With improved survival in the post-highly active antiretroviral therapy (HAART) era, we have witnessed an increase in the incidence of both acute and chronic kidney disease among patients with human immunodeficiency virus (HIV-1) infection. Much has been learned in the past three decades about the pathophysiological concepts of HIV-1 infection and its association with kidney disease. The extent of HIV-1 associated kidney disease is vast and represents a variety of clinical and histopathological conditions. While HIV-associated nephropathy (HIVAN) remains the most sinister kidney disease related to the direct effects of HIV-1, there are other contributors to kidney disease such as toxic effects of antiviral therapy, high prevalence of hepatitis C, cigarette, and injection drug use. This review presents the pathophysiological principles behind HIV-1 associated kidney diseases, with particular attention to thrombotic microangiopathy, drug-related kidney disease and HIVAN. Therapeutic options such as HAART, corticosteroids and angio-tensin-converting enzyme inhibitors are discussed. Advances in basic science medicine provided some insights into the role of cyclin-dependent kinase inhibitors as a potential therapeutic option for HIVAN. The emerging role of organ transplantation in HIV patients with kidney disease is also presented. Emphasis is placed on early diagnosis and timely treatment of kidney disease and heightened awareness particularly among the vulnerable population that bears most of the disease burden.