*Keywords:* HIV, prejudice, socially engaged arts, participatory theatre intervention, mixed methods

‘isabelle-gatt’, ‘milosh-raykov’, ‘raphael-vella’

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Volume 15, Supplement Issue pp. 727 Faculty of Education©, UM, 2021

Not Safe for Work (NSFW)Persons living with HIV

A study of a socially engaged theatre work-in-progress

Isabelle Gatt

University of Malta isabelle.gatt@um.edu.mt

Milosh Raykov

University of Malta milosh.raykov@um.edu.mt

Raphael Vella*

University of Malta *Corresponding author: raphael.vella@um.edu.mt Abstract The human immunodeficiency virus (HIV) that causes acquired immunodeficiency syndrome (AIDS) is one of the most severe health challenges that affect the lives of an increasingly large number of people in the World. Lack of information, stigma, and marginalization of people with HIV are serious challenges that prevent early diagnostic of HIV infections and timely interventions that can improve the conditions of the affected people and the transmission of HIV. The existing body of research provides some evidence about the potential of socially engaged arts to expand knowledge, influence attitudes and empower participants to regularly take tests and visitors to understand and accept people affected by HIV. However, studies in this domain are scant and usually conducted in the areas with the highest prevalence of the HIV epidemic. Due to the limited evidence and the need to examine the potential of socially engaged arts in empowering people with HIV, this study examined and presented the initial results from an experimental theatre production focusing on participatory design and co-creation by applying a mixed method research design. A set of structured interviews with the participants, and discussions during the experimental reading session were used to study participants’ experiences, complementing pre-, and post-reading survey results of this small sample of participants. Results demonstrate very high interest in and expectations from socially engaged arts and a particular value of participatory design and co-creation during the development of the evaluated artistic creation. Keywords : HIV, prejudice, socially engaged arts, participatory theatre intervention, mixed methods

Introduction After almost 40 years of identification of human immunodeficiency virus (HIV), the outbreak of acquired immunodeficiency syndrome (AIDS) is still one of the most serious global health problems. According to the most recent estimates of the World Health Organization (WHO, 2021 ), in 2020, approximately 37.7 million (30.2–45.1 million) people were living with HIV and approximately 1.5 million (between 1.0 and 2.0 million) people acquired HIV during this year. As stated by the same report, in 2020, approximately 2.6 (between 2.3 and 3.0) million people lived in Europe, and at the same time, 170,000 (between 140,000 and 200,000) people in Europe acquired HIV. More than 30 years ago, when the estimated number of people infected with HIV was between 5 and 10 million, the director of the World Health Organization Special Programme on AIDS (Mann, 1988 ) identified three phases of the new global epidemic in a speech at the UN General Assembly: the epidemic of human immunodeficiency virus, the epidemic of acquired immunodeficiency syndrome, and the third phase of social, cultural, economic and political reaction to AIDS in the form of stigmatization and discrimination of infected people. According to this statement, the third epidemic is as challenging as HIV and AIDS (Mann 1988, p. 130). Several consequent studies confirmed the growing social challenges, including stigmatization and its detrimental impact on the health and quality of life of people with HIV (Mawar, Sahay, Pandit & Mahajan, 2005; Cao, Sullivan, Xu, Wu & Team, 2006; Hatzenbuehler, Phelan & Link, 2013). There are many consequences of stigmatization of people living with HIV, including limitation of their rights and health services, freedom and social interactions (Arefaynie, Damtie, Kefale & Yalew, 2021). Stigma as “an attribute that is deeply discrediting” (Goffman, 1963, p. 3) and consequent discrimination have a strong negative impact on the ambitious UNAIDS (2014) target to diagnose 90% of people with HIV, to provide antiretroviral therapy to 90% of and also viral suppression to 90% of people with HIV. Since the identification of HIV, the advancement of medical aid led to the development of effective solutions for the treatment of AIDS, but stigma and discrimination remain serious challenges that prevent the early identification of infections and timely interventions that could improve the conditions of affected people as well as the transmission of HIV (Stangl, Lloyd, Brady, Holland & Baral, 2013 ). According to Parker and Aggleton (2003) and the UN preventative actions,

