I go through and clean them up pretty regularly. I have a method, if I have not used an app for a while it gets moved to a folder on page 2. If I find that i use it again before the cleanup then it goes back to page 1. Helps cut down on the clutter.
Many of them are just sitting in folders titled "various", but every once in a while, I'm glad I have a specific app or game with my which I've rarely or never used before. I access those through Spotlight.
One day I'll do a cleanup of those I never used...
At least the first few pages of my homescreen are tidily filled with apps I use regularly.
I've narrowed my list to around 65 total - I'm pretty good about deleting apps I don't use regularly but I do tend to collect games! - but what has really changed everything for me is the folders from iOS 4.1... I am loving having only one page of folders and apps, and I find that I don't bother to routinely check Facebook and Twitter on my phone like I used to now that they are hidden away in my 'Social' folder