Public health officials in Toronto are stepping up syphilis prevention and testing efforts in a bid to curb a dramatic increase of the disease among the city's middle-aged gay men. In 1998, Toronto health officials recorded 19 syphilis cases, the lowest incidence in years. But cases have increased 20-fold since then, reaching 353 in 2004.

In response, officials are visiting bathhouses and giving information sessions to teach prevention and encourage men to get tested for syphilis. "A lot of gay men have forgotten about syphilis and don't remember what it is," said Dr. Rita Shahin, assistant medical officer of health.

One explanation for the resurgence is that gay men, especially those ages 35-50, are having more casual and unprotected oral sex. This type of sexual activity is an efficient way to transmit syphilis because of the exchange of bodily fluids. "It's an older group that you would think would know about HIV and the risks of unsafe sex," Shahin said.

Like other cities, Toronto is struggling to find ways to eliminate syphilis. "We are trying our best to get the message out about testing and treatment and safer sex, but it is hard to change people's behavior," noted Shahin. In addition, "we are working closely with community partners in terms of outreach, including educating physicians who may not have seen syphilis in years," she said.

Shahin said it is too early to tell if the number of syphilis cases will continue to rise this year. Most alarming, she added, is that about one-third of those infected with syphilis are also HIV-positive.

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