negative stigmatization and discrimination of people affected with HIV are the main reasons the AIDS epidemic remains highly pervasive. Through a comprehensive critical analysis of the intervention programs, Parker and Aggleton (2003) acknowledged the limitations of the individualistic models to mitigate stigma. They recommended a focus on social change and interventions that emphasize the resistance of stigmatized HIV-affected individuals and communities. Research provides the evidence that dominant information-based approaches in the form of written information and brochures are not highly efficient (Stangl, Lloyd, Brady, Holland & Baral, 2013 ). Similarly, some health awareness campaigns and educational interventions are more likely to suppress than to change negative attitudes and stigmatization of people with HIV (Andersson et al., 2020 ). Despite considerable efforts to confront and mitigate HIV-related stigma and discrimination (UNAIDS, 2010) and efforts to understand stigma (Andersson et al., 2020; Cao et al., 2006 ), there are still evident knowledge gaps (Grossman & Stangl, 2013) and a need for more efficient forms for attitude change, increased tolerance, care for people with HIV. There is a need to understand the impact of different interventions on the reduction of stigma and the duration of such interventions (Brown, Macintyre & Trujillo, 2003). Many scholars agree that more research is needed to identify the effectiveness of various interventions and factors that influence the development and change of attitudes toward people with HIV (Stangl et al., 2013). A relatively small number of studies that examine the impact of arts-based interventions on the reduction of stigma toward people with HIV found that such interventions can increase knowledge about HIV and improve attitudes of the general public and at-risk populations (Nambiar, Ramakrishnan, Kumar, Varma, Balaji &, Rajendran et al.. 2011). An extensive study of the impact of science theatre performances on students’ behavioural intentions (Walker, Stocklmayer & Grant, 2013) based on standardized and previously validated preand post-performance surveys demonstrated that such performances could attract students’ interest in learning and increased knowledge about HIV risk. The multivariate regression analysis applied in this study identified a significant association between emotions and enjoyment of informal learning on students’ motivation to change their behavioural intentions.

A study of the participatory theatre approach conducted at the Bagamoyo College of Arts by Mabala and Allen (2002) found that such an approach can encourage communication about transmission and HIV and the measures that can reduce transmission. This approach is perceived as an effective way to identify risk behaviours and develop popular culturally appropriate promotional materials for HIV prevention. A more recent qualitative study (Logie et al., 2019) that focused on the exploration of the potential impact of a participatory theatre intervention on the reduction of stigma and the promotion of health equity for LGBT people found that this performance was perceived as exciting and likely to improve participants’ knowledge about HIV. This study was based on in-depth interviews and focus groups with students, health care professionals, educators and community members. The study found that such participatory interventions could contribute to the reduction of stigma and, in this way, mitigate barriers to HIV prevention and treatment, particularly in countries with a high prevalence of HIV. Since only a small number of studies examine strategies for reducing stigma toward people with HIV, this study explores how a theatrical production focused on the stigma of people living with HIV influences participants’ attitudes toward the possibility of reducing stigma and empowering participants to engage in social life. The main research questions were focused on the exploration of the perceived impact of theatre advocacy for the rights of HIV positive persons and the impact of these theatrical productions on participants’ attitudes towards discrimination towards people with HIV. Methods The study being discussed here was based on a mixed methods approach that combines the strengths of qualitative and quantitative methods (Creswell & Plano-Clark, 2007) to explore the complex issues related to the stigmatization of people living with HIV in Malta. The data collection included in-depth interviews with people with HIV and online preand post-performance surveys of the members of the Malta LGBTIQ Rights Movement (MGRM) who attended a preand post-reading session of the ‘Not Safe for Work’ (NSFW; later called ‘ Il-Pożittivi ) experimental online session. The study is part of a larger European AMASS project that examines the impact of socially engaged arts on the empowerment of marginalized groups and focuses on promoting resilience and inclusion of marginalized social groups.

The study examines the complex issues related to the stigmatization of people living with HIV, focusing on the presentation of the results of the preand postreading session of the NSFW experimental online session. This ongoing research was conceptualized as a critical and dialogical mixed methods study that was found helpful for the integration of quantitative and qualitative findings from mixed methods studies conducted by researchers with different methodological orientations (Taylor & Raykov, 2020). Due to the small number of participants, the main focus of this article is on the qualitative analysis of indepth interviews and mixing methods in a qualitatively driven way (Mason, 2006), while quantitative results mainly illustrate some tendencies regarding participants’ perception of this experimental reading session that was inspired by the in-depth interviews of people with HIV. The presentation of the quantitative findings was focused on the graphical presentation of results (Rose, 2016) to visualise results and identify some tendencies through their combination with the findings from qualitative analysis. The quantitative data are integrated with the findings that emerged from the qualitative analysis of five in-depth interviews with persons living with HIV conducted in the preliminary stage of the research project. Other combined data were the opinions which the members of the audience gave immediately after watching a live-streamed performance of the work-in-progress on Zoom (recorded 1/4/2020). The main objective of this analysis was to examine attitudes of the participants towards socially engaged arts and discrimination and how theatre can influence or change people’s attitudes towards discrimination and marginalization of people affected by HIV. This report includes answers from 8 participants who completed the preand post-performance surveys. The study was approved by the Institutional Ethics Board. Written informed consent was obtained from all the study participants, and the interviews were administered by the MGRM (Malta LGBTIQ Rights Movement) and anonymised. Background to the research study and the socially-engaged performance NSFW The objective for the interviews with the five interviewees had a dual purpose: one was to collect their stories, ideas, fears, hopes, desires, challenges and opinions so that the script writer would base the NSFW script on these, and the other was to collect data of their perceptions about living with HIV, their attitudes towards socially-engaged arts, their perceptions as to how theatre can

