Abstract: Objective To explore the way to improve blood donation-blood transfusion process and reduce the risk of HIV infection through blood transfusion. Methods The analysis was conducted on the blood transfusion process to find out the key point of HIV infection. Results The HIV test result of the blood donor was negative, but 2 patients who received the donated blood were detected to be HIV positive. The re-test confirmed that the blood donor was HIV positive. The 2 HIV infections were caused by blood transfusions during the window phase of the blood donor. Conclusion It is essential to strengthen the management of blood donation and transfusion, especially the blood donor's recruitment, health examination and blood detection, to reduce the HIV infection through blood transfusion.