Bone health in people living with HIV (PLWH) has emerged as a significant concern in the era of effective antiretroviral therapy (ART). While ART has transformed HIV infection into a chronic condition, it has also unmasked long-term health complications, including an increased risk of osteoporosis and fractures. This review aims to elucidate the multifactorial mechanisms contributing to bone health deterioration in PLWH, such as direct viral effects, immune activation, and ART-induced bone metabolism changes. We examine the current evidence on bone mineral density (BMD) reductions and the heightened fracture risk in this population. Furthermore, we evaluate diagnostic and management strategies, including radiological and non-radiological evaluations, vitamin D optimization, bisphosphonates, and other emerging treatments, to provide a comprehensive overview of effective interventions. By synthesizing the latest research, this review seeks to enhance the understanding of bone health issues in PLWH and guide clinicians in implementing strategies to mitigate these risks, ultimately improving patient outcomes.