influence or change people’s attitudes towards discrimination and the marginalization of people affected by HIV. During an interview with the scriptwriter, Simon Bartolo, he said that he gained much insight from the interview transcriptions and, in writing the script, he ensured that certain research-informed perspectives come through clearly. One important aspect was, for example, respecting the interviewees’ insistence that they do not want their life to be portrayed as dramatic but as a normal life and to bring out their positive attitude to life nothwithstanding the challenges of living with HIV. He opted not to have five characters living with HIV, each representing one of the interviewees, and he did not limit the characters in the plot to only HIVinfected characters. Bartolo created six characters, three of whom are affected with HIV, one of these three affected is a heterosexual woman. There are also two young gay men and the mother of one of these. In this way he creates narrative possibilities that highlight the challenges faced by the HIV positive persons. Bartolo manages to weave the different anecdotes and opinions in a cohesive storyline, with dramatic intense moments but many humorous moments which offer comic relief, cutting the tension. Due to the various Covid restrictions in 2020, the performance could not be held live as originally planned. Actors stopped meeting for rehearsals in March due to Covid restrictions in force and there was so much uncertainty that the theatre space bookings had to be cancelled. As the restrictions continued, it was decided to have online rehearsals and eventually show a reading of an online work-in-progress only to an invited audience. The reading of the play affords an opportunity to both performers and audiences alike to get closer to the reallife experience. The format is similar to what Saldaña (2011) categorizes as one of the approaches to ethno-drama, that is, ethno-dramatic dramatization of interview transcripts (p. 17). Performing ethnography is a useful and appealing form to present research (Ackroyd & O’Toole, 2010, p.23), interconnecting phases of fieldwork, analysis, interpretation and representation (Wolcott, 1995) and such practice influences and enhances the researchers’ theatre making practices. Bartolo’s script had a strong element of ethnodrama with a good dose of fantasy. Having read the transcipts prior to the reading, the researchers could identify the ethnographic instances which ran through the whole reading clearly. A key aspect of sharing work-in progress with an audience is the fact that it can give the creative team valuable feedback which will impact the eventual script/performance. After the performance the audience is invited to ask

questions, discuss and offer feedback to the writer, the director. The audience invited to view NSFW stayed on after the reading and was extremely articulate in the feedback given. This audience was carefully chosen and specific, in that it consisted of other artists, MGRM officials and their members, including some of the interviewees who kept their video camera switched off but still gave their verbal feedback. The support, the constructive criticism and even negative comments of other artists is invaluable for the improvement of such a production. In this case, the creative team listened to the feedback of the MGRM members and the officials and, consequently, based on the feedback, made some substantial changes. The title, for example, was changed based on the feedback given and one particularly powerful scene was modified drastically, as a result of vehement objections from most of the audience who insisted it was disrespectful and perpetuated certain negative perceptions about male homosexuals, even if there were other members in the audience who disagreed and felt it should remain given it gave the storyline a dramatic twist. Perceptions and knowledge about people living with HIV Most participants who attended the online reading and completed the preand post-session survey indicated their interest in contributing to the promotion of rights of persons affected by HIV (87%), to contribute to the community (83%) and to learn more about HIV-related issues (79%). The data from the interviews also highlighted the importance of society being made aware and informed about HIV-related issues and debunking certain misconceptions that society has about HIV. This category emerged clearly from the data and the argument came up spontaneously by the interviewees. Out of the five interviewed three of them stressed the importance of educating the public and mentioned the importance of schools including this aspect in the curriculum as from primary school: it’s an unspoken – and I blame it on education, heavily…I think. Like HIV and certain chronic diseases should be taught to kids in elementary schools because, let’s say, unfortunately not everyone gets a full education and this information needs to be taught to children growing up…. like in elementary schools, in secondary schools, so that they can have access to it. You know, my secondary education, tipo in PSD, sex was – the topics were very lightly touched upon. I think, in general, Malta still suffers of a type of taboo around the whole sphere of sexuality. (P1 interview)

