Africa is home to the majority of people with HIV (PWH) worldwide. Improved availability and access to antiretroviral treatment (ART) has improved survival, resulting in an ageing population now facing long-term HIV-associated morbidity, including musculoskeletal conditions. There is growing evidence on the impact of chronic HIV infection and ART on muscle and bone health. Musculoskeletal complications among PWH increase the risk of injury, disability, pain, reduces quality of life, and incurs substantive healthcare and economic costs. This review discusses mechanisms by which HIV may affect bone and muscle, including direct cellular stress, indirect chronic inflammation, immunosenescence and hormonal dysregulation, as well as ART-related effects. It appraises evidence for bone and muscle health among PWH across different age groups and populations in Africa. Potential interventions such as improved nutrition, physical activity, vitamin D and calcium supplementation, and use of bisphosphonates to attenuate musculoskeletal morbidity are discussed. Musculoskeletal health services need to be integrated into core HIV-care services. Routine fracture risk assessments and robust preventive management strategies should become the norm, to reduce musculoskeletal morbidity among PWH in Africa.