstrates indifference to the collateral groups harmed.”

Fisk notes that this study is “emblematic” of how seriously the researchers at YSPH take their duty to inform the public of the public health effects of political decisions being made in the U.S. They believe that this work is especially important in future advocacy efforts. 

According to the Center of Disease Control, it was estimated at the end of 2019 that 1,189,700 people aged 13 and older had HIV in the U.S.

Jessica Kasamoto covers the Yale School of Public Health for the SciTech desk. She is a graduate student in computational biology and bioinformatics.