P4 (a Maltese male who moved to the UK some years after being diagnosed with HIV and holds a managerial post) also spoke at length about the lack of education about HIV in schools locally: When I was diagnosed as HIV positive, I brought up the subject with my daughter and I asked her whether she had heard of HIV from school. She said “” isn’t that when like they die after a short while” …it all needs to start from school, … as soon as they are the age of being actually active they should learn about HIV as part of sex education. And he also spoke about the lack of knowledge about HIV in Maltese society in general: So this is the mentality, but it is even with my mates, I only could bring myself to tell them after 5 years I had been diagnosed and their reaction was very similar (avoiding me). Not so, here, in the UK, for example here at work, I make it a point that when someone new joins the office, I tell them about being HIV positive and they ask questions and discuss with a certain knowledge about this, but in Malta this is absolutely not the case. P2 recounted an anecdote that highlights the need for society to learn more about HIV-related issues. Her story reveals that such lack of knowledge is found even in hospitals: Lots of ignorance. I’ll give you an example and this is quite a while ago (16 years ago). I was hospitalised in Gozo for something very, erm, totally unrelated. I had an infection an ovarian infection and I had paratenitis and my partner rushed me to the emergency department and I ended up having an emergency operation to deal with that and that was absolutely fine, then when I was given the anaesthetic and was wheeled to the ward, the orderly wheeling me to the ward, was actually shouting at people to get out of the way because I have HIV!” As the participant recounted this she laughted incredulously. This anecdote was picked up by the scriptwriter and was acted out in what was a really effective tragicomic scene.

Findings about societal challenges and arts-related activities Most participants indicated their interest in learning more about art-related activities (70%) and developing skills to cope with HIV-related issues (63%). A smaller but considerable number of the participants (28%) indicated their interest to develop drama skills (See Table 1). Table 1: Participants motivation to attend socially engaged artistic events (%) Completely Disagree Disagree Neither Agree Completely Agree Total Agree … To contribute to the promotion of rights of persons affected by HIV

• 2 11 41 46 87 … To contribute to the community - 2 16 48 35 83 … To learn more about HIV-related issues

• 3 18 41 38 79 … I would like to learn more about art-related activities 3 10 18 41 29 70 … To develop skills to cope with HIV-related issues 3 6 27 41 22 63 … To develop drama skills 14 24 35 18 10 28 Most of the differences between pre- and post-session surveys were not statistically significant. Some discrepancies regarding the pre- and post-session responses are evident, but the differences are not statistically significant, probably due to the single, short exposure to this event and due to the limited number of participants who attended and completed both pre- and post- session surveys. However, the difference is statistically significant regarding the participants’ interest to contribute to promoting the rights of persons affected by HIV (Chi-sq. = 8.869, p < .05). While almost all participants in the pre-session survey indicated their desire to contribute to the promotion of rights of persons affected by HIV (93%), a smaller but still large proportion of the participants indicated that they were actually able to contribute to such promotion (77%). Also, a large proportion of participants in this study demonstrated an interest to learn more about art-related activities (69.9%). Before the online performance (the reading of the script), 78% of the participants indicated their interest in learning more about art-related activities. However, only half of the people (50%) who attended the online session indicated that they actually acquired new knowledge after they participated in the reading session of the

script. Due to the small number of participants, this difference is not statistically significant, but this finding indicates that the educational aspect of socially engaged arts is significant for participants and that an experimental approach, like this pre-performance reading session, can contribute to the refinement of the script and some other pedagogical interventions that can be taken to satisfy the interests (educational needs) of the participants. The smallest, but significant number of participants (27%) who attended the online reading and completed the preand post-session survey indicated an interest to develop drama skills. Some differences regarding the preand post-session responses are evident, but the differences are not statistically significant. One of the main preliminary findings of this study is that most participants who attended the play’s online reading have very high expectations of socially engaged art (See Figure 1). Also, most of the participants evaluated this form of socially engaged art quite positively after attending the online reading. Figure 1: Participants’ perception of socially engaged art

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Analysis of the data obtained from the 7 point semantic differential with a maximal positive value of +3 and maximal negative value of 3 demonstrate that most participants perceive socially engaged arts as valuable, relevant, powerful, progressive and collaborative. The average values for this group of adjectives (qualifiers) attributed to the socially engaged art was above the value of +2. Also, many participants perceive socially engaged arts as exciting, empowering, safe, productive, active, friendly, and acceptable. The values of this group of qualifiers had a value between +1.5 and +2. Less favourably but still positively evaluated were the following aspects of socially engaged arts: organized, flexible, provocative, pleasant, optimistic, consistent and decisive. The average value for this group of qualifiers was between +1 and +1.5. Overall, on the 7 point somatic differential scale with a maximum value of +3 and a minimal value of 3, almost all evaluations are more or less favourable. The only expectation was the scale ’ Simple – Complex ’ that was slightly negative (-.07) indicating that the participants in this study perceive socially engaged arts as complex rather than simple. The difference between the mean evaluation scores of all socially-engaged art scales (see Figure 2) between the participants who attuned both the preassessment survey and the survey conducted after the online session is not statistically significant (t=1.061, p = 0.32). Results show that a larger number of participants evaluated socially engaged arts favourably, but a smaller number had a significantly less favourable perception. However, due to the small number of participants and certain other factors not controlled in this analysis, this difference was not statistically significant. Figure 2: Overall evaluation of the qualifiers attributed to socially engaged arts before and after the online script reading M e a n P R E P O S T M e a n 0 1 2 3 4

