Since the advent of potent antiretroviral therapy in combination regimens, multiple epidemiologic studies have shown that osteopenia and osteoporosis are common among patients with HIV infection. However, there remain many areas of uncertainty about this potential complication, which can be confusing for the HIV clinician. This review summarizes the epidemiology, pathophysiology, suggested screening strategies, and management options of decreased bone mineral density in patients with HIV. Our aims are to review the available data, highlight controversial issues, and provide guidance for clinicians where supporting data are unavailable.