Background: Global Fund (GF) allocates funding to countries on the basis of a two-stage Formula: a quantitatively-measured raw allocation is qualitatively adjusted for contextual indicators, including HIV prevalence among key populations (KP). However, availability of KP data is limited, possibly diverting funds from concentrated epidemics. By modeling funding allocations, we identify the major drivers of allocations and qualitative adjustments and the impact of data availability.
Methods: We applied the Formula to available data across 101 recipient countries. HIV allocations (2017-2019) were linearly regressed on the raw allocation (per the Formula, number of people living with HIV and economic capacity, adjusted for minimum/ maximum shares and external funding sources) and data reportedly used in qualitative adjustments: domestic spending on HIV, past grant rating, ART coverage, World Bank income category, ''smoothing'' of changes in 2014-2016 allocation to current raw allocation, and HIV prevalence data among KPs.
Results: Total allocations from the GF declined by 34% for 2017-2019 relative to 2014-2016. For individual countries, the strongest predictor of final allocation was raw allocation (adjusted R² = 0.713), with 88% of variation captured in a parsimonious model of raw allocation, domestic spending, income category, ART coverage, and smoothing in allocation differences relative to 2014-2016. Qualitative adjustments were primarily driven by smoothing to account for sharp declines in HIV allocations relative to 2014-2016; in addition, countries with higher domestic investments and lower ART coverage had greater proportional adjustments (p < 0.05). After controlling for other factors, KP prevalence data did not significantly predict allocation nor qualitative adjustments, although only 40% of countries had data for all KPs.
Conclusions: Country allocations were largely captured by public data, with remaining variation likely due to indicators described in the Formula but not publicly available. Qualitative adjustments to allocations were driven by the significant drop in HIV allocations relative to 2014-2016, possibly obscuring adjustments made for KP prevalence. Reducing year-to-year fluctuations in budget is needed to ensure Global Fund''s ability to make epidemiologically appropriate allocations and ensure programmatic continuity. Greater transparency in methodology is needed to clarify how KP data are used in allocation decision-making.

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