The effectiveness of socially engaged arts, particularly theatre, as a medium to communicate accurate knowledge about HIV, reduce knowledge gaps and misconceptions and help audiences empathise with HIV positive individuals all emerged as strong themes from the qualitative data: Like art is something that is projected from that person whose thinking, processing a viewpoint and putting it onto a canvas or a play or, you know, in some form of expression. I think it’s a good… I’m trying to find the right words, erm… If you look at, you know, art, past art and like, you know, current art, they can lead to addressing social issues. They can address stigma, they can address fight against repression. (P1) Participant 4 believes: Art helps, it takes time but this is a sensitive and hot subject through art you can make people start to think, that would be the first step. Participant 1 spoke at length about the effectiveness of socially engaged theatre and the important role that an artist has in helping society understand the AIDS crisis more realistically and humanely: I think artists have a very important role in society, in the sense that they can pioneer the liberties, they can pioneer expression, they can pioneer certain depths that not everyone has access to. So, I think, yes, it’s a big yes actually, it’s not “I think”. (P1) P2 highlighted the fact that theatre could present the complex perspective on the medical and personal aspects of the disease. portraying the whole human aspect of persons living with HIV rather than their HIV condition itself: Through theatre we need to see more about the totality of people’s lives not just focusing on doom and gloom stuff. Because that makes people more human. That removes some of the stigma. P5’s comment about socially engaged arts was, on the other hand, more of a warning as to certain pitfalls when dealing with a sensitive subject that there is a stigma about such as HIV. He made reference to Philadelphia , the 2013, successful gay-themed Hollywood movie which many in the LGBTI community deem unethical in it being a purposeful misrepresentation of historically oppressed individuals and for its perpetuation of falsities and entertainment of problematically distorted realities (Kramer, 1994):

Philadelphia is to gay people with HIV… as Jaws the movie is to sharks (laughs). I meant that as a joke, you know, Jaws, the writer of the book spent the rest of his life doing activism to save sharks, noting how much damage he caused the shark population. Further quantitative analysis shows that most participants had similar attitudes before and after, and the negative perception was related to the attributes of socially engaged art that were initially most highly evaluated on scales such as Progressive Old-fashioned, Powerful – Weak, Relevant – Irrelevant, Valuable – Worthless, and Collaborative – Individual (See Figure 3). The mean difference regarding preand post-average evaluation was statically significant (t=2.643, p = .03). It is likely that the participants who most highly value socially engaged arts are also highly critical but also, the applied semantic differential scale is limited at the bot side, and it is not possible to provide higher evaluations if some of the participants want to do so. Figure 3: Evaluation of the most positively evaluated attributes before and after the online script reading M e a n P R E P O S T M e a n 0 1 2 3 4 The comparison of the results at the summary scale on the relatively positively evaluated attributes indicates that there are no statistically significant differences (t=1.352, p = 0.210) regarding this group of attributes that include the following qualities: Empowering – Discouraging; Exciting Boring; Safe Insecure; Productive Unproductive; Active Passive; Friendly Unfriendly; Acceptable Unacceptable; Organized Disorganized; and Flexible – Rigid (See Figure 4 ).

Figure 4: Evaluation of the relatively positively evaluated attributes before and after the online script reading M e a n P R E P O S T M e a n 0 1 2 3 4 Finally, comparing the results on the summary scale on the least positive attributes indicates that the participants in the post-assessment, on average, evaluate these attributes slightly higher. Still, this difference is not statistically significant (t=1.075, p = 0.32). This group of attributes includes the following qualifiers: Pleasant – Unpleasant; Provocative Subdued; Optimistic Pessimistic; Consistent Inconsistent; Decisive Indecisive; and Simple – Complex (See Figure 5 ). Figure 5: Evaluation of the least positively evaluated attributes before and after the online script reading M e a n P R E P O S T M e a n -1 0 1 2 3 Despite the identified differences, all participants who completed the postsession online feedback during the reading performance indicated that they would consider visiting similar performances in the future if they have the

