Until they require fTPMs, an attacker can just choose to use a regular TPM.
A more sophisticated attacker could plausibly extract key material from the TPM itself via sidechannels, and sign their own attestations.
I remember there's a PCI device that's meant to be snooping and manipulating RAM directly by using DMA. Pretty much one computer runs the game and one computer runs the cheat. I think kernel anti cheats are just raising the bar while pretty much being too intrusive
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