opportunity. More than a third (39%) indicated that they would ‘probably’, and almost two-thirds (61%) indicated that they would ‘definitely’ consider visiting similar performances in the future. Similarly, nearly all of the participants (94%) said they would consider recommending this performance to their friends or relatives. The analysis of the mixed method data revealed that the arts are perceived to be an effective medium to contribute to the promotion of the rights of persons affected by HIV. This emerged in the preand post-assessment surveys and also in the interviews with persons living with HIV conducted in the preliminary stage of the research project. Also, the vast majority of the audience members who stayed on to give feedback after the online reading of the workinprogress clearly expressed their opinion that the performance had the potential to inform and pass on accurate knowledge about HIV, reduce knowledge gaps and misconceptions and help audiences empathise with HIV positive individuals. The data from the audience feedback revealed that NSFW helped the audience understand the challenges that people living with HIV face because of stigma, lack of information and misinformation in Maltese society about this condition. Various members in the audience mentioned that, prior to watching the performance, they were not aware that the medication exists for persons living with HIV that helps them get an undetectable viral load, and that this means that they do not pass HIV on, not even through sex. The audience reported clear significant positive changes in HIV knowledge and HIV awareness after watching NSFW and consequently their attitudes changed and any fear of such persons declined substantially. This finding correlates with previous international research based on theatre-based interventions, also about sex health education, mainly targeted towards adolescents which have shown similar results (Munro et al, 2007; McEwan, 1991.) Forum Theatre and Popular Theatre, based on Freirean principles of education, are theatre genres that invite audience reflection, participation and create a space to address “taboo” issues in depth (Boal, 1985; Greene, 1995; Matarasso, 1997; Prentki & Selman, 2000). The potential of theatre in terms of helping the audience to empathise with marginalised groups is significant (Munro, 2007). As the NSFW script develops, the story becomes increasingly compelling and emotionally engaging. The audience is presented with the characters’ uncertainties, challenges, anger, frustrations and, at times, sheer desperation. The theatre experience moves the audience to critically reflect, empathise and

consequently become emotionally attached (Gatt, 2020) to the characters’ feelings and their situations as they struggle with society’s ignorance and stigma. Studies have shown that theatre based-interventions prove to have more impact than traditional teaching methods (Lieberman et al., 2012) and NSFW contains much information. This was commented on by during the post reading forum with comments like: “I have learnt much about certain social media, the dangers that young people run into for the sake of exploration and entertainment, chem sex for example. Things I was not aware of. Also that, with effective HIV treatment, the viral load can become undetectable and HIV positive people are safe to have sexual relationships with.” (P x post zoom reading forum) Even more important is the fact that the empathic impact is stronger when the actors resemble the audience in terms of age, gender and race. The actors were all professional and all but one were Maltese. This helped make them all the more relatable to the audience. In fact various people in the audience reported they found it extremely emotional. Research by Levine et al. (2002, 2005) reveals that empathy is stronger for people from the same social group; when people witness violence or bullying they are more likely to intervene if the victim is from their social group. Studies exploring the mirror-neuron-system using electroencephalogram (EEG) machines also reveal that the brain is more sensitive to race and ethnicity: there tends to be reduced motor resonance and experience sharing with racial out-groups (Gutsell & Inzlicht, 2010; Gutsell & Inzlicht, 2012). NSFW clearly had an impact on people’s attitudes towards discrimination and this was done mainly through changes in HIV knowledge and HIV awareness and the empathy with the characters. During their verbal feedback the audience also indicated that they would like to learn more both about HIV issues and about similar artistic activities. Many participants in the survey evaluated the online reading positively and indicated that their expectations of socially engaged arts are high. The majority also indicated that they would consider attending similar artistic events in the future, which demonstrates that there is definitely scope for other researchers and theatre companies to develop projects revolving around similar healthrelated societal challenges in Malta.

The thematic analysis of the interviews highlighted a concern felt by various participants. This was a lack of support for and amongst HIV positive persons: And within the superstructure of the health system there was nothing. In terms of psychological support, moral support. Nothing! (P5 – interview) As far as I know there’s nothing. There’s certain feeling of omerta almost when there is the day when everyone… my understanding is that people meet in the room, everyone knows that they are there for their check up but no one says anything and stays in his little bubble (P5 – interview) This theme was picked up and given prominence by the script writer. It is Susan, the only female and heterosexual character living with HIV in the play, that champions the idea of creating a social club for HIV positives. She is a colourful, boisterous, energetic sixty-year-old who has made it her mission to befriend everyone in the GU clinic and invite them to join her in her mission. This is no easy feat, considering that everyone prefers to “stay in their bubble” as participant 5 put it. The end scene sees Susan finally bringing all the characters in NSFW together at her house for her 60 th^ birthday. This is a climactic scene with an ultimate confrontation when many truths are revealed. The NSFW work-in-progress portrayed the challenges and hurdles of living life with HIV but also highlighted the important potential of a social support network amongst people living with HIV. The audience feedback also related to the importance of having a support group for HIV people. One of the audience members said that most of Maltese society seems to be stuck back in the early 80’s perception of HIV, and that is precisely why HIV positive persons keep their condition to themselves. The perception of negative value judgements in Maltese society often means persons with HIV do not reach out for help, not even from each other. This was the case with the lack of medication available in December 2020 when only one activist spoke out publicly, asking the government to resolve this issue. It just so happened that this person was a foreigner living in Malta. Conclusion The small number of participants was one of the main challenges to generalize findings about the impact of socially engaged arts on the empowerment of

participants. It is expected that the integration of comparable data conducted from participants in other testbed studies in Malta will provide more reliable and generalizable findings of the potential of socially engaged arts to contribute to the empowerment of participants and to influence perception and attitudes of the general public toward people with HIV. Co-creation was a leading strategy in this play and was particularly productive since the interviews of MGRM members inspired the play’s development. Moreover, additional feedback from participants provided valuable suggestions for the refinement of the script and the performance that was perceived as a highly promising strategy for changing perceptions toward HIV and attitudes toward people with HIV. Overall, the results from this testbed experiment demonstrate a very high level of expectations and significant potential of socially engaged arts to contribute to the improvement or mitigation of some of the issues that marginalized members of the community face. The results from the preand post-assessment surveys, together with qualitative findings, provide valuable evidence that the artists and educators can use or consider during the creation and organization of artistic events in order to maximize the effects of socially engaged cultural activities. The research evidence obtained from this study is also expected to help professional actors develop artistic performances that advocate for the rights of persons living with HIV, which was one of this study’s objectives. Acknowledgement The authors of this paper would like to acknowledge and express appreciation to Toni Attard, director of Culture Venture, for his organization of the theatre production. Also, we highly appreciate the work of the Maltese AMASS study research support officer Margerita Cotter Pule for assistance with data collection and support during the entire preparation of the research component of this study. The authors of this paper are listed in alphabetical order. References: Ackroyd, J. and O’Toole, J. (2010), Performing Research: Tensions, Triumphs and TradeOffs of Ethnodrama. Trentham Books. Andersson, G. Z., Reinius, M., Eriksson, L. E., Svedhem, V., Esfahani, F. M., Deuba, K., et al. (2020). Stigma reduction interventions in people living with HIV to improve health-related quality of life. The Lancet HIV, 7 (2), e129–e140. https://doi.org/10.1016/S2352-3018(19)303431

Arefaynie, M., Damtie, Y., Kefale, B., & Yalew, M. (2021). Predictors of Discrimination Towards People Living with HIV/AIDS Among People Aged 15 – 49 Years in Ethiopia: A Multilevel Analysis. HIV/AIDS Research and Palliative Care, 13 , 283 – 292. https://doi.org/10.2147/HIV.S299812 Bagamoyo College of Arts, Tanzania Theatre Centre, Mabala, R., & Allen, K. B. (2002). Participatory action research on HIV/AIDS through a popular theatre approach in Tanzania. Evaluation and Program Planning, 25 (4), 333 – 339. Bird, J. (2020). More than words: Performance ethnography as a research method that values sustained ethnographic orientation and imaginative theatre-making. International Journal of Education & the Arts, 21(22). http://doi.org/10.26209/ijea21n22 Boal, A. (1985). Theatre of the Oppressed. Theatre Communications Group. Brown, L., Macintyre, K., & Trujillo, L. (2003). Interventions to reduce HIV/AIDS stigma: what have we learned? AIDS education and prevention, 15 (1), 49 – 69. https://doi.org/10.1521/aeap.15.1.49.23844 Cao, X., Sullivan, S. G., Xu, J., Wu, Z., & Team, C. C. P. (2006). Understanding HIV– related stigma and discrimination in a “blameless” population. AIDS education & prevention, 18 (6), 518 – 528. https://doi.org/10.1521/aeap.2006.18.6.518 Creswell, J., & Plano-Clark, V. (2007). Designing and conducting mixed methods research. Sage. Grossman, C. I., & Stangl, A. L. (2013). Editorial: Global action to reduce HIV stigma and discrimination. Journal of the International AIDS Society, 16 (3 Suppl. 2), http://dx.doi.org/10.7448/IAS.7416.7443.18881 Gatt, I. (2020). Theatre—A space for human connection. Taboo: The Journal of Culture and Education , 19(2). https://digitalscholarship.unlv.edu/taboo/vol19/iss2/5 Goffman, Erving. 1963. Stigma: Notes on the Management of Spoiled Identity. Simon & Schuster. Greene, M. (1995). Releasing the imagination: Essays on education, the arts, and social change. Jossey-Bass. Hatzenbuehler, M. L., Phelan, J. C., & Link, B. G. (2013). Stigma as a fundamental cause of population health inequalities. American journal of public health, 103 (5), 813 –

821. https://doi.org/10.2105/AJPH.2012.301069 Kramer, L. (1994) Why I Hated ‘Philadelphia: A playwright and gay activist goes to see Hollywood’s first major AIDS movie and comes away bitterly disappointed. Los Angeles Times. https://www.newspapers.com/image/157228855/?terms= why%20i%20hated%20philadelphia&match=1 Logie, C. H., Dias, L. V., Jenkinson, J., Newman, P. A., MacKenzie, R. K., Mothopeng, T., et al. (2019). Exploring the potential of participatory theatre to reduce stigma and promote health equity for lesbian, gay, bisexual, and transgender (LGBT) people in Swaziland and Lesotho. Health Education & Behavior, 46 (1), 146 – 156. https://doi.org/10.1177/1090198118760682 Mann, J. M. (1988). Statement at an informal briefing on AIDS to the 42nd session of the United Nations General Assembly. Journal of the Royal Statistical Society.

Series A (Statistics in Society), 151 (1), 131 – 136. https://apps.who.int/ iris/handle/10665/61546 Mason, J. (2006). Mixing methods in a qualitatively driven way. Qualitative Research, 6 (1), 9 – 25. Matarasso, F. (1997). Use or ornament? The social impact of participation in the arts. Comedia. Mawar, N., Sahay, S., Pandit, A., & Mahajan, U. (2005). The third phase of HIV pandemic: social consequences of HIV/AIDS stigma & discrimination & future needs. Indian Journal of Medical Research, 122 (6), 471 – 484. McEwan, R. T., Bhopal, R., & Patton, W. (1991). Drama on HIV and AIDS: An evaluation of a theatre-in-education programme. Health Education Journal , 50 (4), 155 – 160. https://doi.org/10.1177/001789699105000402 Munro, B., Selman, J., Esmail, S. & Ponzetti, J. (2007). Are We There Yet?: Using Theatre in Sexual Education: A Combinationaion of Academic and. Theatre Groups. The International Journal of Diversity in Organizations, Communities, and Nations, 7 (3), 131 – 138. http://dx.doi.org/10.18848/1447-9532/cgp/v07i03/39376 Nambiar, D., Ramakrishnan, V., Kumar, P., Varma, R., Balaji, N., Rajendran, J., et al. (2011). Knowledge, stigma, and behavioral outcomes among antiretroviral therapy patients exposed to Nalamdana’s radio and theater program in Tamil Nadu, India. AIDS education and prevention, 23 (4), 351 – 366. https://doi.org/10.1521/aeap.2011.23.4.351 Parker, R., & Aggleton, P. (2003). HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for action. Social Science & Medicine, 57 (1), 13 – 24. https://doi.org/10.1016/S0277-9536(02)003040 Prentki, T., & Selman, J. (2000). Popular theatre in political culture: Britain and Canada in focus. Intellect. Presanis, A. M., Harris, R. J., Kirwan, P. D., Miltz, A., Croxford, S., Heinsbroek, E., et al. (2021). Trends in undiagnosed HIV prevalence in England and implications for eliminating HIV transmission by 2030: an evidence synthesis model. The Lancet Public Health, 6 (10), e739-e751. https://doi.org/10.1016/S24682667(21)001420 Rose, G. (2016). Visual methodologies: An introduction to researching with visual materials (4th edition). Sage. Saldaña, J. (2011). Ethnotheatre: Research from Page to Stage. Left Coast Press. Stangl, A. L., Lloyd, J. K., Brady, L. M., Holland, C. E., & Baral, S. (2013). A systematic review of interventions to reduce HIV-related stigma and discrimination from 2002 to 2013: how far have we come? Journal of the International AIDS Society, 16(Suppl 2) , 18734. https://doi.org/10.7448/IAS.16.3.18734 Taylor, A. & Raykov, M. (2020). Towards critical and dialogical mixed methods research: Reflections on our journey. In F. Finnegan & B. Grummell (Eds.), Doing critical and creative research in adult education (pp. 127 – 137 ). Sense Publishing.

UNAIDS. (2010). Getting to zero: 2011 2015 strategy. Joint United Nations Programme on HIV/AIDS. UNAIDS. http://www.unaids.org/en/resources/ documents/2010/ 20101221_JC2034_UNAIDS_Strategy UNAIDS. (2014). 90 – 90 – 90. An ambitious treatment target to help end the AIDS epidemic. https://www.unaids.org/en/resources/documents/2017/9090 90 Walker, G. J., Stocklmayer, S. M., & Grant, W. J. (2013). Science theatre: Changing South African students’ intended behaviour towards HIV AIDS. International Journal of Science Education, Part B, 3 (2), 101 – 120. https://doi.org/ 10.1080/09500693.2011.633939 WHO. (2021). Global progress report on HIV, viral hepatitis and sexually transmitted infections, 2021. https://www.who.int/publications/i/item/9789240027077